VACCINES

1

• VACCINES IMMUNISATION

Dr. I. M. Gemmill Medical Officer of Health
KFLA Public Health Kingston, Canada Associate
Professor Department of Community Health
Epidemiology Department of Family Medicine,
Queens University
Hosted by Paul Webber paul_at_webbertraining.com www.
webbertraining.com
A Webber Training Teleclass
I. M. GEMMILL, MD, CCFP, FRCP(C)
2
OBJECTIVES
IMMUNISATION

• To describe the value of vaccines in reducing the
  morbidity and mortality from communicable
  diseases
• To describe the various types of vaccines,
  desirable qualities in a vaccine, their
  components and how they work
• To describe correct storage, handling,
  administration and documentation of immunisation
• To describe the nature of side effects of
  vaccines and to distinguish between real and
  alleged side effects
• To communicate effectively with vaccine
  recipients and their parents about the benefits
  and risks of vaccines
• To outline reputable and disreputable sources of
  information on immunisation

I. M. GEMMILL, MD, CCFP, FRCP(C)
3
COST BENEFIT OF VACCINE
IMMUNISATION

• Vaccination programmes are considered to be the
  most cost-beneficial health intervention and one
  of the few that systematically demonstrate far
  more benefits than costs.
• Intervention Cost per Life Year Saved
• MMR vaccine for children lt 0
• Mammography gt 50 810
• Smoking cessation advice (gt 1 ppd) 9800
• Low cholesterol diet (men gt20, gt180 mg/dl)
  360.000

I. M. GEMMILL, MD, CCFP, FRCP(C)
4
POLIO INCIDENCE 1949-1995
IMMUNISATION
I. M. GEMMILL, MD, CCFP, FRCP(C)
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DIPHTHERIA CASES 1924-1995
IMMUNISATION
I. M. GEMMILL, MD, CCFP, FRCP(C)
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TETANUS DEATHS 1924-1995
IMMUNISATION
I. M. GEMMILL, MD, CCFP, FRCP(C)
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MEASLES INCIDENCE 1924-1995
IMMUNISATION
I. M. GEMMILL, MD, CCFP, FRCP(C)
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RUBELLA CASES 1924-1995
IMMUNISATION
I. M. GEMMILL, MD, CCFP, FRCP(C)
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IMPACT OF VACCINES ON COMMUNICABLE DISEASES IN
CANADA
IMMUNISATION

• DISEASE Before vaccine 2001
• Diphtheria 9000 0
• Polio 20.000 0
• Measles 300.000 33
• Rubella 69.000 23
• Number of cases in an outbreak year

I. M. GEMMILL, MD, CCFP, FRCP(C)
10
TYPES OF IMMUNISATION
IMMUNISATION

• Active immunisation
• the formation of antibodies in response to an
  antigenic stimulus
• protection tends to be long-term
• Passive immunisation
• the administration of preformed antibody, from a
  human or animal source, to provide short-term
  protection against disease
• e.g. gamma globulin, specific immune globulin

I. M. GEMMILL, MD, CCFP, FRCP(C)
11
QUALITIES OF A GOOD VACCINE
IMMUNISATION

• Effective
• immunogenicity
• induces antibodies in individuals
• efficacy
• reduces disease in populations
• duration of protection
• need for boosters is limited

I. M. GEMMILL, MD, CCFP, FRCP(C)
12
QUALITIES OF A GOOD VACCINE
IMMUNISATION

• Safe
• common side effects are mild
• serious side effects are rare
• does not cause disease
• not transmissible to others

I. M. GEMMILL, MD, CCFP, FRCP(C)
13
QUALITIES OF A GOOD VACCINE
IMMUNISATION

• Ease of administration
• injectable
• needle
• jet injector
• nasal spray
• oral
• edible

