Vaccination & Immunization Program- Live, Killed & Toxoids Vaccines

💉 Community Health & Pediatric Nursing – NORCET 2025

Vaccination &
Immunisation Program

Complete nursing notes on Live Attenuated, Killed/Inactivated, Toxoid, Subunit & mRNA vaccines — with easy mnemonics, UIP National Schedule (India), Cold Chain management, AEFI, contraindications and high-yield MCQs for NORCET, AIIMS & State Nursing Exams 2025.

🟢 Live Attenuated

🔵 Killed/Inactivated

🔴 Toxoid Vaccines

🗓️ UIP National Schedule

❄️ Cold Chain

❓ 16 MCQs

💡 Introduction to Vaccination & Immunisation

Vaccination is the process of administering a vaccine — a biological preparation — that stimulates the body's immune system to produce immunity against a specific disease without causing the actual disease. Immunisation is the broader process by which an individual becomes protected against an infectious disease, either through vaccination (active) or antibody transfer (passive).

💉

Lives Saved/Year

2–3 Million

By vaccines globally (WHO)

🌍

Eradicated

Smallpox (1980)

First disease eradicated by vaccine

🇮🇳

India UIP Launched

1978

Universal Immunisation Programme

👶

Target Group

0–2 Years

Primary UIP target children

🏥

Herd Immunity

70–95%

Coverage needed (varies by disease)

🏆

Near Eradicated

Polio

Wild polio virus near elimination

🛡️ Types of Immunity – Foundation

Type	Sub-type	Mechanism	Example	Duration
Active Immunity	Natural Active	Body produces antibodies after surviving an infection	Recovering from measles → lifelong immunity	Long-lasting / Lifelong
	Artificial Active	Body produces antibodies after receiving a vaccine	Receiving MMR vaccine	Long-lasting (may need boosters)
Passive Immunity	Natural Passive	Antibodies transferred from mother to baby	IgG crosses placenta; IgA in breast milk (colostrum)	Temporary (3–6 months)
	Artificial Passive	Ready-made antibodies given externally	Anti-tetanus serum (ATS), Anti-rabies serum, HBIG	Very short-lived (weeks)

🧠

Mnemonic – Types of Immunity: "NANA PAIR"

NAtural Active = Natural infection → your own antibodies

NAtural Passive = Mother → Baby (placenta/colostrum)

PAssive Artificial = Ready-made antibodies injected (ATS, HBIG)

IRtificial Active = Vaccine stimulates your own antibody production

👉 Active immunity = YOU make the antibodies (slow onset, long duration). Passive immunity = BORROWED antibodies (immediate onset, short duration)

👥 Herd Immunity (Community Immunity)

Herd immunity occurs when a sufficiently large proportion of a community becomes immune to an infection (through vaccination or prior infection), thereby reducing the likelihood of further spread — even protecting those who are not immune (immunocompromised, too young to vaccinate, etc.).

Disease	Herd Immunity Threshold	Vaccine
Measles	92–95% (highest — very contagious R₀ = 12–18)	MMR / MR / Measles vaccine
Polio	80–85%	OPV / IPV
Smallpox	80–85%	Vaccinia (achieved eradication)
Diphtheria	83–85%	DPT / DT / Td
COVID-19	~70% (estimated)	mRNA, Adenoviral vector

🟢

Live Attenuated Vaccines

Weakened (attenuated) live organism — strongest immune response — closest to natural infection

Live attenuated vaccines contain weakened (attenuated) but living microorganisms that can replicate in the host but do NOT cause disease in immunocompetent individuals. They produce a strong, long-lasting immune response similar to natural infection — stimulating both humoral (antibody) AND cellular immunity.

🧠

Mnemonic – Live Attenuated Vaccines: "BCG & MMR – BOYS Always Vow Zealously"

BCG (Tuberculosis)

OPV – Oral Polio Vaccine (Sabin)

Yellow Fever vaccine

Measles vaccine / MMR

Mumps vaccine

Rubella vaccine

Varicella (Chickenpox) vaccine

Zoster (Herpes Zoster/Shingles) vaccine

Rotavirus vaccine (oral)

Influenza (LAIV – intranasal)

Typhoid (oral Ty21a)

Easy remember: "BCG MMR VZR OT" → BCG, MMR, Varicella, Zoster, Rotavirus, OPV, Typhoid (oral)

🟢

Live Attenuated – Key Properties

Strongest immune response

Weakened live organism

Organism	Live but weakened (attenuated) — cannot cause disease
Replication	YES — replicates in host (like natural infection)
Immunity Type	Both humoral (B cells/antibodies) AND cellular (T cells)
Doses needed	Usually 1 dose sufficient (powerful response)
Adjuvant needed?	No — replication itself provides adequate stimulation
Duration	Long-lasting / lifelong (often)
Stability	Heat sensitive — requires cold chain strictly
Storage	2–8°C (some require freezing: OPV at −20°C)

🟢 ADVANTAGE: Best immune response. DISADVANTAGE: Risk of reversion to virulence (rare) — risk in immunocompromised patients. CONTRAINDICATED in pregnancy & immunocompromised!

🚨

Critical Contraindications for ALL Live Vaccines: (1) Pregnancy — risk of fetal infection. (2) Immunocompromised patients (HIV, on immunosuppressants, chemotherapy, steroids >2 weeks, congenital immunodeficiency). (3) Severe febrile illness (defer until recovered). Exception: BCG is given even in HIV-exposed infants unless symptomatic HIV.

