1. Zero dose polio drops: Polio drops given at birth are called "zero dose". It provides early mucosal immunity and results in better intestinal uptake because neonatal gut flora does not yet interfere with vaccine virus replication. Additionally, it serves as the first contact point with healthcare services.
2. Contents:
   • Type 1: ${10}^6{\text{ TCID}}_{50}$
   • Type 3: ${10}^{5.5}{\text{ TCID}}_{50}$
     (Type 2 component has been withdrawn globally; the current formulation is bivalent OPV or bOPV).
3. Reason for multiple doses: Thermal lability, interference by non-polio enteroviruses in the gut, and relatively lower mucosal take per dose require multiple doses to achieve satisfactory individual and herd seroconversion.
4. Instructions: The mother does not need specific dietary/feeding restrictions (breastfeeding can continue), but must be instructed to bring the baby for subsequent scheduled vaccinations on time.

1. Risk of transmission: ~30% if mother is HBsAg positive alone; rises to 80–90% if mother is also HBeAg positive.
2. Protection / Immunoprophylaxis:
   • Hepatitis B vaccine: First dose ($0.5\text{ ml}$ IM) within 12 hours of birth.
   • Hepatitis B Immunoglobulin (HBIG): $0.5\text{ ml}$ IM administered simultaneously at a different anatomical site (other anterolateral thigh) within 12 hours.
   • Complete standard vaccination at 6, 10, 14 weeks (or 0, 1, 6 months) with post-vaccination serology testing at 9–12 months.
3. Infection despite prophylaxis: Yes, if intra-uterine transplacental transmission has already occurred prior to delivery (~1–3%).
4. Prognosis: ~90% of infected neonates become chronic carriers, and ~25% of chronic carriers eventually develop chronic active hepatitis, cirrhosis, or hepatocellular carcinoma in early adulthood.

1. Cold chain: A system of storing, transporting, and distributing vaccines at recommended temperatures ($+2^{\circ }\text{C}$ to $+8^{\circ }\text{C}$ for most vaccines, $-{15}^{\circ }\text{C}$ to $-{25}^{\circ }\text{C}$ for OPV) from the point of manufacture to the point of administration.
2. Vaccine carrier: An insulated, thick-walled container lined with 4 conditioned ice packs, used to carry small quantities of vaccines (6–8 vials) to outreach sessions and vaccination booths.
3. Duration: Up to 1 working day (approx. 24–48 hours depending on ambient temperature and carrier specifications with conditioned ice packs).

1. Upper age limit: No upper age limit; recommended for all non-immune adolescents and adults.
2. Dose & Route: $0.5\text{ ml}$, Subcutaneously (SC) in the anterolateral thigh or upper arm (deltoid).
3. Side effects:
   • a. Rash immediately after giving the vaccine: False (Rash occurs after 5–12 days due to measles replication).
   • b. Parotid swelling: True (Parotitis can occur 10–14 days post-vaccination due to mumps component).
   • c. Carditis: False.
4. Current IAP schedule: 3 doses — 1st dose at 9 months, 2nd dose at 15 months, and 3rd dose (booster) at 4–6 years of age.

1. Initiation: 1985 (expanded from the Expanded Programme on Immunization [EPI] launched in 1978).
2. Main aim: To immunize all infants ($\ge 85\mathrm{\%}$ coverage) before their 1st birthday against major vaccine-preventable diseases, and to achieve tetanus toxoid immunization in all pregnant women.
3. Other objectives:
   • Self-sufficiency in vaccine production.
   • Establishment of a reliable and functional cold chain network.
   • Phased introduction of district-level monitoring and adverse event surveillance (AEFI).
4. Vaccines used in UIP: BCG, bOPV, fIPV, Pentavalent (DTwP + HepB + Hib), Rotavirus, PCV, MR (Measles-Rubella), JE (in endemic districts), DPT boosters, and Td (tetanus-diphtheria).
5. Targets: Rapidly achieve and sustain $\ge 90-100\mathrm{\%}$ full immunization coverage across all districts.

1. Live-attenuated bacterial: BCG (Bacillus Calmette-Guérin), oral typhoid Ty21a.
2. Live-attenuated viral: OPV, Measles / MMR, Varicella, Rotavirus (live), Yellow fever.
3. Killed bacterial: Whole-cell Pertussis (wP), Cholera vaccine (killed oral).
4. Killed / Inactivated viral: Inactivated Polio Vaccine (IPV), Inactivated Hepatitis A, Rabies vaccine (CCRV), Inactivated Influenza vaccine, Japanese Encephalitis killed (JENVAC).

