dnb pediatrics osce-immunization

VACCINES- OSCE

DR. NIBEDITA MITRA

SOUTHERN RAILWAYS

1.When was mission Indra dhanush launched? ½ 2. . What is the aim of this program? 1 3. Enumerate the vaccine preventable diseases covered? 3 ½

QUESTION-1

ANSWER-1

1. It was launched by Ministry of Health and Family Welfare on Dec 25, 2014

2. Its aim is to expand full immunization coverage from 65% to at least

90%of all children against 7 preventable diseases by 2020. Its aim is to

cover all children who have been left out or missed out of immunization

through systematic immunization drive, through ‘catch up’ campaign

mode.

3. The 7 diseases covered are-Diphtheria Tetanus

childhood Tuberculosis Pertussis

Polio Hepatitis B

Measles

( Additionally JE and Hib in selected states)

Question-2 1.Vaccination at birth means within _______ hours of birth or at

least not later than ________.

2.__________ number of vaccines can be given on the same day.

3.If simultaneous administration is not possible, they should be given within _____ hours.

4.If two live vaccines are not given on the same day, they should be given at least 28 days apart. This rule does not apply to___.

5.Vaccine doses administered upto_____ days before the recommended age or interval is counted as valid.Vaccines given > ____ days before minimum period is counted as invalid and should be repeated.

6.The distance separating 2 injections should be at least _______

7. I.M injection is given at _____ angle and SC inj at ____ angle with skin.

ANSWER -2 1.Vaccination at birth means within 24 to 72hours of birth or at

least not later than 7 days of life.

2.Any number of vaccines can be given on the same day.

3.If simultaneous administration is not possible, they should be given within 24 hours.

4.If two live vaccines are not given on the same day, they should be given at least 28 days apart. This rule does not apply to oral live vaccines.

5.Vaccine doses administered up to 4 days before the recommended age or interval is counted as valid. Vaccines given > 5 days before minimum period is counted as invalid and should be repeated.

6.The distance separating 2 injections should be at least 1 inch

7. I.M injection is given at 90 degree angle and SC inj at 45 degree angle with skin.(each answer ½ mark)

QUESTION 3 Time limit for using after reconstitution—

Varicella

BCG

Measles/ MMR

Yellow Fever

Meningococcal polysaccharide

DTap/ Hib combination

Answer 3

Time limit for using after reconstitution—

Varicella 30 minutes (protect from sunlight)

BCG 4 hours (protect from sunlight)

Measles/ MMR 4 to 6 hours

Yellow Fever 1 hour

Meningococcal polysaccharide 30minutes

DTap/ Hib combination 30 minutes

Question 4

Answer the following regarding BCG vaccine-

1. Type, dose, route and age of vaccination.

2. What is the diluent used?

3. Special precaution during vaccination.

4. Sequence of reaction after vaccination.

5. Till what age can the catch up vaccination given.

Answer 4 1. Live attenuated,0.1ml,intradermal, left shoulder at

level of deltoid insertion, given soon after birth.

2. Diluent is normal saline

3. Protect from sunlight. Use within 4 hrs of reconstitution.

4. A papule develops after2-3 wks, increases to a size of 4-8 mm by end of 5-6 wks, often heals with ulceration and results in scar after 6-12 wks

5. Catch up vaccination up to 5 years

Question 5

1. Enumerate the types of JE vaccine, dose, route and schedule for each type.

2. Catch up vaccination is recommended till what age.

Answer 5 Vaccine Type Dose Route Schedule

Inactivated Kolar strain

0.5ml i.m Minimum age 1yr. Two doses at 4 wks interval

Inactivated SA-14-14-2 strain

1-3yr:0.25ml > 3yrs:0.5ml

i.m Minimum age 1yr. Two doses at 4 wks interval

Live SA-14-14-2

0.5ml SC 1st dose at 9m with measles and 2nd dose at 16-18m withDPT booster.

Answer -5 (cont)

Catch up vaccination for JE to be given up to 15 years during out break in endemic areas.