I. M. GEMMILL, MD, CCFP, FRCP(C)
14
QUALITIES OF A GOOD VACCINE
IMMUNISATION

• Stability
• Freezer stable
• Fridge stable
• Stable at room temperature

I. M. GEMMILL, MD, CCFP, FRCP(C)
15
QUALITIES OF A GOOD VACCINE
IMMUNISATION

• Cost
• Older vaccines cost a few dollars per dose
• Newer vaccines enter the market at 60 per dose
  or higher
• Competition brings the price down

I. M. GEMMILL, MD, CCFP, FRCP(C)
16
HOW DO VACCINES WORK?
IMMUNISATION

• Vaccines cause the immune system to provide
  protection against disease without causing
  disease
• They stimulate an immune response to provide
  protective antibodies, memory cells, or both

I. M. GEMMILL, MD, CCFP, FRCP(C)
17
NEW VACCINE DEVELOPMENT
IMMUNISATION

• Vaccines go through a number of processes
• Bench research
• Animal trials
• Clinical trials for safety efficacy
• Licensure
• National expert recommendations
• Field use private pay or provincial programme

I. M. GEMMILL, MD, CCFP, FRCP(C)
18
VACCINES MANUFACTURING
IMMUNISATION

• Vaccines are among the most rigorously controlled
  medical products
• Production purification of the desired antigen
• Inactivation or disruption
• Sterilisation
• Packaging preservatives

I. M. GEMMILL, MD, CCFP, FRCP(C)
19
TYPES OF VACCINES
IMMUNISATION

• Live vaccines
• measles, mumps, rubella
• varicella
• yellow fever
• oral polio vaccine (Sabin)
• BCG

I. M. GEMMILL, MD, CCFP, FRCP(C)
20
TYPES OF VACCINES
IMMUNISATION

• Killed vaccines, whole cell
• polio
• rabies
• hepatitis A
• Killed vaccines, particles
• pertussis
• influenza

I. M. GEMMILL, MD, CCFP, FRCP(C)
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TYPES OF VACCINES
IMMUNISATION

• Killed vaccines, polysaccharide
• meningococcal
• pneumococcal
• Killed vaccines, conjugated
• meningococcal
• pneumococcal
• haemophilus influenzae

I. M. GEMMILL, MD, CCFP, FRCP(C)
22
TYPES OF VACCINES
IMMUNISATION

• With live vaccines, a small amount of vaccine
  virus is administered
• The vaccine virus replicates, thereby mimicking
  the disease process more closely
• The protection that they provide is generally
  therefore longer-lasting and requires fewer total
  doses
• The fact that live virus replicates in this
  process means that these vaccines have special
  precautions
• Pregnancy
• People whose immune status is compromised
• Cold chain must be respected

I. M. GEMMILL, MD, CCFP, FRCP(C)
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TYPES OF VACCINES
IMMUNISATION

• With vaccines that are not live, the total dose
  administered is all that the immune system has to
  work with
• Some vaccines therefore have adjuvants or protein
  carriers to make them more immunogenic

I. M. GEMMILL, MD, CCFP, FRCP(C)
24
COMPONENTS OF VACCINES
IMMUNISATION

• Vaccines contain
• Antigens to induce an immune response
• Vaccines may also contain
• Adjuvant aluminium hydroxide
• Preservatives thimerosal
• Antibiotics neomycin
• Other stabilisers albumin

I. M. GEMMILL, MD, CCFP, FRCP(C)
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VACCINE INDICATIONS
IMMUNISATION

• Indications for use are based on epidemiological
  risk
• May be for universal use e.g. pertussis
• May be for targeted populations e.g. travel,
  lifestyle
• May be for pre-exposure (routine) use
• May be for post-exposure (outbreak control) use
  e.g. hepatitis A
• Refer to national expert statements for
  indications, rather than product monographs

I. M. GEMMILL, MD, CCFP, FRCP(C)
26
VACCINE SCHEDULES
IMMUNISATION

• Every vaccine has a schedule of administration
• The schedule is determined by clinical trial
  design and post-marketing research
• The product monograph is a legal document
  providing the most conservative approach to
  vaccine use
• Recommendations of expert bodies are the most
  valid sources for reference for vaccine use