1. Vaccines using adjuvants: DPT, Hepatitis B, Hepatitis A (inactivated), Pneumococcal conjugate (PCV), HPV.
2. Advantages:
   • Enhance immunogenicity and prolong antigen exposure (depot effect).
   • Induce higher and longer-lasting antibody titers with lower antigen doses (antigen sparing).
3. Drawbacks:
   • Local adverse reactions (sterile abscess, pain, tenderness, persistent nodule).
   • Adjuvanted vaccines cannot be frozen (freezing precipitates aluminium salts, destroying potency and increasing reactogenicity).
   • Primarily induce humoral, but poor cell-mediated, immunity.
4. Newer adjuvants: Liposomes, squalene (MF59, AS03), AS04 (aluminium hydroxide + MPL), virosomes, bacterial toxins/products (CpG ODN, flagellin).

1. Possibilities:
   • Fading or disappearance of the scar over time (seen in up to 10–20% of vaccinated children).
   • Faulty technique (subcutaneous instead of intradermal injection) or inadequate vaccine potency.
   • Non-response / true lack of take.
2. Re-vaccination: No revaccination is needed if reliable documentation of birth vaccination exists. If documentation is absent, perform a Mantoux test; revaccination is not routinely recommended after 5 years of age.
3. Simultaneous administration: Yes, BCG can be given simultaneously with OPV and DT (at different anatomical sites).
4. Skin preparation: Clean the skin with sterile water only. Do not use alcohol, spirit, or other chemical disinfectants because residual disinfectant kills the live-attenuated BCG bacilli.

1. Management: Reassure the parents; no intervention is required as a painless aluminium granuloma/nodule resolves spontaneously over several months. Incision and drainage or antibiotics should not be done.
2. Contents per 0.5 ml:
   • Diphtheria toxoid: $20-30\text{ Lf}$ (standard $\ge 25\text{ Lf}$)
   • Tetanus toxoid: $5\text{ Lf}$
   • Pertussis: $\ge 4\text{ IU}$ ($\sim 20,000\text{ million}$ killed B. pertussis bacteria)
3. Freezing: No. DPT must never be frozen (stored at $+2^{\circ }\text{C}$ to $+8^{\circ }\text{C}$). Freezing denatures the aluminium adjuvant.
4. Contraindications:
   • Absolute:
     • Anaphylaxis or immediate severe allergic reaction to a previous dose.
     • Encephalopathy (e.g., coma, prolonged seizures) within 7 days of a previous pertussis dose not attributable to another identifiable cause.
   • Relative / Precautions (switch to DTaP or DT):
     • Temperature $\ge {40.5}^{\circ }\text{C}$ within 48 hours not due to another cause.
     • Collapse or shock-like state (hypotonic-hyporesponsive episode [HHE]) within 48 hours.
     • Persistent, inconsolable crying lasting $\ge 3\text{ hours}$ within 48 hours.
     • Convulsions with or without fever within 3 days.
     • Progressive neurological disorder.

1. Need for TT: No. For a clean, minor wound in a fully immunized person, tetanus booster is only needed if the last dose was $>10\text{ years}$ ago. For dirty/tetanus-prone wounds, a booster is given if $>5\text{ years}$ have elapsed.
2. Hazards of hyperimmunization:
   • High circulating tetanus antitoxin levels causing severe Arthus-type hypersensitivity reactions (local pain, swelling, induration, sterile necrosis).
   • Risk of neuropathy, brachial neuritis, urticaria, amyloidosis.
3. Td vaccine: Contains standard Tetanus toxoid ($5\text{ Lf}$) and reduced Diphtheria toxoid ($2-2.5\text{ Lf}$ vs $25\text{ Lf}$ in DPT). It is recommended to replace TT in all children $\ge 7\text{ years}$ and adults to boost immunity against both tetanus and diphtheria without the reactogenicity of pediatric full-strength diphtheria toxoid.