BCG Vaccine

Bacillus Calmette-Guérin (TB vaccine)

Live Attenuated | Intradermal

Protects against	Tuberculosis (miliary TB, TB meningitis in children)
Type	Live attenuated Mycobacterium bovis
Route	Intradermal (ID) — LEFT upper arm (deltoid region)
Dose	0.05 mL (birth) | 0.1 mL (after 1 month)
When given	At BIRTH (as early as possible, within first week)
Storage	2–8°C (NOT frozen)
Reaction	Indurated nodule → ulceration → scar (normal reaction, takes 6–12 weeks)
Scar significance	Scar = evidence of successful vaccination
Test association	Mantoux test (PPD) turns positive after BCG — use IGRA for diagnosis

OPV (Sabin Vaccine)

Oral Polio Vaccine

Live Attenuated | Oral drops

Protects against	Poliomyelitis (all 3 serotypes)
Type	Live attenuated poliovirus (Sabin)
Route	Oral — 2 drops in mouth
Doses	Birth + 6, 10, 14 weeks + boosters
Storage	−20°C (freezer) — MOST FREEZE-SENSITIVE
Advantage	Intestinal immunity (IgA), herd immunity, easy to administer
Disadvantage	VAPP (Vaccine-Associated Paralytic Polio) — 1 in 2.7 million doses
IPV	Inactivated Polio Vaccine (killed) — given IM, no VAPP risk, added to UIP

MMR Vaccine

Measles-Mumps-Rubella

Live Attenuated | Subcutaneous

Protects against	Measles, Mumps, Rubella (German Measles)
Type	Live attenuated (all 3 components)
Route	Subcutaneous (SC) — upper arm
Schedule (India)	MR vaccine at 9 months & 16–24 months (India UIP); MMR in private practice
Storage	2–8°C (protected from light)
Contraindication	Pregnancy (teratogenic), immunocompromised, egg allergy (severe)
Rubella importance	Prevents Congenital Rubella Syndrome (CRS) in babies
Note	No proven link to autism (multiple large studies confirmed safety)

Rotavirus Vaccine

Rotarix / RotaTeq / ROTAVAC

Live Attenuated | Oral

Protects against	Severe rotavirus gastroenteritis (diarrhoea) — leading childhood killer
Type	Live attenuated oral vaccine
Route	Oral drops
Schedule	6, 10, 14 weeks (India UIP — ROTAVAC 116E)
Contraindication	Severe immunodeficiency; history of intussusception
India vaccine	ROTAVAC (indigenously developed by Bharat Biotech) — introduced in UIP 2016
Efficacy	~53% against severe rotavirus diarrhoea in India

Yellow Fever Vaccine

17D strain vaccine

Live Attenuated | Subcutaneous

Protects against	Yellow Fever (Flavivirus)
Type	Live attenuated 17D strain of yellow fever virus
Route	Subcutaneous (SC)
Single dose	One dose = lifelong protection (WHO revised from 10-yearly booster)
Certificate	International Certificate of Vaccination (ICV) required for travel to endemic areas
Valid from	10 days after vaccination (previously 10 years but now LIFELONG per WHO)
Contraindication	Infants <6 months, pregnancy, immunocompromised, severe egg allergy, thymus disease

Varicella & Zoster Vaccines

Chickenpox & Shingles vaccines

Live Attenuated | Subcutaneous

Varicella vaccine	Prevents chickenpox (VZV) — 2 doses (12–15 months, 4–6 years)
Zoster vaccine (Zostavax)	Live — prevents shingles reactivation in adults >50 years
Shingrix	Recombinant (non-live) zoster vaccine — preferred over Zostavax (more effective)
Route	Subcutaneous (SC)
Contraindication	Pregnancy, severe immunosuppression, neomycin allergy

🔵

Killed / Inactivated Vaccines

Dead microorganism — safer but weaker immune response — multiple doses needed — adjuvants used

Killed/inactivated vaccines contain whole microorganisms that have been killed (inactivated) by heat, chemical (formaldehyde), or radiation. They CANNOT replicate in the host → weaker immune response → require multiple doses and adjuvants to achieve adequate immunity. SAFER — no risk of disease from vaccine.

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Mnemonic – Killed/Inactivated Vaccines: "PIT RICH"

Pertusis (whole cell — in DPT)

IPV – Inactivated Polio Vaccine (Salk)

Typhoid (TAB vaccine, Vi polysaccharide IM)

Rabies vaccine (HDCV, PCECV)

Influenza (whole virion killed)

Cholera vaccine (killed whole cell)

Hepatitis A vaccine (killed HAV)

Also: Plague vaccine, Japanese Encephalitis (killed), Q-fever vaccine

🔵

Killed Vaccines – Key Properties

Inactivated organisms

Dead microorganism

Organism	Dead (killed by heat, chemicals, radiation)
Replication	NO — cannot replicate in host
Immunity Type	Mainly humoral (antibody-mediated) — weaker cellular immunity
Doses needed	Multiple doses required (primary + boosters)
Adjuvant needed?	YES — needed to enhance immune response (aluminium salts)
Duration	Shorter — requires boosters
Safety	Safer — no risk of reversion to virulence
Storage	2–8°C (should NOT be frozen — freezing damages killed vaccines)

🔵 ADVANTAGE: Safe in immunocompromised & pregnancy (most). DISADVANTAGE: Weaker, shorter immunity. Multiple doses + boosters needed. Adjuvant required. Freeze damage risk!

⚠️

Freeze-Sensitive Vaccines (MUST NOT BE FROZEN): DPT, DT, TT, Hepatitis B, Hib, Pentavalent, IPV, Typhoid Vi, Rabies, Meningococcal, Pneumococcal. Freezing causes loss of potency — use Freeze Indicator Cards (FIC) / Shake Test to detect freeze damage. These are stored at 2–8°C ONLY.