I. M. GEMMILL, MD, CCFP, FRCP(C)
27
VACCINE SCHEDULES
IMMUNISATION

• Some vaccines have more flexible schedules than
  others
• hepatitis B vaccine vs. conjugated pneumococcal
• Schedules need to accommodate the requirements
  and precautions for all vaccines that are
  recommended e.g. timing of live virus vaccines

I. M. GEMMILL, MD, CCFP, FRCP(C)
28
IMMUNE MEMORY AND THE NEED FOR BOOSTERS
IMMUNISATION

• There are two ways in which vaccines protect
• Antibodies are produced that may last for years
• Memory cells may be produced, that create
  antibodies quickly in response to an antigenic
  challenge
• We judge vaccines by antibody, but they may
  protect through the second mechanism

I. M. GEMMILL, MD, CCFP, FRCP(C)
29
IMMUNE MEMORY AND THE NEED FOR BOOSTERS
IMMUNISATION

• Some vaccines need only one dose for lasting
  protection
• Conjugated meningococcal vaccine in adults
• Most vaccines need more than one dose to be fully
  effective
• Some vaccines need regular boosting throughout
  life
• Toxoids tetanus diphtheria

I. M. GEMMILL, MD, CCFP, FRCP(C)
30
IMMUNE MEMORY AND THE NEED FOR BOOSTERS
IMMUNISATION

• Live virus vaccines may need less doses in
  general because they mimic the disease process
  better
• Oral polio requires more than one dose because
  one of the three types predominates with ease
  dose
• Some vaccines just work incredibly well after two
  or three doses
• hepatitis A, inactivated polio

I. M. GEMMILL, MD, CCFP, FRCP(C)
31
VACCINE ADMINISTRATION
IMMUNISATION

• There are several ways to administer vaccines
• IM
• SC (usually live virus vaccines)
• Oral
• ID
• The route of administration is specific to each
  vaccine.
• It is essential to check and be sure of the route
  of administration for a given vaccine.

I. M. GEMMILL, MD, CCFP, FRCP(C)
32
VACCINE ADMINISTRATION
IMMUNISATION

• Technique
• Use the right-sized needle (e.g. 1 inch for adult
  I.M.)
• Deltoid for adults and older children
• Anterolateral surface of the thigh for infants
  and young children
• No gluteal injections
• Sharp needles only

I. M. GEMMILL, MD, CCFP, FRCP(C)
33
VACCINE ADMINISTRATION
IMMUNISATION

• Technique
• Cleanse the area with alcohol and let it
  evaporate
• Separate needle and syringe for each injection
• Aspirate
• Practise doing it quickly, so that patients are
  less uncomfortable

I. M. GEMMILL, MD, CCFP, FRCP(C)
34
VACCINE TIPS
IMMUNISATION

• Prophylactic use of antipyretics may decrease
  minor side effects
• Interruption of the recommended schedule does not
  usually mean restarting (exception conjugated
  pneumococcal)
• Giving a vaccine after too short an interval is a
  problem
• Recommended vaccine dosage should NEVER be
  reduced
• Prematurity does not affect vaccines schedules

I. M. GEMMILL, MD, CCFP, FRCP(C)
35
STORAGE COLD CHAIN
IMMUNISATION

• The storage requirements may vary from vaccine to
  vaccine
• Storage requirements must be respected
• Some vaccines can undergo one insult without loss
  but no insult to the vaccine is preferred
• Live virus vaccines are generally more
  susceptible to insult that others
• The prime example is fridge failure
• In general, most vaccines are kept at 2 to 8 C

I. M. GEMMILL, MD, CCFP, FRCP(C)
36
IMMUNISATION RECORDS
IMMUNISATION

• Every immunisation event should be recorded on
  the patients chart and a record provided to the
  vaccinee
• Immunisations are reportable in some provinces
• Provincial systems vary from province to province
  but are not connected
• There is currently no national system to keep
  track of immunisations