1. Likely cause: Transient vaccine-associated parotitis due to replication of the attenuated mumps virus strain (occurs typically 7–14 days post-vaccination in 1–2% of recipients; benign and self-limiting).
2. Prior mumps: Yes. Clinical diagnosis of mumps is often inaccurate, prior mumps does not increase adverse events, and MMR is required to provide immunity against measles and rubella.
3. Only to girls: No. It must be given to both boys and girls to prevent measles/mumps morbidity, orchitis, and to stop transmission of rubella (herd immunity) to protect pregnant females.
4. Adolescent girls: Yes. Strongly recommended for adolescent girls and women of childbearing age (who are non-pregnant and agree to avoid pregnancy for 1 month) to prevent Congenital Rubella Syndrome (CRS).
5. 2021 ACVIP/IAP update: 3-dose schedule: 1st dose at 9 months, 2nd dose at 15 months, and 3rd dose at 4–6 years of age.

1. Recommendation: Yes, typhoid conjugate vaccine (TCV) can be given, though it will not protect against the immediate household incubation period if already exposed.
2. Time to protection: 2–3 weeks following vaccination for protective antibody titers to develop.
3. Other precautions: Strict food hygiene, drinking boiled/treated water, hand hygiene with soap and water after using the toilet and before preparing food, isolating household cooking from the index patient.
4. Available vaccines:
   • Typhoid Conjugate Vaccine (TCV - conjugated with TT or ${\text{CRM}}_{197}$, e.g., Typbar-TCV, Typhibev)
   • Vi Polysaccharide vaccine (unconjugated)
   • Live oral Ty21a vaccine
5. 2021 IAP changes:
   • Single dose of Typhoid Conjugate Vaccine (TCV) starting at 6 months of age (licensed up to 45 years).
   • No routine booster dose is required with TCV.
   • Catch-up vaccination with TCV recommended throughout childhood, adolescence, and up to 45 years.

1. Etiology: No, jaundice can be caused by HAV, HEV, HCV, malaria, hemolysis, drugs, or biliary tract disease. However, blood banks exclude donors to minimize HBV/HCV transmission.
2. Transfusion transmission:
   • HAV: Extremely rare (viremia is short-lived), though theoretically possible in acute pre-icteric phase.
   • Non-A non-B (HCV / HDV): Yes, readily transmitted parenterally via blood and blood products.
3. Protection against HDV: Yes. Hepatitis D (Delta agent) is a defective RNA virus that requires HBsAg coat for assembly and infection. Preventing HBV prevents HDV infection.
4. Transmission efficiency: Extremely high (~90–100% chance of infection following transfusion of HBsAg-positive blood unit).

1. Rabies PEP in pregnancy: Yes. Rabies is 100% fatal; pregnancy is NOT a contraindication to post-exposure prophylaxis (both cell-culture rabies vaccine and rabies immunoglobulins/monoclonal antibodies are safe and indicated).
2. Transplacental transmission: No; rabies virus is not transmitted across an intact placenta.
3. Lactating mother: Yes. Rabies vaccination is safe during lactation and does not affect the breastfed infant.
4. Neonates: Yes. Neonates with animal exposures must receive the full PEP regimen at full pediatric doses.

1. Indication: Yes. Any questionable unprovoked bite or scratch by a stray mammal in an endemic region warrants full post-exposure prophylaxis.
2. Essen protocol: 5-dose intramuscular regimen on Days 0, 3, 7, 14, and 28 (or Day 30) in the deltoid/anterolateral thigh ($0.5\text{ or }1.0\text{ ml}$ per dose). (Note: WHO also endorses the 4-dose Zagreb IM schedule or 2-site ID Thai Red Cross schedule).
3. Transmission by vaccinated dog: Yes. A vaccinated dog may transmit rabies if the vaccine was degraded, improperly administered, expired, or if regular annual/3-yearly booster doses were missed.
4. Dog rabies vaccines & schedule:
   • Inactivated tissue-culture or live-attenuated veterinary rabies vaccines.
   • Schedule in dogs: First dose at 3 months of age, booster at 1 year, and revaccination every 1 to 3 years thereafter.