IPV (Salk Vaccine)

Inactivated Polio Vaccine

Killed | IM injection

Type	Formalin-inactivated poliovirus (all 3 types)
Route	Intramuscular (IM) or Subcutaneous
Advantage	No VAPP risk; safe in immunocompromised
Disadvantage	No intestinal (mucosal) immunity unlike OPV; expensive; requires injection
UIP India	IPV added to Indian UIP — given fractional dose (0.1 mL ID) at 6 & 14 weeks
Storage	2–8°C — freeze sensitive

Hepatitis A Vaccine

HAV (Killed)

Killed | IM injection

Type	Formalin-inactivated Hepatitis A virus
Route	Intramuscular (IM)
Schedule	2 doses: primary + booster 6–12 months later
Safe in	Immunocompromised, pregnancy (no live virus)
Indication	Travellers to endemic areas, food handlers, children in endemic regions
Storage	2–8°C — freeze sensitive

Rabies Vaccine

HDCV / PCECV / PVRV

Killed | IM injection

Types	HDCV (Human Diploid Cell Vaccine), PCECV, PVRV (Vero cell)
Route	Intramuscular (IM) — deltoid (NOT gluteal — poor response)
Pre-exposure	Days 0, 7, 21/28 (3 doses)
Post-exposure	Days 0, 3, 7, 14 (Essen regimen) — 4 doses with RIG on Day 0
RIG (Rabies Immunoglobulin)	HRIG or ERIG — given on Day 0 with first dose, infiltrated around wound
Wound care	Thorough washing with soap and water for 15 minutes = FIRST action after animal bite

Influenza Vaccine

Flu vaccine (killed)

Killed (TIV/QIV) | IM

Types	TIV (Trivalent) or QIV (Quadrivalent) — killed whole virus
Route	Intramuscular (IM); LAIV (live) = intranasal spray
Frequency	ANNUAL vaccination — virus mutates (antigenic drift)
Recommended for	Elderly (>65), healthcare workers, chronic disease patients, pregnant women, children 6m–5yrs
Contraindication	Severe egg allergy (contains egg proteins); LAIV contraindicated in immunocompromised

Cholera Vaccine

Oral / Parenteral

Killed whole cell

Types	Oral (WC/rBS) — preferred. Parenteral (heat-killed — old, less used)
Efficacy	~50–60% for 3–5 years (oral vaccine)
Indication	Travellers to endemic areas; outbreak control; endemic populations
Key fact	NOT included in routine UIP India; used in outbreak settings

Typhoid Vaccines

TAB / Vi polysaccharide / Ty21a (oral)

Killed + Subunit + Live

TAB Vaccine	Killed (Heat/phenol inactivated S. Typhi + S. Paratyphi) — old, not recommended now
Vi Polysaccharide	Subunit — capsular polysaccharide; IM; 1 dose; 2 years duration; NOT <2 years
Ty21a (Oral)	Live attenuated; oral capsules; 3–4 doses every other day; NOT <6 years; 5 years protection
Vi Conjugate	Newer; effective from 6 months; used in TCV (Typhoid Conjugate Vaccine) in India's UIP
India UIP	TCV (Typhoid Conjugate Vaccine) introduced — for infants from 9 months

🔴

Toxoid Vaccines

Inactivated bacterial TOXIN — immunity against the toxin, not the organism itself

Toxoid vaccines are prepared from bacterial exotoxins that have been chemically inactivated (usually with formaldehyde) to remove toxicity while retaining their immunogenicity (ability to stimulate immune response). The immune system makes antibodies against the toxin (antitoxin) — not against the bacteria itself. These are very stable and safe vaccines.

🧠

Mnemonic – Toxoid Vaccines: "DT & TT — Double TroublE makes Toxoid Two"

Diphtheria Toxoid (component of DPT, DT, Td)

Tetanus Toxoid (TT, Td, DPT) — MOST IMPORTANT

👉 Only Diphtheria and Tetanus are currently covered by toxoid vaccines. Clostridium perfringens and Botulinum toxoids also exist but not in routine UIP.

Adjuvant used: Alum (Aluminium Hydroxide) — adsorbs toxoid, prolongs immune stimulation = "Adsorbed" vaccines (APT, ADSORBATE)

🔴

Toxoid Vaccines – Key Properties

Inactivated bacterial toxin

Modified toxin (inactivated)

Preparation	Toxin treated with formaldehyde → toxoid (no toxicity, retains antigenicity)
Immunity	Antitoxin antibodies — NOT against the bacteria itself
Organism killed?	N/A — no organism — just the toxin (modified)
Adjuvant	Aluminium hydroxide (alum) — enhances immune response
Safety	Extremely safe — no living or dead organism
Doses	Multiple doses + boosters (primary series + maintenance)
Storage	2–8°C — freeze sensitive (aluminium salt damaged by freezing)

🔴 Toxoid = "Anatoxin" in French. Formaldehyde treatment inactivates toxicity but preserves immunogenicity. Alum adjuvant = "depot effect" — slow release = prolonged immune stimulation.

Tetanus Toxoid (TT)

Tetanus Toxoid Vaccine

Toxoid | IM injection

Protects against	Tetanus (Clostridium tetani toxin)
Preparation	Tetanospasmin toxin + formaldehyde = Tetanus Toxoid
Route	Intramuscular (IM) — deltoid or anterolateral thigh
Pregnancy TT schedule	TT1: Early pregnancy (1st contact) | TT2: 4 weeks after TT1 | Booster: if previous TT within 3 years
Primary immunisation	3 doses (as DPT at 6, 10, 14 weeks) + boosters at 16–24 months, 5 years, 10 years, 16 years
Neonatal tetanus prevention	2 doses TT to mother >4 weeks apart → infant protected at birth
Post-exposure	Clean wound + immunised: no action. Tetanus-prone wound + unimmunised: TT + TIG (Tetanus Immune Globulin)
TIG (Tetanus Immunoglobulin)	Passive immunity — 500 IU IM; given with TT (different sites) for contaminated wounds in unimmunised

DPT Vaccine

Diphtheria-Pertussis-Tetanus

Combined: Toxoid + Killed | IM

Components	D = Diphtheria Toxoid | P = Killed Bordetella pertussis (whole cell) | T = Tetanus Toxoid
Type	D & T = Toxoid | P = Killed organism (whole cell)
Route	Intramuscular (IM) — anterolateral thigh (<2 yrs) or deltoid (>2 yrs)
Schedule	Primary: 6, 10, 14 weeks | Booster 1: 16–24 months | Booster 2: 5 years
Upper age limit	DPT not given after age 7 (use Td — adult formulation with low D)
Side effects	Fever, local pain/swelling (from P component), rarely high-pitched cry, febrile seizure, HHE
Acellular pertussis (DTaP)	Purified pertussis proteins — fewer side effects; used in developed countries
Storage	2–8°C — NEVER freeze (freeze destroys it)