I. M. GEMMILL, MD, CCFP, FRCP(C)
37
VACCINE SAFETY MONITORING
IMMUNISATION

• Vaccines are probably the best monitored of all
  medical interventions
• The process of licensing vaccines is rigorous
  (average 2 years)
• There is a requirement to report possible AVEs in
  most provinces
• Companies conduct post-marketing surveillance
• Immunisation Monitoring Programme ACTive (IMPACT)
• Advisory Committee on Causality Assessment (ACCA)

I. M. GEMMILL, MD, CCFP, FRCP(C)
38
VACCINE CONTRAINDICATIONS
IMMUNISATION

• The only true contraindication to any vaccine is
  a previous anaphlylactic reaction or severe
  hypersensitivity to any component of the vaccine.

I. M. GEMMILL, MD, CCFP, FRCP(C)
39
VACCINE CONTRAINDICATIONS
IMMUNISATION

• Contraindications to live virus vaccines
• Pregnancy
• although no birth defect has ever been recorded
• may have to balance risk versus benefit e.g.
  Yellow Fever vaccine
• Some immunodeficiency states

I. M. GEMMILL, MD, CCFP, FRCP(C)
40
VACCINE SIDE EFFECTS
IMMUNISATION

• SIDE EFFECTS INCLUDE
• Local (at the injection site)
• Swelling, induration, tenderness, erythema
• Systemic (examples)
• Fever, rash, arthralgia, myalgia,
• Severe anaphylaxis, GBS

I. M. GEMMILL, MD, CCFP, FRCP(C)
41
VACCINE SIDE EFFECTS
IMMUNISATION

• Common side effects are generally milder
• Serious side effects are generally rare
• Side effects may vary from vaccine to vaccine,
  based on the components
• Some side effects are simply owing to the
  injection

I. M. GEMMILL, MD, CCFP, FRCP(C)
42
VACCINE SIDE EFFECTS
IMMUNISATION

• Every medical intervention has risks
• Vaccines are no exception
• Patients must be informed about risks and side
  effects
• Informed consent for immunisation is a requirement

I. M. GEMMILL, MD, CCFP, FRCP(C)
43
VACCINE SIDE EFFECTS
IMMUNISATION

• CONDITIONS THAT ARE NOT DUE TO VACCINES
• Chronic fatigue syndrome (hepatitis B vaccine)
• Multiple sclerosis (hepatitis B vaccine)
• Autism (MMR vaccine, vaccines containing
  thimerosal)
• Ulcerative colitis (MMR vaccine)
• Brain damage (pertussis vaccine)
• SIDS (many vaccines)

I. M. GEMMILL, MD, CCFP, FRCP(C)
44
VACCINE PRECAUTIONS
IMMUNISATION

• There are precautions for giving any medical
  intervention, including vaccines
• Precautions are specific to the vaccine
• Example
• Live virus vaccines must be given at the same
  time or with an interval of at least 28 days

I. M. GEMMILL, MD, CCFP, FRCP(C)
45
VACCINES IN PREGNANCY
IMMUNISATION

• Live virus vaccines are contraindicated in
  pregnancy because of the theoretical risk of
  congenital anomaly
• Inadvertent immunisation of a pregnant woman with
  a live virus vaccine should be reported for
  monitoring purposes
• Other vaccines may be used safely in pregnancy
• Risk versus benefit must be considered
• Some vaccines are indicated in pregnancy
• influenza

I. M. GEMMILL, MD, CCFP, FRCP(C)
46
VACCINE RISK VERSUS BENEFIT
IMMUNISATION

• Every vaccine as some small risk attached to it
• The benefit of vaccine normally far outweighs any
  risk
• Sometimes, it is better to respect even a
  theoretical risk e.g. live virus vaccine in
  pregnancy
• Example YF vaccine in immunocompromised
  travellers
• If the risk outweighs the benefit, vaccine should
  not be administered e.g. smallpox vaccine