1. Simultaneous administration: Yes. All routine pediatric vaccines (live and inactivated) can be administered on the same day at separate anatomical injection sites with separate syringes.
2. Types of conjugate vaccines:
   • PRP-T (conjugated to Tetanus toxoid)
   • PRP-OMP (conjugated to Outer Membrane Protein complex of N. meningitidis)
   • PRP-CRM (conjugated to non-toxic mutant diphtheria toxin ${\text{CRM}}_{197}$)
   • PRP-D (conjugated to Diphtheria toxoid)
3. Reason for protein conjugation: Polyribosylribitol phosphate (PRP) capsular polysaccharide is a T-cell independent antigen that induces poor immunity in infants $<2\text{ years}$. Conjugation to a protein carrier converts it to a T-cell dependent antigen, stimulating immunological memory, affinity maturation, and high IgG antibody titers in young infants.

1. Available vaccine: Live-attenuated Varicella zoster virus vaccine (Oka strain).
2. Indication: Yes. Chickenpox in adolescents and adults is associated with significantly higher morbidity and complications (e.g., varicella pneumonia, encephalitis).
3. Dose schedule: 2 doses of $0.5\text{ ml}$ Subcutaneously, given at an interval of 4–8 weeks (minimum 4 weeks).
4. Protective efficacy: ~95–98% against moderate-to-severe chickenpox and 80–90% against all forms of disease.
5. 2021 IAP Update: 1st dose at 15 months, 2nd dose preferably 3–6 months after the 1st dose (can be given up to 4–6 years).

1. IAP Recommendations for HIV-Exposed / Infected Children:

   • BCG: Given at birth to asymptomatic infants; contraindicated in infants with symptomatic HIV / severe immunosuppression.
   • Polio: IPV (Inactivated Polio Vaccine) is strongly preferred over OPV. OPV is contraindicated in severely immunocompromised children and their household contacts.
   • DTwP / DTaP / Hib / HepB / PCV / Rotavirus: Administered according to routine schedule.
   • MMR / Varicella: Given if child is not severely immunocompromised ($\text{CD4}>15\mathrm{\%}$).
   • Influenza & Hepatitis A: Recommended routinely.

2. BCG Axillary Lymphadenitis:

   • Management: Reassurance and watchful observation; most cases resolve spontaneously over several months without therapy.
   • Do NOT give anti-tubercular therapy (ATT) or perform early incision and drainage (which risks sinus tract formation). If fluctuant, fine-needle aspiration can be performed.

1. Types & 2021 Changes:
   • Live attenuated vaccine (e.g., Biovac-A): Single dose at $\ge 12\text{ months}$ of age (no booster required).
   • Inactivated / Killed vaccine (e.g., Havrix, Avaxim): 2 doses (1st dose at 12 months, 2nd dose 6 months later at 18 months).
2. Decision: Yes, vaccination provides $>95-100\mathrm{\%}$ seroconversion and long-term protection against hepatitis A.
3. Special indications:
   • Patients with chronic liver disease or hepatitis B/C carriers.
   • Travelers to high-endemicity areas.
   • Persons with clotting-factor disorders receiving blood products.
   • Laboratory personnel handling HAV.
   • Outbreak control / post-exposure prophylaxis within 2 weeks of exposure.
4. Other preventive measures: Safe potable drinking water supply, sanitary disposal of human excreta, and meticulous personal and food hand hygiene.

1. Re-exposure Rabies Schedule:

   • For previously fully vaccinated individuals re-exposed within any time:
   • Vaccine: 2 doses of rabies vaccine ($0.5\text{ ml}$ IM or $0.1\text{ ml}$ ID) on Day 0 and Day 3.
   • Rabies Immunoglobulin (RIG): NOT indicated in previously documented fully vaccinated individuals.
   • Immediate wound washing with soap and water for 15 minutes.

2. WHO Categorization of animal bite and management:

Category	Type of Contact / Bite	Recommended Management
Category I	Touching/feeding animals, licks on intact skin	Wash exposed skin; no PEP needed
Category II	Minor scratches/abrasions without bleeding, nibbling of uncovered skin	Immediate wound washing + full Rabies Vaccine course
Category III	Single/multiple transdermal bites or scratches, licks on broken skin, mucosal contamination, bat exposures	Immediate wound washing + Rabies Immunoglobulin (RIG/RMAb) local infiltration + full Rabies Vaccine course

1. Lyophilization: Freeze-drying process in which a vaccine is frozen and then the water is removed by sublimation under vacuum, producing a stable dry powder with enhanced shelf-life that requires reconstitution with a specific diluent prior to injection.
2. Lyophilized vaccines: BCG, MMR, Measles, Varicella, Yellow Fever, Hib (certain brands), Live oral typhoid.