Pentavalent Vaccine

DPT + Hep B + Hib (5-in-1)

Combination Vaccine | IM

Components	DPT (Diphtheria + Pertussis + Tetanus) + Hepatitis B + Hib (Haemophilus influenzae type b)
Schedule	6, 10, 14 weeks (India UIP) — replaced separate DPT + Hep B
Route	Intramuscular (IM) — anterolateral thigh
Introduced in India	2011 (phased introduction in UIP)
Advantages	Fewer injections, reduces vaccine fatigue, same immunogenicity
Storage	2–8°C — freeze sensitive

Td / dT Vaccine

Adult Tetanus-Diphtheria (low-dose D)

Toxoid | Adults & Boosters

Use	Booster for adults/adolescents >7 years; pregnancy TT booster
Difference from DT	Low-dose diphtheria (d) — reduces local reactions in older patients
Schedule	Every 10 years for tetanus boosters in adults; Tdap once (includes acellular pertussis)
Pregnancy	Td/TT given in pregnancy to prevent maternal and neonatal tetanus

🟣

Subunit, Conjugate, Recombinant & mRNA Vaccines

Modern vaccine technology — use parts of the pathogen or genetic instructions

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Mnemonic – Subunit/Recombinant Vaccines: "HiPP HMR"

Hepatitis B (recombinant)

iHPV – Human Papillomavirus (VLP)

Pneumococcal (PCV – conjugate)

Pertussis acellular (DTaP – subunit)

Hib conjugate

Meningococcal (conjugate)

Recombinant Zoster vaccine (Shingrix)

🧬

Hepatitis B Vaccine

Recombinant DNA vaccine

Recombinant Subunit – HBsAg

Type	Recombinant HBsAg (Surface Antigen) produced in yeast (Saccharomyces cerevisiae)
Route	Intramuscular (IM) — deltoid (adults); anterolateral thigh (infants)
Schedule (UIP)	Birth (within 24 hours) + 6, 10, 14 weeks (as Pentavalent)
Birth dose	Single component Hep B within 24 hours of birth — prevents vertical transmission
Response check	Anti-HBs titre after 3 doses — >10 mIU/mL = protective
Non-responders	Repeat 3-dose series; if still no response = permanent non-responder (rare)
Storage	2–8°C — NEVER freeze

🧬 Hep B birth dose within 24 hours prevents 70–95% of mother-to-child transmission! HBIG (Hepatitis B Immunoglobulin) given WITH Hep B vaccine to HBsAg-positive mother's infant for passive + active protection.

🌸

HPV Vaccine

Virus-Like Particles (VLP)

Recombinant VLP – Cervical Cancer Prevention

Type	Virus-Like Particles (VLP) — recombinant capsid proteins; NO viral DNA
Vaccines	Cervarix (bivalent: HPV 16,18), Gardasil (quadrivalent: 6,11,16,18), Gardasil 9 (9-valent)
Route	Intramuscular (IM)
Target age	Girls 9–14 years (before sexual debut — optimal); India UIP: Class 6 girls (9–14 yrs)
Schedule (<15 yrs)	2 doses: 0 and 6 months
Schedule (≥15 yrs or immunocompromised)	3 doses: 0, 1–2, 6 months
India UIP	Cervavac (indigenously developed quadrivalent HPV vaccine) added to UIP 2023 for girls 9–14 yrs

🌸 HPV 16 & 18 = cause 70% of cervical cancers. HPV 6 & 11 = cause genital warts. Best given BEFORE sexual debut — does NOT treat existing HPV infection. CERVAVAC = India's indigenous HPV vaccine!

🫁

Pneumococcal Vaccines

PCV (Conjugate) & PPSV (Polysaccharide)

Conjugate / Polysaccharide

PCV (Pneumococcal Conjugate)	PCV10, PCV13, PCV15, PCV20 — conjugated to carrier protein → T-cell dependent — effective in infants
PPSV23	23-valent polysaccharide — T-cell INDEPENDENT — NOT effective <2 years; adults & elderly
India UIP	PCV introduced in UIP (select states) — 6, 14 weeks + booster at 9 months
Target	Children <5 yrs, Elderly >65, Immunocompromised (PCV preferred)
Route	Intramuscular (IM)

🫁 Conjugate vaccines (PCV) = polysaccharide LINKED to protein carrier → converts T-cell independent response to T-cell dependent → effective in infants under 2 years!

🧬

mRNA Vaccines

COVID-19 vaccines – Modern technology

mRNA technology – NEW generation

Examples	Pfizer-BioNTech (Comirnaty), Moderna (Spikevax) — COVID-19
Mechanism	mRNA encodes for spike protein of virus → body's cells produce spike protein → immune response
Does NOT	Does NOT enter cell nucleus; does NOT alter DNA; mRNA degraded after few days
Advantages	Rapid development, can be modified quickly for variants, highly effective
Storage	Ultra-cold (-70°C for Pfizer original; -20°C for Moderna); newer formulations need only 2–8°C
India COVID vaccines	Covishield (ChAdOx1 — adenoviral vector), Covaxin (killed whole virion — BBV152), mRNA coming

🧬 mRNA vaccines represent a REVOLUTION in vaccinology. Covaxin (India's indigenous killed vaccine by Bharat Biotech) was the world's first whole-virion inactivated COVID-19 vaccine approved.

📊 Vaccine Types – Master Comparison Table

🚨

MOST HIGH-YIELD for NORCET! Know whether each vaccine is live, killed, or toxoid — and its key properties. This comparison is tested in almost every nursing exam.

