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close this bookEssential Drugs - Practical Guidelines (Médecins Sans Frontières)
View the document(introductory text...)
View the documentAcknowledgeements
View the documentPreface
View the documentPart one: drugs, infusions, vaccines
View the documentOral drugs
View the documentInjectable drugs
View the documentInfusion solutions and Electrolytes
View the documentVaccines and sera
View the documentDrugs for external use and Disinfectants
View the documentPart two
View the documentOrganization and management of a pharmacy
View the documentPreservation and quality of the drugs
View the documentPrescription, cost, compliance
View the documentUse of antibiotics in precarious situations
View the documentAntiseptics and disinfectants
View the documentThe New Emergency HeaIth Kit (WHO)
View the documentBibliography
View the documentPharmaco-therapeutical index WHO essential drug list (7th list, 1992)
View the documentAlphabetical index (with indicative prices)

Vaccines and sera

Antiamaril vaccine
Antimeningococcal vaccine A + C
Antitetanic serum
BCG vaccine
DPT vaccine
Measles vaccine
Oral antipoliomyelitis vaccine
Tetanus vaccine

Vaccines and sera are sensitive products to heat and light. Even if new productions give vaccines more stable to heat (called "thermostable"), they still have to be stocked in the refrigerator between 0 and 8°C, and cold chain strictly have to be respected during transport.
Information mentioned hereafter concerning stability only helps to decide if vaccines stocked during a short time at a temperature superior to 8°C could be used or have to be destroyed.

ANTIAMARIL VACCINE (Stamaril, Amarela)

Health clinic

Indications
- Prevention of yellow fever
- Must be integrated in the national Expanded Program of Immunization (EPI)

Presentation and route of drug administration
- Live attenuated viral vaccine, freeze-dried powder to be diluted with a special solvent. There are vials of powder for 10 doses, 20 doses and 50 doses, with the vials of solvent.
- Administration in deep subcutaneous or IM injection in the deltoid muscle of the arm.

Dosage and vaccination scheme
- Child and adult :0.5 ml
- May be administered as of the age of 6 months (4 months during epidemics)
- Efficiency: after 10 days for 10 years

Contra-indications, side-effects, precautions
- Contra-indicated in case of immunodeficiency and genuine allergy to eggs.
- Local reaction possible in 20 % of the cases.
- Fever and myalgia 4 to 10 days after the injection in 5 to 10 % of the cases.
- Complications:
· neurological reactions (encephalitis),
· allergic reactions: erythema, urticaria, oedema (1 case in 1 million doses).

- Pregnancy: this vaccine can be administered to pregnant women only if there is a major risk of infection (epidemic)
-Lactation: no contra-indication

Remarks
- It is always better to use the solvent delivered with the vaccine. In case of loss, we recommend sodium chloride 0.9 % or water for injection as the solvent, using the same quantity as the solvent delivered.
- Combinations
· Simultaneous combination (at the same time, in a separate syringe)
Compatible with other vaccines given by EPI; contra-indicated with cholera and typhoid A and B.
· Combinations with other vaccines (in the same syringe)
Possible with measles vaccine.

- Storage
· Freeze-dried powder
Store between O and 8°C. Freezing (-20°C) recommended for long periods. At 37°C, freeze-dried vaccine is stable for 7 to 14 days.
· After dilution
Between O and 8°C, the vaccine is stable for 3 hours; at 37°C, it becomes unefficient in less than 1 hour. This vaccine is one of the most sensitive to heat. At the moment of dilution, the solvent must be at the same temperature as the vaccine (0 to 8°C).

ANTIMENINGOCOCCAL VACCINE A + C

Health clinic

Indications
- Prevention of meningococcal meningitis type A and C

Presentation and route of drug administration
- Polysaccharide vaccine from meningococcal serogroup A and C, freeze-dried powder to be diluted with a solvent.
There are vials of powder for 10 doses and 50 doses.
- Administration in deep subcutaneous or IM injection in the deltoid muscle of the arm.