Question 6-fill up vaccine Type Dose Route Schedule

OPV

IPV

Measles

Hepatitis B

vaccine Type Dose Route Schedule

OPV LAV Sabin strain

2 drops oral Birth,6,10,14 wks,15-18m, 5yrs,NID,SNID

IPV Inactivated Salk strain Type 1-40units Type 2-8 units Type 3-32units

0.5ml i.m 6,10,14 wks, booster at 15-18 months

Measles LAV 1000CCID50 of Edmonston zagreb strain

0.5ml SC At 9 mo (completed 270 days)

Hepatitis B

Recombinant vaccine 20µg/ml of HBsag

0.5ml i.m 0,1,6mo Or birth 6,10,14 wks

Answer-6

VITAMIN A 1. How many total doses of Vitamin A

should be given and till what age?

2. What are the storage guidelines?

3. How long can a bottle of vitamin A

be used once it is opened?

4. Hari, 8 months old malnourished

infant is suffering from measles.

Please write the Vitamin A

supplementation schedule for him.

5. How should Vit A be

administered?

QUESTION-7

ANSWER-7

1. A total of 9 prophylactic doses of Vitamin A should be given at 6 months interval till 5 years age.

2. Vitamin A solution should be kept away from sunlight and unopened bottle can be used till expiry date.

3.Once opened, should be used with in 6 to 8 wks. Write the date of opening on the bottle.

4.Vit A 1ml on day one, 1ml next day, repeat same dose after 4 wks

5.Vit A syrup should be administered ONLY using the spoon provided. The half mark in the spoon indicates 1,00,000 IU and full spoon is 2,00,000 IU.

VACCINES IN SPECIAL SITUATIONS

QUESTION- 8

Please read the following case

scenarios and answer accordingly

Question-8,CASE SCENARIOS

I. Five years age Arjun, was diagnosed to have Nephrotic syndrome, 4 wks back. Presently he is on treatment and has no complaints. So parents have brought him for immunization. Please advice. 2. Preethi’s mother has brought her for MMR vaccine. She thinks two vaccines on the same day will be very painful and wants to come after 2 days for varicella vaccine. Please advise. 3. 12 months old Surabhi was given I/V immunoglobulin for Immune mediated Thrmbocytopenia. Please write the immunization advise at the time of discharge. 4. Abhi, 3years age, known case of Thalassemia Major has succesfully undergone BMT 5 months back. His sister was the donor. Please advice regarding immunization.

Answer 8,Case 1

• Arjun can be given DPT (2nd Booster), IPV and Vit A 2ml. He should be advised about Varicella vaccine

and Pneumococcal Vaccine, when in remmision.

• Children receiving steroids ≥ 2 mg/kg/day or ≥20mg/day for 14 days or more should not receive live vaccines until therapy has been discontinued for at least one month.

• Children on same dose but less than 2 wks may receive live vaccines.

Answer-8,Case -2

• Both the vaccines can be given on the same day. If not given on the same day, two live vaccines should be given at least one month apart.

Answer-8,Case -3

• After i/v immunoglobulin, live vaccines are to be avoided for 3 -11months.

• MMR to be avoided at 15 months

• At 18 months she can receive DPT booster

HiB booster

MMR

IPV

Vit A 2 ml

Answer 8,Case-4

Abhi needs to be revaccinated after 6 months of BMT He should receive

• DPT- 3 doses

• Hib – 3 doses

• Hepatitis B- 3 doses. If post vaccination Anti- HBs conc is not≥ 10mIU/ml, course to be repeated.

• Pneumococcal Vaccine- 3 doses

• Yearly Influenza Vaccine.

Immune Deficiency Category

Contraindicated Vaccines

Risk specific recommended vaccines

B lymphocyte (Burton's)

OPV, small pox, LAIV BCG, Live Typhoid YF

Pneumococcal Consider measles and Varicella vaccine

T lymphocyte and combined ( SCID)

OPV, BCG, YF ,Rota virus (other live vaccines appear to be safe)

Pneumococcal

Complement None Pneumococcal Meningococcal

Phagocyte function Live Bacterial vaccines pneumococcal

In which compartment of the fridge each of these should be kept.