Property	🟢 Live Attenuated	🔵 Killed/Inactivated	🔴 Toxoid
Content	Weakened live organism	Dead organism (killed)	Inactivated toxin (formaldehyde)
Replication in host	Yes	No	No organism — toxin only
Immune response	Strongest — humoral + cellular	Mainly humoral	Antitoxin antibodies
Doses needed	Usually 1	Multiple (2–4+)	Multiple + boosters
Adjuvant needed	No	Yes (alum)	Yes (alum)
Duration of immunity	Long / Lifelong	Shorter — needs boosters	Shorter — needs boosters
Risk of disease	Very rare (reversion) — VAPP in OPV	No risk	No risk
Safe in immunocompromised?	⚠️ NO (avoid)	✅ YES	✅ YES
Safe in pregnancy?	⚠️ Generally NO	✅ Most yes (IPV, Hep A, flu)	✅ YES (TT mandatory in pregnancy)
Storage / Stability	Heat sensitive — strict cold chain	Freeze sensitive — 2–8°C only	Freeze sensitive — 2–8°C only
Examples	BCG, OPV, MMR, Varicella, Yellow Fever, Rotavirus, Influenza (LAIV)	IPV, DPT (P component), Hep A, Rabies, Influenza (killed), Typhoid (Vi), Cholera	Tetanus Toxoid, Diphtheria Toxoid (DT, DPT-D, Td)

🗓️

Universal Immunisation Programme (UIP) – India

National schedule — all vaccines, ages, routes, doses at a glance

The Universal Immunisation Programme (UIP) was launched in India in 1978 (initially as EPI — Expanded Programme on Immunisation, then UIP from 1985). India's UIP is one of the LARGEST immunisation programmes in the world, covering 12 vaccine-preventable diseases with newer additions ongoing.

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Mnemonic – UIP India Diseases Covered: "PPDD MMT HCHH"

Polio

Pertusis (Whooping cough)

Diphtheria

Diarrhoea (Rotavirus)

Measles / Rubella (MR)

Meningitis (Hib — via Pentavalent)

Tetanus (Neonatal + Maternal)

Hepatitis B

Cervical Cancer (HPV — Cervavac)

Hib (Pneumonia/Meningitis)

Human Papillomavirus

Typhoid (TCV)

Age	Vaccine	Route	Site	Dose
Birth	BCG + OPV 0 + Hepatitis B (birth dose)	ID + Oral + IM	Left upper arm + Mouth + Anterolateral thigh	0.05 mL + 2 drops + 0.5 mL
6 Weeks	OPV 1 + Pentavalent 1 + Rotavirus 1 + IPV 1 (fIPV — fractional)	Oral + IM + Oral + ID	Mouth + Thigh + Mouth + Right upper arm	Standard doses
10 Weeks	OPV 2 + Pentavalent 2 + Rotavirus 2	Oral + IM + Oral	Mouth + Thigh + Mouth	Standard doses
14 Weeks	OPV 3 + Pentavalent 3 + Rotavirus 3 + IPV 2 (fIPV)	Oral + IM + Oral + ID	Mouth + Thigh + Mouth + Right upper arm	Standard doses
9 Months	MR 1 + Vitamin A 1 (1 lakh IU) + PCV Booster	SC + Oral + IM	Right upper arm + Mouth + Thigh	0.5 mL + 1 mL + 0.5 mL
9–12 Months	Typhoid Conjugate Vaccine (TCV)	IM	Anterolateral thigh	0.5 mL
16–24 Months	MR 2 + OPV Booster + DPT Booster 1 + Vitamin A 2 (2 lakh IU)	SC + Oral + IM + Oral	Right arm + Mouth + Left thigh + Mouth	0.5 mL each
5 Years	DPT Booster 2 + OPV Booster	IM + Oral	Left upper arm + Mouth	0.5 mL + 2 drops
9–14 Years (Girls)	HPV (Cervavac) — 2 doses (0 and 6 months)	IM	Upper arm	0.5 mL
10 & 16 Years	TT (Tetanus Toxoid)	IM	Upper arm	0.5 mL
Pregnancy	TT1 (early) + TT2 (4 wks after TT1) / Booster if <3 yrs since last TT	IM	Upper arm	0.5 mL each

❄️

Cold Chain in Immunisation

System to maintain vaccine potency from manufacturer to patient — temperature critical

The Cold Chain is a system of storing and transporting vaccines at recommended temperatures (between +2°C and +8°C for most vaccines, −20°C for OPV) from the point of manufacture to the point of administration. Breaking the cold chain renders vaccines ineffective.

🥶

−20°C

Deep Freezer (DF)

OPV (Oral Polio Vaccine) stored here. Regional vaccine store level. Also used for ice pack conditioning.

🧊

+2 to +8°C

ILR (Ice-Lined Refrigerator)

Most vaccines stored here at PHC/CHC level. Maintains temperature even during power cuts (12–24 hrs). BCG, MMR, DPT, Hep B, Pentavalent.

📦

+2 to +8°C

Cold Box / Vaccine Carrier

Used for transporting vaccines from PHC to outreach/session sites. Maintains temperature for 12–24 hrs with ice packs.

🔷

Frozen solid

Ice Packs / Cold Packs

Filled with water, frozen at −20°C. Used in vaccine carriers and cold boxes. Conditioned before use (to prevent freeze damage to freeze-sensitive vaccines).

