osce on immunization for DNB post graduates in the department of Pediatrics, southern Railway hospital, chennai

1. VACCINES- OSCE
DR. NIBEDITA MITRA
SOUTHERN RAILWAYS

2. 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

3. 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)

4. 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.

5. 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)

7. QUESTION 3
Time limit for using after reconstitution—
Varicella
BCG
Measles/ MMR
Yellow Fever
Meningococcal polysaccharide
DTap/ Hib combination

8. 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

9. 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.

10. 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

11. 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.

12. 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

13. Answer -5 (cont)
Catch up vaccination for JE to be given up to 15
years during out break in endemic areas.

14. Question 6-fill up
vaccine Type Dose Route Schedule
OPV
IPV
Measles
Hepatitis B

15. 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

16. 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

17. 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.

18. VACCINES IN SPECIAL SITUATIONS
QUESTION- 8
Please read the following case
scenarios and answer accordingly

19. 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.

20. 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.

21. 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.

22. 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

23. 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.

25. 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

26. 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

27. 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

29. 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?

30. 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.

31. 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

32. 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

34. 1
2
3 4
QUESTION- 12
I. Identify
II. Give your comment
on
1.
2.
3.
4.

35. ANSWER-12
I. VACCINE VIAL MONITOR
II.

36. Question-13
Arrange the following vaccine according to heat
and freezing sensitivity (Most to least)-
DPT DT
OPV JE
BCG
Measles
HepB
TT

37. ANSWER-13

39. Question-14
Write the catch up immunization schedule for a
10 year old Adolescent girl.

40. 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

41. Question -15
Write the immunization schedule for
HIV-infected children

42. 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

43. QUESTION 16(A)
10 years, Ravi has been bitten by a
street dog.
1. Classify the wound.
2. Write the steps of management.

44. 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.

45. 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?

46. 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.

47. RABIES- BEWARE!!!
ONLY
PROPHYLAXIS
NO
CURE

49. Question-17
Define:
1. Vaccine Efficacy
2. Vaccine effectiveness
3. Ro
4. Phase 2 trial
5. Phase3 trial

50. 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

51. 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

52. 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

53. 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

54. •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

55. 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

62. 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

63. 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