1. Water bottle

2. Dial thermometer

3. Ice packs

4. OPV

5. BCG

6. Hepatitis B

7. DPT/TT/

8. Diluents

9. Measles vaccine

10. Varicella

11.Typhoid

12.Hepatitis A

QUESTION- 9

ANSWER-9

COMPARTMENT ITEM NUMBERS TO BE

KEPT IN THIS

COMPARTMENT

MARKS

ALLOTED

Freezer Ice packs , OPV

0.5

1st shelf in main compartment Dial thermometer ,BCG,

Measles, Varicella

0.5x4

2nd and 3rd shelf in main compartment . Hepatitis B , DPT/TT,

Typhoid, Hepatitis A

0.5x4

Vegetable tray Water bottles 0.5

Door nil 1

Total 5

QUESTION-10

1. Identify

2. Mode of action

3. Name the vaccines for which

it is useful.

4. Why should not

freeze sensitive vaccines be

frozen?

Answer-10

1. Freeze watch Indicator.

2. The vial breaks if the temperature where the indicator is located, drops below zero degrees for more than an hour.

3. Useful for freeze sensitive vaccines like- DPT, TT, Td, DT, Hepatitis B.

4. The potency of vaccines is reduced as the antigen is dissociated from the adjuvant and increased chances of adverse reaction like sterile abscess.

QUESTION-11

1. Write true or false

a. Minimum 2 conditioned ice packs should be put in this vaccine

carrier.

b. Vaccine can be stored at -8 to +8 degree cent in this vaccine

carrier.

c. Vaccines returned unused up to five times should be discarded.

d. OPV vaccine can be frozen and thawed up to 10 times if maintained

at proper temperature after thawing.

e. Vaccine can be kept in this carrier up to 1-2 days.

2.

a. Why should you condition the ice pack.

b. What is the proper method of conditioning the ice-pack.

3. Write the steps of properly loading the vaccine carrier.

VACCINE CARRIER

Answer-11 1 a. F (4 conditioned ice packs needed)

b. F ( 2 to 8 degree centigrade)

c. F ( after 3 times return unused, discard)

d. T

f. F ( up to 12 hours)

2.a. Ice packs to be conditioned to prevent damage to freeze sensitive vaccines

b

1

2

3 4

QUESTION- 12

I. Identify

II. Give your comment

on

1.

2.

3.

4.

ANSWER-12

I. VACCINE VIAL MONITOR

II.

Question-13

Arrange the following vaccine according to heat and freezing sensitivity (Most to least)-

DPT DT

OPV JE

BCG

Measles

HepB

TT

ANSWER-13

Question-14

Write the catch up immunization schedule for a 10 year old Adolescent girl.

Answer 14

Vaccine Schedule

Tdap/ Td Tdap at 10 years followed by Td every 10 years

MMR 2 doses at 4- 8 weeks interval

Hepatitis B 3 doses at 0, 1 and 6 months

Typhoid 1 dose every 3 years

Hepatitis A 2 doses at 0 and 6 months

Varicella 2 doses, 3 months apart

HPV 2 doses, 6 months apart

Question -15

Write the immunization schedule for

HIV-infected children

Answer -15 Vaccine Asymptomatic Symptomatic

BCG Yes( at birth) No

DTP Yes ,as per schedule Yes ,as per schedule

Polio OPV/IPV IPV at 6,10, 14 wks,18 mo, 5yrs( if IPV is not affordable, OPV to used

Measles Yes at 9 mo Yes if CD4+count>15%

MMR Yes Yes if CD4+count>15%

Hepatitis B Yes at 0,1,6 mo Yes, double dose, check seroconversion and give regular boosters

Hib Yes yes

QUESTION 16(A)

10 years, Ravi has been bitten by a street dog. 1. Classify the wound. 2. Write the steps of management.

Answer 16 (A)

1.Class III bite

2. Step 1.- thorough cleansing of the wound with soap and flushing

under running water for 10 minutes.