🌡️ Vaccine Vial Monitors (VVM) & Cold Chain Indicators

Indicator	Purpose	How It Works	Action
VVM (Vaccine Vial Monitor)	Detect heat exposure (cumulative heat damage)	Square inside circle on vial label. If inner square is LIGHTER than outer circle = OK. If DARKER or SAME = discard	VVM dark = DISCARD vaccine
FIC (Freeze Indicator Card)	Detect freezing of freeze-sensitive vaccines	Changes colour if vaccine has been frozen; cannot be reversed	FIC triggered = SHAKE TEST → if clumps remain = discard
Shake Test	Detect freeze damage in adsorbed vaccines (DPT, DT, TT, Hep B)	Shake suspect vial and control vial, set aside 30 min — if flocculates settle in suspect (vs milky in control) = freeze-damaged	Positive shake test = DISCARD
Cold Chain Thermometer	Monitor refrigerator temperature twice daily	Record morning and afternoon temperatures in vaccine temperature log	Out of range = report immediately

🧠

Cold Chain Rule: "OPV FREEZES — Others 2 to 8"

OPV = Store at −20°C (freeze)

BCG = 2–8°C (can tolerate mild freezing)

MMR / Varicella = 2–8°C (light sensitive)

DPT / DT / TT / Hep B / Pentavalent / IPV = 2–8°C only (NEVER freeze)

👉 FREEZE-SENSITIVE vaccines (DPT, DT, TT, Hep B, Pentavalent, IPV, Typhoid Vi) must NEVER be frozen — aluminium salt (alum) adjuvant clumps irreversibly!

⚠️ AEFI – Adverse Events Following Immunisation

AEFI (Adverse Event Following Immunisation) is any untoward medical occurrence which follows immunisation and does not necessarily have a causal relationship with the vaccine. Classification: vaccine-related, programme-related, coincidental, or unknown.

AEFI Type	Description	Examples	Management
Minor (Local reactions)	Most common; expected; self-limiting	Pain, redness, swelling at injection site; mild fever; irritability	Paracetamol for fever; cold compress; reassure parents
BCG Reactions	Normal localised reaction	Induration → ulceration → scar (normal). BCG abscess if deep injection. Keloid in susceptible	Normal scar = no action. Abscess = cold compress; refer if large
Febrile Seizure	Due to fever, usually 6–12 hrs after DPT	Convulsion with fever after DPT/MMR	Antipyretic premedication; manage seizure; usually benign; acellular DTaP for future
Anaphylaxis	Severe immediate hypersensitivity — rare but serious	Within 15–30 min: urticaria, bronchospasm, hypotension, collapse	Adrenaline (Epinephrine) 0.01 mg/kg IM thigh = FIRST action; O₂; IV fluids; observe 30 min post-vaccination
VAPP	Vaccine-Associated Paralytic Polio from OPV	Rare (1 in 2.7 million doses); paralysis similar to wild polio	IPV now added to UIP to reduce risk; supportive care; report
HHE	Hypotonic Hyporesponsive Episode — DPT related	Baby goes limp, pale, unresponsive for minutes after DPT; recovers fully	Usually self-limiting; reassure parents; acellular pertussis for next dose
Persistent Crying	>3 hours high-pitched cry after DPT — P component	Inconsolable high-pitched cry for >3 hours within 48 hrs of DPT	Usually benign; paracetamol; substitute acellular pertussis
Programme Error	Wrong dose, wrong route, wrong site, wrong vaccine	BCG given SC instead of ID; overdose; contaminated vaccine	Report; manage specific complication; prevent recurrence

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ANAPHYLAXIS after vaccination — First Action: Epinephrine (Adrenaline) 1:1000 → 0.01 mg/kg IM into outer thigh. ALWAYS observe patients for 30 minutes after vaccination at the facility before allowing them to leave. Keep emergency kit (adrenaline, antihistamine, IV fluids) at every vaccination site!

🚫 Vaccine Contraindications

Vaccine	True Contraindication	False Contraindication (Common Myths)
ALL Vaccines	Anaphylaxis to previous dose or vaccine component	Mild illness (cold, mild fever), Breastfeeding, Premature birth, Stable chronic disease
ALL Live Vaccines (BCG, OPV, MMR, Varicella, Yellow Fever)	Pregnancy, Severe immunodeficiency (HIV symptomatic, chemotherapy, high-dose steroids)	HIV-exposed but asymptomatic infant (BCG & OPV STILL given), Mild illness
DPT / Pertussis-containing	Encephalopathy within 7 days of previous DPT dose	Fever after previous dose (not contraindication), Family history of seizures, Stable neurological condition
MMR	Severe egg allergy (risk of anaphylaxis), Pregnancy, Immunocompromised	Mild egg allergy (MMR safe in most), Family history of autism (NO scientific basis)
Yellow Fever	Infants <6 months, Pregnancy, Immunocompromised, Thymus disease, Severe egg allergy	Breastfeeding (YF can be given), HIV-positive with CD4 >200
Influenza (egg-based)	Anaphylaxis to eggs (not just allergy)	Mild egg allergy (can give with monitoring); egg-free alternatives available

👩‍⚕️ Nursing Responsibilities in Immunisation

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Pre-Vaccination Assessment

• Check immunisation history and due vaccines
• Assess for contraindications (current illness, allergy history, immunocompromised)
• Take consent from parent/guardian
• Check VVM on vaccine vials before use
• Verify vaccine not expired, proper storage maintained
• Weigh child — dose depends on weight (some vaccines)
• Check 5 Rights of administration: Right vaccine, Right dose, Right route, Right site, Right patient

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Vaccine Preparation & Administration

• Use proper aseptic technique throughout
• Reconstitute freeze-dried vaccines (BCG, MMR, Varicella) just before use
• BCG: strictly INTRADERMAL (10–15°) — LEFT arm; wheal must form
• OPV: 2 drops orally; do NOT touch dropper to mouth
• IM vaccines: anterolateral thigh (<2 yrs), deltoid (>2 yrs)
• Never recap needles; dispose in puncture-proof sharps container
• Multiple injections: different sites/limbs; do not mix in same syringe

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Post-Vaccination Monitoring

• Observe child/patient for 30 minutes after vaccination — anaphylaxis watch
• Keep emergency kit ready: Adrenaline, Antihistamine, IV fluids, O₂
• Advise paracetamol for mild fever/pain at site
• Explain normal reactions: BCG scar, mild fever, soreness at site
• Advise when to return to hospital: high fever, convulsions, anaphylaxis signs
• Record in immunisation card & register immediately