Dosage and vaccination scheme
- Child and adult :0.5 ml
- Age of administration
· meningococcus type A: from 3 months of age
· meningococcus type C: the vaccine is effective only if given after 18 months of age

- Efficiency: 1 week after injection for 3 years (if injection after 2 years of age)

Contra-indications, side-effects, precautions
- There are no contra-indications.
- There are no side-effects, vaccine is well tolerated.
- In some cases, redness at injection site for 24 hours.
- In 0.4 % of the cases, fever (up to 38.5°C).
- Pregnancy: no contra-indication
- Lactation: no contra-indication

Remarks
- It is always better to use the solvent delivered with the vaccine. In case of loss, we recommend sodium chloride 0.9 % or water for injection as the solvent, using the same quantity as the solvent delivered.
- Combinations
· Simultaneous combination (at the same time, in a separate syringe)
Compatible with other vaccines given by EPI.
· Combinations with other vaccines (in the same syringe)
Possible with measles and antiamaril vaccine.

- Storage
· Freeze-dried powder
Store between 0 and 8°C.
Freezing (-20°C) recommended for long periods.
The freeze-dried vaccine is very stable (18 months: at 37°C; 4 weeks: at 45°C).
· After dilution
Store between 0 and 8°C is possible.
Vaccine remains stable for 4 days at 37°C, but, for asepsis, it is preferable to destroy the vial when the vaccination session is over.
At the moment of dilution, the solvent must be at the same temperature as the vaccine (0 to 8°C).

ANTITETANIC SERUM equine tetanus antitoxin

District hospital

Therapeutic action
- Neutralises the tetanus toxin

Indications
- Prevention of tetanus for non-vaccinated wounded patients
- Treatment of tetanus

Preparation and route of drug administration
- Ampoule (or ready-to-use syringe) of 1,500 IU/ml, 1 ml for SC or IM injection Serum equine origin (horse)

Dosage
- Prevention of tetanus: 1,500 IU
- Treatment of tetanus
· Newborn: 1,500 IU
· Child : 5,000 IU
· Adult : 10,000 IU
It is necessary to administer the injection following the Besredka method: inject 0.1 ml, wait 15 minutes leaving the needle and syringe in place, inject 0.25 ml and wait 30 minutes; if there is no reaction, finish the injection.

- Efficiency: during 1 to 2 weeks.

Duration: single dose

Contra-indications, side-effects, precautions
- Do not administer if known allergy to anti-tetanic serum.
- May cause severe, sometimes deadly, allergic reactions.
- Anti-tetanic serum only has a transitory action and must be combined with anti-tetanic vaccination.
- Pregnancy: CONTRA-INDICATED
- Lactation: no contra-indication

Remarks
- In cases of tetanus, immediately apply antibiotic and symptomatic treatment.
- Anti-toxin from human origin (tetanus immunoglobulin) exists. It does not cause allergic reactions and is not contra-indicated during pregnancy, but it is much more expensive.
- This product is not included in the WHO essential drug list.
- Storage: keep refrigerated, between 2 and 8°C. Do not freeze.

BCG VACCINE (Glutamate BCG vaccine)

Health clinic

Indications
- Prevention of tuberculosis
- Must be integrated in the national Expanded Program of Immunization (EPI)

Presentation and route of drug administration
-Live attenuated bacterial vaccine, freeze-dried powder to be diluted with a solvent. There are vials of powder for 10 doses, 20 doses and 50 doses, with the vials of special solvent.
-Injections are given strictly intracutaneously ("pig skin") in the middle third of the upper arm, external side.

Dosage and vaccination scheme
- 0.05 ml for child under 1 year.
- 0.10 ml for child abeve 1 year.
-BCG is given at birth in a single dose. If after 3 months, there is no scar, BCG vaccine must be repeated (maximum 3 times).
- Efficiency: (80 %) during 10 years.

Contra-indications, side-effects, precautions
- Absolutely contra-indicated in patients with Acquired or Congenital Immune Deficiency Syndrome (AIDS).
- Contra-indicated in cases of progressive dermatoses.
- Normal local reaction: after 2 to 4 weeks, appearance of a small red nodule, becoming a vesicle. - This reaction will remain for 2 to 5 months and leave a superficial scar, 2 to 10 mm in diameter.
- Possibility of abscess on the scar (Becegitis).
- Presence of an axillary or cervical adenitis in 1 to 4 % of the cases, 2 to 3 months after the injection. The adenitis may sometimes cause suppuration and fistulization.
- Fatal disseminated infections with the BCG are very seldom.