I. M. GEMMILL, MD, CCFP, FRCP(C)
47
COMMUNICATING RISK VERSUS BENEFIT
IMMUNISATION

• The advice of a health professional is the most
  important factor in whether a person receives a
  vaccine
• Clear, simple, concise information must be
  provided about both the risks and the benefits of
  vaccines (CMPA policy on pneumococcal
  meningococcal vaccines)
• Some people may need more detailed explanations
  than others
• Public health and professional bodies can help

I. M. GEMMILL, MD, CCFP, FRCP(C)
48
MYTHS ABOUT VACCINES
IMMUNISATION

• Common myths about vaccines
• Vaccines dont really work
• Vaccines arent safe
• We dont need vaccines because the diseases are
  rare
• There are too many antigens given to children now
• Vaccines weaken the immune system
• A healthy lifestyle is all one needs to prevent
  infection
• There is an industry conspiracy to poison
  children for profit

I. M. GEMMILL, MD, CCFP, FRCP(C)
49
ANTI-VACCINATIONISTS
IMMUNISATION

• There is a small group of zealots who are opposed
  to vaccine
• They believe that vaccines are unsafe and
  subscribe to conspiracy theories about them
• They are willing to spread untruths about
  vaccines publicly
• They may cause damage to public programmes
• hepatitis B in Manitoba, France

I. M. GEMMILL, MD, CCFP, FRCP(C)
50
ANTI-VACCINATIONISTS
IMMUNISATION

• There are many books published and web sites
  maintained by the anti-vaccine faction
• Many have respectable names and purport to be
  authoritative
• Some are supported by health paraprofessionals

I. M. GEMMILL, MD, CCFP, FRCP(C)
51
ANTI-VACCINATIONISTS
IMMUNISATION

• Web sites to check
• Vaccine Risk Awareness Networkhttp//64.41.99.118
  /vran/membership/contact_us.htm
• National Vaccine Information Centre
• http//www.909shot.com/
• Children of God for Lifehttp//www.cogforlife.org
  /
• Dr. Joseph Mercola
• http//www.mercola.com/article/vaccines/death.htm
  

I. M. GEMMILL, MD, CCFP, FRCP(C)
52
RELIABLE VACCINE WEB SITES
IMMUNISATION

• Web sites to check
• Canadian Public Health Association
• http//www.immunize.cpha.ca/english/links.htm
• Public Health Agency of Canada
• http//www.phac-aspc.gc.ca/dird-dimr/immunization
  _e.html
• United Kingdom Department of Health
• http//www.immunisation.nhs.uk/

I. M. GEMMILL, MD, CCFP, FRCP(C)
53
RELIABLE VACCINE WEB SITES
IMMUNISATION

• Web sites to check
• World Health Organisation
• http//www.who.int/vaccines/
• Centres for Disease Control Prevention
• http//www.cdc.gov/nip/

I. M. GEMMILL, MD, CCFP, FRCP(C)
54
VACCINES ARE NOT JUST FOR KIDS
IMMUNISATION

• People have the impression that vaccines are
  primarily for children
• While vaccines do prevent disease in children,
  there are many vaccines that adults need
• Routine tetanus, diphtheria, pertussis
• Lifestyle hepatitis A B
• Travel YF, typhoid, hepatitis A, etc.

I. M. GEMMILL, MD, CCFP, FRCP(C)
55
VACCINES ARE NOT JUST FOR KIDS
IMMUNISATION

• Other occupations
• Health care provider hepatitis B, MMR,
  influenza
• Vets rabies. hepatitis A
• Zookeepers hepatitis A vaccine
• Staff of some institutions hepatitis A B
• Prison guards hepatitis B
• Lab workers many vaccines
• Military many including anthrax, plague

I. M. GEMMILL, MD, CCFP, FRCP(C)
56
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