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Cold Chain Management

• Check refrigerator temperature twice daily (morning & evening) — record in log
• Check VVM on each vial before use
• Open multi-dose vials last to prevent wastage
• Discard opened vials at end of session (BCG, MMR within 4 hours)
• Check shake test if freeze damage suspected
• Never put vaccines in freezer compartment of domestic fridge
• Report cold chain breaks immediately

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Parent/Community Education

• Importance of completing the vaccination schedule
• Common, expected side effects — fever, soreness
• BCG scar is normal and expected
• Debunk myths: vaccines do NOT cause autism, infertility, or other false claims
• Bring immunisation card to every visit
• Missed vaccines can be given later (no need to restart)
• Vaccines free of cost under UIP India

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Documentation & Reporting

• Record in child's immunisation card (MCP card — Mother & Child Protection card)
• Enter in facility immunisation register
• Report any AEFI on AEFI reporting form within 24–48 hours
• Maintain vaccine stock register — IN and OUT records
• Calculate dropout rates and immunisation coverage
• Report adverse events to district immunisation officer

📝 High-Yield MCQs – Vaccination (NORCET 2025)

Q1. BCG vaccine is an example of which type of vaccine?

• A) Killed vaccine
• B) Toxoid vaccine
• C) Live attenuated vaccine
• D) Subunit vaccine

💡 Tip: BCG = Live attenuated Mycobacterium bovis. Given by INTRADERMAL route in the LEFT upper arm at birth. Dose: 0.05 mL (birth) / 0.1 mL (after 1 month). Formation of scar = successful vaccination. Normal reaction: nodule → ulceration → scar over 6–12 weeks.

Q2. Which of the following vaccines should be stored at −20°C (FREEZER)?

• A) DPT
• B) Hepatitis B
• C) OPV (Oral Polio Vaccine)
• D) BCG

💡 Tip: OPV (Sabin live vaccine) = stored at −20°C. All others (BCG, DPT, Hep B, MMR, Pentavalent, IPV) stored at 2–8°C. DPT, DT, TT, Hep B, Pentavalent, IPV = FREEZE SENSITIVE (never put in freezer — alum salt clumps). Rule: "OPV FREEZES — Others 2 to 8!"

Q3. Tetanus Toxoid is an example of which type of vaccine?

• A) Live attenuated
• B) Killed whole cell
• C) Toxoid (inactivated toxin)
• D) Recombinant subunit

💡 Tip: Toxoid = Bacterial exotoxin inactivated with formaldehyde (removes toxicity, preserves immunogenicity). ONLY two toxoid vaccines: Tetanus Toxoid and Diphtheria Toxoid. Alum (aluminium hydroxide) = adjuvant used in toxoids. FREEZE SENSITIVE. Given IM. Pregnancy schedule: TT1 + TT2 (4 weeks apart).

Q4. A vaccine Vial Monitor (VVM) on a vaccine vial shows the inner square DARKER than the outer circle. The nurse should?

• A) Use the vaccine — normal appearance
• B) Shake the vial and then use it
• C) DISCARD the vaccine — VVM indicates heat damage (potency lost)
• D) Refrigerate it immediately and use within 24 hours

💡 Tip: VVM Rule: Inner square LIGHTER than outer circle = OK to use. Inner square SAME as or DARKER than outer circle = DISCARD (heat damage has occurred). VVM detects CUMULATIVE HEAT exposure. FIC (Freeze Indicator Card) detects FREEZING of freeze-sensitive vaccines.

Q5. The DPT vaccine contains which component that is a TOXOID?

• A) Pertussis component (P)
• B) Pertussis + Diphtheria
• C) Diphtheria (D) and Tetanus (T) components — both are toxoids
• D) All three (D, P, T) are toxoids

💡 Tip: DPT: D = Diphtheria TOXOID | P = KILLED whole-cell Bordetella pertussis organism | T = Tetanus TOXOID. So DPT is a COMBINATION: 2 toxoids + 1 killed vaccine. Pertussis (P) is NOT a toxoid — it's a killed whole-cell bacterium (causing most side effects of DPT).

Q6. Live attenuated vaccines are CONTRAINDICATED in which patient group?

• A) Children with mild cold or fever
• B) Premature infants
• C) Immunocompromised patients and pregnant women
• D) Children who are breastfed

💡 Tip: Live vaccines (BCG, OPV, MMR, Varicella, Yellow Fever) are CONTRAINDICATED in: (1) Immunocompromised (HIV symptomatic, on chemo/immunosuppressants, severe immune deficiency) and (2) Pregnancy (risk of fetal infection). Mild illness, breastfeeding, prematurity = FALSE contraindications — vaccinate!

Q7. Which vaccine is the MOST freeze-sensitive and should NEVER be frozen?

• A) BCG
• B) OPV
• C) DPT, Hepatitis B, TT (Adsorbed/alum vaccines)
• D) MMR

💡 Tip: Alum-adsorbed (adsorbed) vaccines (DPT, DT, TT, Hep B, Pentavalent, IPV) are MOST FREEZE SENSITIVE — freezing causes irreversible clumping of aluminium hydroxide. Use Shake Test to detect freeze damage. OPV = stored frozen at -20°C (it's intentionally frozen). BCG can tolerate mild freezing.

Q8. The FIRST IMMEDIATE action after a child develops anaphylaxis following vaccination is?

• A) IV Chlorpheniramine (antihistamine)
• B) IV Hydrocortisone
• C) Epinephrine (Adrenaline) 1:1000 — 0.01 mg/kg IM into outer thigh
• D) Oxygen by face mask

💡 Tip: Anaphylaxis management: FIRST = Adrenaline (Epinephrine) 1:1000 → 0.01 mg/kg IM outer thigh. This is the PRIORITY over antihistamines, steroids, or oxygen. Always observe patients for 30 minutes post-vaccination. Keep emergency kit at every vaccination site.

Q9. The Oral Polio Vaccine (OPV) is associated with which rare but serious AEFI?