1. Meaning of IPV: Inactivated (Salk) Polio Vaccine (or enhanced-potency IPV [eIPV]).
2. IAP Recommendations:
   • Primary series: 3 doses at 6, 10, and 14 weeks.
   • 1st Booster: 16–18 months.
   • Recent change: A 2nd booster dose of IPV is now recommended at 4–6 years of age (along with DPT).
3. VVM (Vaccine Vial Monitor):
   • A heat-sensitive label on the vial showing cumulative heat exposure.
   • When NOT to use: Do not use when the inner square is the same colour as, or darker than, the outer circle (VVM Stage 3 and Stage 4), or if the expiry date has passed.
4. Risk of VAPP: 1 case in $2.5\text{ million}$ doses (highest with 1st dose, $\sim 1\text{ in }750,000$).
5. Contents of standard IPV per 0.5 ml:
   • Type 1 (Mahoney strain): 40 D-antigen units
   • Type 2 (MEF-1 strain): 8 D-antigen units
   • Type 3 (Saukett strain): 32 D-antigen units

• Top / Freezer / Coldest Zone ($-{15}^{\circ }\text{C}$ to $-{25}^{\circ }\text{C}$): OPV, Measles, MMR, Varicella, BCG (freeze-resistant live vaccines).
• Middle Shelves ($+2^{\circ }\text{C}$ to $+8^{\circ }\text{C}$): BCG, MMR, PCV, Typhoid conjugate, Inactivated Influenza, IPV, Rotavirus.
• Bottom Shelves / Warmer Zone ($+2^{\circ }\text{C}$ to $+8^{\circ }\text{C}$): DPT, DT, Td, Tdap, Hepatitis B, Hepatitis A, Hib, and Rabies (Adsorbed vaccines — must NEVER touch freezer lining or be frozen).
• Diluents: Kept on middle shelf or chilled at $+2^{\circ }\text{C}$ to $+8^{\circ }\text{C}$ at least 24 hours before reconstitution.
• Bottom bin / Door: Water bottles to maintain temperature during power outages (no vaccines in the door).
• Monitoring: Twice-daily temperature logging using calibrated digital thermometer / data logger.

• Sickle Cell Disease (Functional Asplenia) at 4 years:
  • Should receive a single dose of Pneumococcal Conjugate Vaccine (PCV13 or PCV15 - $0.5\text{ ml}$ IM).
  • Followed 8 weeks later by a single dose of 23-valent Pneumococcal Polysaccharide Vaccine (PPSV23 - $0.5\text{ ml}$ IM/SC).
  • A booster dose of PPSV23 is given 5 years after the first PPSV23 dose.
• New pneumococcal vaccines: PCV10 (Pneumosil), PCV14, PCV15, and PCV20.

1. Indication: Children residing in or traveling to JE-endemic areas (e.g., Uttar Pradesh, Bihar, Assam, West Bengal, parts of South India).
2. Recommended vaccines:
   • Live attenuated SA 14-14-2 vaccine (CD-JEV).
   • Inactivated Vero-cell-derived vaccine (JENVAC / JEEV).
3. Dose & Schedule:
   • Inactivated (JENVAC / JEEV): 2 doses ($3\mu \text{g}$ IM for 1–3 years; $6\mu \text{g}$ for $>3\text{ years}$) given 4 weeks apart starting at $\ge 1\text{ year}$ of age, with a booster dose at 1 year after the primary series.
   • Live SA 14-14-2 (in UIP): 1st dose at 9 months (with MR-1) and 2nd dose at 16–24 months (with MR-2).

1. Strains: Vibrio cholerae ${\text{O}}_1$ (Inaba and Ogawa serotypes, classical and El Tor biotypes) and ${\text{O}}_{139}$ (Bengal strain).
2. Contraindications: Infants $<1\text{ year}$ of age, acute severe febrile or gastrointestinal illness, pregnancy (for certain live formulations).
3. WHO prequalified oral cholera vaccines (OCV): Shanchol, Euvichol / Euvichol-Plus, Dukoral.
4. Rapid diagnostic test: Rapid immunochromatographic dipstick test (e.g., Crystal VC), and darkfield microscopy for darting motility inhibited by specific ${\text{O}}_1/{\text{O}}_{139}$ antisera.
5. Antibiotic therapy:
   • Above 9 years: Doxycycline (single dose $300\text{ mg}$), Azithromycin, or Ciprofloxacin.
   • Below 9 years: Azithromycin ($10-20\text{ mg/kg}$ single dose), Cotrimoxazole, or Erythromycin.