Remarks
- It is always better to use the solvent delivered with the vaccine. In case of loss, we recommend sodium chloride 0.9 % or water for injetion as the solvent, using the same quantity as the solvent delivered.
- Combinations
· Simultaneous combination (at the same time, in a separate syringe)
Compatible with other vaccines given by EPI.
· Combinations with other vaccines (in the same syringe)
Impossible.

-Storage
· Freeze-dried powder
Store between 0 and 8°C.
Freezing is possible.
Defrosting/re-freezing is possible. At 37°C, stability of the freeze-dried vaccine is very variable, with loss of effectiveness after 3 to 14 days.
· After dilution
Keep for maximum 5 to 6 hours between 0 and 8°C.
Protect from light.

DPT VACCINE (DTP, DTCoq)

Health clinic

Indications
-Prevention of diphteria, tetanus and pertussis
-Must be integrated in the national Expanded Program of Immunization (EPI)

Presentation and route of drug administration
-Adsorbed vaccine (diphtheric and tetanic toxoid and killed bacterial vaccine against pertussis), ampoule with ready to use solution.
There are ampoules of 10 doses, 20 doses and 50 doses.
-Administration in deep subcutaneous or IM injection in the outer part of the mid-thigh or in the deltoid muscle of the arm.

Dosage and vaccination scheme
-0.5 ml per injection
3 injections given 4 weeks apart, followed by a booster 1 year after the 3rd dose.
-Age of administration
The first dose may be given from 6 weeks of age.
-Efficiency: during several years after 3 doses.

Contra-indications, side-effects, precautions
-Contra-indicated if history of neurological disorder.
- In case of significant reactions after the first dose of DTP (high fever, convulsions, neurological signs), only give diphtheria-tetanus vaccine.
- Febrile reactions (39° - 40°C) during approximately 48 hours.
- Local reactions: induration and painful reaction at injection site.
- Complications are often due to the anti-pertussis component: toxic shock, encephalopathies.

Remarks
-Combinations
· Simultaneous combination (at the same time, in a separate syringe)
Compatible with other vaccines given by EPI.
· Combinations with other vaccines (in the same syringe)
Possible with measles vaccine (DPT serves as solvent).

-Storage
Between 2 and 3°C.
NEVER FREEZE: if frozen, the adjuvant can cause aseptic abscesses and a poor diffusion of the vaccine.
At 37°C, the vaccine will remain stable for 6 weeks.
Attention: univalent pertussis vaccine: will remain stable for only 3 to 7 days at 37°C.

MEASLES VACCINE (Rouvax, Morbilvax, Rimevas)

Health clinic

Indications
-Prevention of measles
Must be integrated in the national Expanded Program of Immunization (EPI)

Presentation and route of drug administration
-Live attenuated viral vaccine (Schwarz strain), freeze-dried powder to be diluted with a special solvent.
There are vials of powder for 10 doses, 20 doses and 50 doses, with the vials of solvent.
-Administration in deep subcutaneous or IM injection in the outer part of the mid-thigh or in the deltoid muscle of the arm.

Dosage and vaccination scheme
-0.5 ml in a single dose
-Age of administration
· From the age of 9 months to 5 years.
· If the population is concentrated, 2 doses may be given:
1 first dose from 6 months of age (between 6 and 8 months),
1 second dose from of 9 months of age.

- Efficiency: undefinitly, some days after injection (when injection after 9 months of age)

Contra-indications, side-effects, precautions
- Contra-indicated in case of genuine allergy to eggs.
-Wait 6 weeks after injection of gammaglobulins to give measles vaccine.
-Local reactions: none.
-Generalized reactions:
· fever after 5 to 10 days (in 15 % of the cases),
· cutaneous rash for 48 hours,
· rhinopharyngitis.

- Complications:
· hyperthermic convulsions,
· encephalitis (1 case in 1 million vaccinations).

Remarks
- It is always better to use the solvent delivered with the vaccine. In case of loss, we recommend water for injection (distilled water) as the solvent, using the same quantity as the solvent delivered.
-A new high dose strain vaccine (AIK C, Edmonstron Zagreb), administered as of the age of 6 months in a single dose of 0.5 ml in deep subcutaneous ir IM injection, should be available in the near future.
-Combinations
· Simultaneous combination (at the same time, in a separate syringe)
Compatible with other vaccines given by EPI.
· Combinations with other vaccines (in the same syringe)
Possible with the DPT vaccine, which can be used as solvent, and with antimeningococcal and antiamaril vaccine.