• A) Intussusception
• B) Encephalitis
• C) VAPP (Vaccine-Associated Paralytic Polio)
• D) Stevens-Johnson Syndrome

💡 Tip: OPV = live vaccine → rare reversion to virulence → VAPP (1 in 2.7 million doses). This is why IPV (killed, no VAPP risk) has been added to UIP India. Rotavirus vaccine is associated with intussusception (rare). MMR can rarely cause febrile seizures (not encephalitis).

Q10. Hepatitis B vaccine belongs to which category of vaccines?

• A) Live attenuated
• B) Killed whole virus
• C) Recombinant subunit (HBsAg produced in yeast)
• D) Toxoid

💡 Tip: Hep B vaccine = recombinant DNA technology — HBsAg (surface antigen) produced in Saccharomyces cerevisiae (baker's yeast). NOT a live or killed vaccine. Given at birth + 6, 10, 14 weeks in India UIP. Birth dose within 24 hours = prevents 70–95% vertical transmission. Anti-HBs >10 mIU/mL = protective.

Q11. Yellow Fever Vaccine International Certificate is valid from when after vaccination?

• A) Immediately after vaccination
• B) 7 days after vaccination
• C) 10 days after vaccination (and now considered LIFELONG — no re-vaccination needed)
• D) 30 days after vaccination

💡 Tip: Yellow Fever vaccine = live attenuated (17D strain). ICV (International Certificate of Vaccination) is valid from 10 days post-vaccination. WHO revised in 2016 — single dose = LIFELONG protection (previously required 10-yearly boosters). Contraindicated <6 months, pregnancy, immunocompromised.

Q12. The Shake Test is used to detect which type of vaccine damage?

• A) Heat damage in live vaccines
• B) Contamination of the vaccine
• C) Freeze damage in adsorbed (alum-containing) vaccines like DPT, DT, TT, Hep B
• D) Expired vaccine detection

💡 Tip: Shake Test: Shake suspect vial + control vial → set aside 30 min. If suspect vial has flocculates/clumps that settle (while control stays milky) = FREEZE DAMAGED → DISCARD. Works for adsorbed vaccines only (DPT, DT, TT, Hep B, Pentavalent). VVM detects heat damage. FIC detects freeze exposure.

Q13. In India's UIP, the MR vaccine is given at which age?

• A) Birth and 6 weeks
• B) 6 weeks and 14 weeks
• C) 9 months and 16–24 months
• D) 12 months and 5 years

💡 Tip: MR (Measles-Rubella) vaccine in India UIP: Dose 1 at 9 months + Dose 2 at 16–24 months. Route = Subcutaneous (SC), right upper arm. Live attenuated. Rubella component prevents Congenital Rubella Syndrome (CRS). MCV coverage needed: 95% for measles elimination.

Q14. Conjugate vaccines (like PCV, Hib conjugate) are superior to plain polysaccharide vaccines in infants because?

• A) They contain live organisms — stronger response
• B) They are given orally — easier administration
• C) Conjugation to a protein carrier converts T-cell independent response to T-cell dependent — effective in infants under 2 years
• D) They do not require cold chain maintenance

💡 Tip: Plain polysaccharide vaccines (PPSV23, old Hib) = T-cell independent → infants <2 yrs can't respond. Conjugate vaccines = polysaccharide LINKED to protein carrier (diphtheria toxoid, tetanus toxoid, etc.) → converts to T-cell DEPENDENT → effective from 6 weeks onwards in infants. That's why PCV13 works in babies but PPSV23 doesn't.

Q15. The BCG vaccine is given by which route and at which site?

• A) Subcutaneous (SC) — right upper arm
• B) Intramuscular (IM) — anterolateral thigh
• C) Intradermal (ID) — LEFT upper arm (deltoid region)
• D) Oral — mouth drops

💡 Tip: BCG = strictly INTRADERMAL (ID) at 10–15° angle. Site = LEFT upper arm (over deltoid). A small pale wheal (7–8 mm) must appear to confirm correct intradermal injection. Deep injection (SC/IM) = subcutaneous abscess, keloid formation. Dose: 0.05 mL at birth; 0.1 mL if given later.

Q16. Which of the following is a FALSE contraindication to vaccination?

• A) Anaphylaxis to previous dose
• B) Severe immunodeficiency for live vaccines
• C) Pregnancy for live vaccines
• D) Child has mild cold with low-grade fever today

💡 Tip: FALSE (incorrect) contraindications — vaccines CAN still be given: Mild illness (mild cold, low-grade fever), Breastfeeding, Premature/low birth weight, Malnutrition, Stable neurological disease, Family history of seizures, Previous mild reaction, Antibiotics (unless related to vaccine component). Vaccinate even with mild illness — missing opportunity = vaccine-preventable disease risk!

⚡ Quick Reference – Vaccination Program

Live Vaccines

BCG, OPV, MMR, Varicella, YF, Rotavirus

Killed Vaccines

IPV, Hep A, Rabies, Flu (killed), Cholera

Toxoid Vaccines

Tetanus Toxoid + Diphtheria Toxoid only

Recombinant

Hepatitis B, HPV (VLP)

OPV Storage

−20°C (freezer)

Most vaccines storage

2–8°C only

Never Freeze

DPT, DT, TT, Hep B, IPV, Penta

BCG Route/Site

ID, Left upper arm

DPT Route

IM, anterolateral thigh

OPV Route

Oral, 2 drops

Anaphylaxis Rx

Adrenaline 0.01 mg/kg IM

VAPP risk

OPV (1 in 2.7 million)

VVM Dark = ?

DISCARD (heat damaged)

Shake Test = ?

Freeze damage detection

Hep B recombinant

HBsAg from yeast

India UIP Launch

1978

YF Certificate valid from

10 days post-vaccination (lifelong)

Observe after vaccination

30 minutes (anaphylaxis watch)

Live vaccine contraindication

Immunocompromised + Pregnancy

Conjugate vaccine advantage

Effective in infants <2 yrs