1. Tdap: Single dose of Tdap (preferred over Td) at 10–12 years, followed by Td every 10 years.
2. HPV vaccine: 2 doses at 0 and 6 months (for females and males aged 9–14 years).
3. MMR: 1–2 catch-up doses if missed earlier (at least 4 weeks apart).
4. Hepatitis B: 3 doses at 0, 1, and 6 months if not vaccinated in infancy.
5. Typhoid conjugate vaccine (TCV): Single dose if not previously received.
6. Varicella vaccine: 2 doses given 4–8 weeks apart (if no reliable history of prior chickenpox).
7. Hepatitis A vaccine: 2 doses of inactivated (0, 6 months) or 1 dose of live vaccine.

1. Advised vaccine: HPV (Human Papillomavirus) Vaccine.
2. Vaccine details:

Feature	Quadrivalent HPV (Gardasil / Cervavac)	9-Valent HPV (Gardasil 9)
Serotypes	HPV 6, 11, 16, 18	HPV 6, 11, 16, 18, 31, 33, 45, 52, 58
Schedule	- Age 9–14 years: 2 doses at 0 and 6 months - Age $\ge 15\text{ years}$ or immunocompromised: 3 doses at 0, 2, and 6 months	- Age 9–14 years: 2 doses at 0 and 6 months - Age $\ge 15\text{ years}$: 3 doses at 0, 2, and 6 months
Protection	Cervical, vaginal, vulvar, and anal cancer (types 16, 18); genital warts / condylomata acuminata (types 6, 11)	Broader coverage: $>90\mathrm{\%}$ of cervical cancers + genital warts

1. BCG $\to$ Live-attenuated bacteria
2. OPV $\to$ Live-attenuated virus
3. DPT $\to$ Toxoids (D, T) and killed bacteria (wP)
4. Hib $\to$ Capsular polysaccharide conjugated to protein carrier
5. Hepatitis B vaccine $\to$ Recombinant viral antigen (HBsAg)
6. Typhoid Vi $\to$ Capsular polysaccharide
7. Hepatitis A vaccine $\to$ Killed virus (inactivated) / Live-attenuated virus
8. Acellular pertussis (aP) $\to$ Bacterial subunit / purified antigens (PT, FHA, Pertactin, FIM)

1. BCG diluent: Sterile Normal Saline ($0.9\mathrm{\%}\text{ NaCl}$).
2. MMR diluent: Sterile distilled water.
3. Reconstituted BCG: Maximum 4 hours (discard thereafter; keep on ice and protect from light).
4. Reconstituted MMR: Maximum 4 hours (keep on ice, protect from light).
5. Vaccines that must NEVER be frozen: DPT, Pentavalent, Td / Tdap / TT, Hepatitis B, Hepatitis A (inactivated), Hib, PCV, Rabies, IPV.
6. 5-year booster: IAP recommends DTwP or DTaP booster along with IPV (or combination DTaP-IPV / Tetraxim) and MMR-3.

1. Category III bites: Single or multiple transdermal bites or scratches, contamination of mucous membranes with saliva (licks on broken skin or mucous membranes), and all exposures to bats.
2. Schedule:
   • Essen IM regimen: 5 doses on Days 0, 3, 7, 14, and 28.
   • (Or Updated Thai Red Cross intradermal regimen: 2-site ID on Days 0, 3, 7, and 28).
3. Extended immunization: Severe immunocompromise (e.g., advanced HIV, immunosuppressive therapy, malnutrition), where an additional 6th dose at Day 90 is recommended along with antibody titer checking.
4. Prerequisites for suturing: Suturing should be avoided if possible. If inevitable for cosmetic/hemostatic reasons:
   • Clean thoroughly with soap and water for 15 minutes.
   • Infiltrate Rabies Immunoglobulin (RIG / RMAb) thoroughly into and around the wound edges.
   • Wait at least 2 hours post-RIG infiltration before placing loose, non-occlusive sutures.