Step 2. irrigation with a virucidal agent such as 70% alcohol or povidone iodine.

Step 3. RIG should be infiltrated in and around the wound (HRIG-20U/Kg, ERIG- 40U/Kg)

Step 4. rabies vaccine post exposure prophylaxis 5 doses-days

0,3,7 ,14 and 28 days.

QUESTION 16(B)

After going through his medical record you see that he has received one course of Rabies vaccine two years back.

How will you manage?

Answer 16(B)

Step 1 and 2 remains the same.

RIG not to be given if an individual has received Rabies Vaccination in the past.

Two doses of Rabies vaccine on day 0 and day 3 to be given.

RABIES- BEWARE!!!

ONLY

PROPHYLAXIS

NO

CURE

Question-17

Define:

1. Vaccine Efficacy

2. Vaccine effectiveness

3. Ro

4. Phase 2 trial

5. Phase3 trial

Answer-17

1. VE = (ARU- ARV/ ARu)×100

2. Vaccine effectiveness = VE+ herd immunity

3. Ro is Basic reproductive rate i.e avg no. of sec cases generated by one primary case in susceptible population.

3. Phase 3 trials are conducted in large no. of healthy human volunteers for assessing vaccine safety & immunogenicity.

4. RCT in large no. of subjects for assessing vaccine safety & immunogenicity

One and a half month old male child Nishanth developed inconsolable cry for

4 hours and fever of 40.5 º C one day after receiving DPT vaccine from a

PHC.

a. Can he receive the second dose of DPT vaccine? (1)

b. Give reasons to substantiate your answer. (1)

c. Will you advice DTaP for the next dose and if so why? (1)

d. What are the absolute contraindications for DPT vaccine? (1)

e. Can DTaP be used if DTwP is contraindicated? (0.5)

f. Is progressive neurological disease a contraindication to DTwP? (0.5)

QUESTION-18

a. Yes b. Inconsolable cry for > 3 hours, fever > 40.5 º C, HHE within 48 hours and seizures with or without fever within 72 hours of DTwP vaccine are

considered as precautions but not contraindications for future doses. c. Yes if parents can afford, as both minor and major side effects are less with DTaP d. Anaphylaxis and encephalopathy within 7 days of DTwP vaccine e. No. Absolute contraindications are same for both f. Progressive neurological illness is a relative contraindication for DTwP.

ANSWER-18

AEFI-Question-19

• Define AEFI

• Classify AEFI

• Categorize the following events

a. Anaphylaxis in a 3 yr boy after influenza vaccine

b. Toxic shock syndrome after measles vaccine.

c. A 10yr girl faints after vaccination

d. A 14 wks infant develops pneumonia after the immunization

e. Sterile abscess at the site of vaccination

f. Hepatitis B after Vaccination

•AEFI is defined as a medical incident that takes

place after an immunization, causes concern, and is

believed to be caused by immunization.

•AEFI is classified as

Vaccine Reaction

Program error

coincidental

Injection

reaction

unknown

AEFI- Answer-19

Answer 19 contd. a. Anaphylaxis in a 3 yr boy after influenza vaccine-

Vaccine reaction

b. Toxic shock syndrome after measles vaccine.- Program error

c. A 10yr girl faints after vaccination- injection reaction

d. A 14 wks infant develops pneumonia after the immunization - coincidental

e. Sterile abscess at the site of BCG vaccination-vaccine reaction

f. Hepatitis B after Vaccination- program error

QUESTION-20

Enumerate the disposal of the following:

1. Needles

2. Plastic part of syringes

3. Wrapper of syringes

4. Empty unbroken vials

5. Broken vials and ampoules

6. Needle caps

Answer-20

1. Needles Hub Cutter, 1% hypochlorite Soln.

1. Plastic part of syringes Red bag

2. Wrapper of syringes Black bag

3. Empty unbroken vials Red bag

4. Broken vials and ampoules : hub cutter or white trnslucent,puncture proof container, 1% hypochlorite soln

5. Needle caps black bag