- Storage
· Freeze-dried powder
Store between O and 8°C.
Freezing (-20°C) recommended for long periods.
Defrosting/re-freezing is possible, but not advisable.
At 37°C, the freeze-dried vaccine is stable for 7 days.
· After dilution
Store between 0 and 8°C, maximum 8 hours; at 37°C, maximum 1 hour.
At the moment of dilution, the solvent must be at the same temperature as the
vaccine (0 to 8°C).
Protect from light.

ORAL ANTIPOLIOMYELITIS VACCINE (Polioral trivalent, Polio Oral Sabin, Oral Poliomyelitis

Health clinic

Indications
-Prevention of poliomyelitis (for the 3 types of polio 1, 2 and 3)
-Must be integrated in the national Expanded Program of Immunization (EPI)

Presentation and route of drug administration
-Live attenuated viral vaccine, monovalent (Sabin), vial with liquid vaccine, limpid and pink colored, ready for administration (do not use the vaccine when cloudy). There are vials of 10 doses, 20 doses, 25 doses and 50 doses, with a plastic dropper.
-Administration: orally, on the tongue.

Dosage and vaccination scheme
-2 to 3 drops (depending on manufacturer)
Three doses of vaccine must be given, minimum 4 weeks apart.
-Age of administration
The first dose is administered at the age of 6 weeks at the same time as DPT.
The WHO recommends an additional dose at birth (Polio zero).
-Efficiency: 5 years after 3 doses.

Contra-indications, side-effects, precautions
-Contra-indicated in case of immunodeficiency.
-Diarrhoea is not a contra-indication, but it is preferable to give a supplementary dose once the child is cured.
-No reactions to this vaccine.
-Complications: 1 case of encephalitis out of 3 million administered doses.
-Pregnancy: CONTRA-INDICATED during the first trimester of pregnancy, except if there is a major risk for poliomyelitis.
Lactation: no contra-indication

Remarks
-Other antipoliomyelitis vaccines: injectable inactivated vaccine.
Not used very often in developing countries because of the high cost.
-Combinations
· Simultaneous combination (at the same time, in a separate syringe)
Compatible with all other vaccines given by EPI.
· Combinations with other vaccines (in the same syringe)
Impossible since this is an oral vaccine and not an injection.
-Storage
Between 0 and 8°C.
Freezing (-20°C) recommended for long periods.
Defrosting/re-freezing is possible.
Stability: the most fragile vaccine (1 day: at 37°C; 1 to 3 hours: at 50°C).

TETANUS VACCINE (Tetanus toxoid, Tetanol)

Health clinic

Indications
-Prevention of tetanus
-Must be integrated in the national Expanded Program of Immunization (EPI)

Presentation and route of drug administration
- Adsorbed tetanic toxoid, monovalent, vial with ready to use solution.
There are vials of 10 doses, 20 doses and 50 doses.
- Administration in deep subcutaneous or IM injection in the outer part of the mid-thigh or in the deltoid muscle of the arm.

Dosage and vaccination scheme
-0.5 ml per injection.
Vaccinate all women of child-bearing age. 5 doses are needed to give a definitive immunization status.
-Newborn child: give 3 doses, one month apart, followed by boosters later. 5 doses are needed to give a definitive immunization status.

Contra-indications, side-effects, precautions
-Slight but rare side-effects, this vaccine is extremely well tolerated.
-Painful, red reaction at injection site possible.
-Complications: none.

Remarks
-Combinations
· Simultaneous combination (at the same time, in a separate syringe)
Compatible with other vaccines given by EPI.
· Combinations with other vaccines (in the same syringe)
Possible with anti-pertussis, diphtheria and polio vaccine.

-Storage
Between 2 and 8°C.
NEVER FREEZE: if frozen, the adjuvant can cause aseptic abscesses and poor
diffusion of the vaccine.
At 37°C, the vaccine remains stable for at least 2 months.
Antitetanic toxoid is the vaccine the most resistant to heat