1. Dosage & Route: $0.5\text{ ml}$ Intramuscular (IM) injection.
2. Composition: Quadrivalent capsular polysaccharides of Neisseria meningitidis serogroups A, C, Y, and W-135 conjugated to diphtheria toxoid / ${\text{CRM}}_{197}$ carrier protein.
3. Contraindications: Severe allergic reaction/anaphylaxis to a previous dose or to diphtheria toxoid carrier protein. History of Guillain-Barré Syndrome (precaution).
4. Special indications:
   • Anatomical or functional asplenia (sickle cell disease, splenectomy).
   • Complement component deficiencies (C3, C5-C9, properdin) or use of complement inhibitors (eculizumab).
   • Travel to hyperendemic/epidemic areas (African meningitis belt, Hajj/Umrah pilgrims).
   • Laboratory personnel exposed to N. meningitidis.
   • Community outbreak control.
5. Available brands:
   • Menactra (conjugated to diphtheria toxoid; 2 doses at 9 and 12 months, or 1 dose $\ge 2\text{ years}$).
   • Menveo (conjugated to ${\text{CRM}}_{197}$; approved $\ge 2\text{ years}$ as a single dose).

d. Complete toxoid course + TIG

Rationale:
For a dirty, tetanus-prone wound (crush injury, compound fracture) with unknown or incomplete immunization history ($<3\text{ doses}$):

• Administer Tetanus Toxoid / Td / Tdap immediately (Day 0) and complete the 3-dose course (at 0, 1, and 6 months).
• Administer Tetanus Immunoglobulin (TIG): $250-500\text{ IU}$ IM at a different anatomical site for immediate passive immunity.

a. Nothing (or routine scheduled 5-year booster)

Rationale:
She has received 4 prior documented doses (3 primary + 1 booster). For clean minor wounds in individuals with $\ge 3$ prior doses, a tetanus booster is required only if the last dose was $>10\text{ years}$ ago. Since her last dose was at 18 months (~3.5 years ago), no immediate emergency TT/TIG is indicated for this wound. (She remains eligible for her routine 5-year DPT booster).

1. Vaccines & Egg Allergy:
   • MMR & Varicella: Can be administered safely without skin testing (measles/mumps viruses are grown in chick embryo fibroblast cultures and contain negligible ovalbumin). Observe the child for 30–60 minutes post-vaccination.
   • Inactivated Influenza Vaccine: Can be given safely without prior skin testing.
   • Intranasal Live Attenuated Influenza & Yellow Fever Vaccine: Contain higher amounts of egg protein; require caution, specialist consultation, or skin testing prior to administration.
2. Neomycin allergy contraindications: MMR, Varicella, IPV, Inactivated Rabies vaccine.
3. HBV regimen for $1.8\text{ kg}$ baby with unknown maternal HBsAg:
   • Administer 1st dose of Hepatitis B vaccine ($0.5\text{ ml}$ IM) within 12 hours of birth.
   • Immediately test maternal blood for HBsAg. If mother tests positive (or test results unavailable within 12 hours), administer HBIG ($0.5\text{ ml}$ IM) as soon as possible (within 7 days).
   • Because birth weight is $<2\text{ kg}$, the birth dose of HBV does not count towards the primary 3-dose series; give 3 additional doses at 1, 2, and 6 months (total 4 doses).

1. Immunization in bleeding disorders:
   • Prefer Subcutaneous (SC) route whenever licensed and effective.
   • For vaccines requiring Intramuscular (IM) administration (e.g., aluminium-adjuvanted vaccines):
     • Administer immediately after factor replacement therapy.
     • Use a fine-gauge needle ($\le 23\text{ G}$ or $25\text{ G}$).
     • Apply firm, continuous direct pressure to the injection site for at least 5 minutes without rubbing.
2. Freezer compartment ($-{15}^{\circ }\text{C}$ to $-{25}^{\circ }\text{C}$): OPV, Measles, MMR, Varicella, BCG.
3. Reconstitution time limits:
   • Varicella: Within 30 minutes (protect from light).
   • Measles / MMR: Within 4 hours (keep on ice, protect from light).
4. Previously vaccinated rabies PEP schedule:
   • 2 doses of rabies vaccine IM ($0.5\text{ ml}$) or ID ($0.1\text{ ml}$) on Day 0 and Day 3.
   • Rabies immunoglobulin (RIG) is not needed.