preventive pediatrics celia t. sy, m.d. pediatric pulmonologist department of pediatrics fatima...
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Preventive Pediatrics
Celia T. Sy, M.D.Pediatric Pulmonologist
Department of PediatricsFatima Medical Center
Immunization Vaccinations Type of vaccine Route of administration Immune response Post- exposure drug prophylaxis
Immunization
Denotes the process of inducing or providing immunity artificially by administering an immunologic substances Active Passive
Active Immunization
When it produces the desired beneficial effects by stimulation of endogenous antibody production by the patient Tetanous toxoid MMR BCG
Passive Immunization
Administration of preformed human or animal antibodies to individuals already exposed or about to be exposed to certain infectious agents Tetanus antitoxins Immune globulins
Immunobiologic Substances
Vaccine - a suspension of live or inactivated microorganism or fractions thereof administered to induce immunity and prevent infectious disease or its sequela
Toxoid – modified bacterial toxin that has been made nontoxic but retains the ability to stimulate the formation of antitoxins
Antitoxins – a solution of antibodies derived from the serum of animals immunized with specific antigens Passive immunization
Diphtheria antitoxin Tetanus antitoxin
Immune globulin (IG) - a sterile solution containing antibodies from human blood. Intended for IM use for passive immunization
Measles immune globulin hepatitis b immune globulin
IV IG – a product derived from blood plasma from the donor pools similar to the IG pool but prepared for IV used Used in primary antibody-deficiency
disorders- Kawasaki disease- ITP- Hypogammaglobulinemia
Immunologic Constituents Suspending fluids – sterile water, saline Preservatives, Stabilizers, Antibiotics
used to inhibit or prevent bacterial growth Stabilize the antigens or antibodies
albumin, phenols, neomycin, mercurial
Adjuvants – evoke suboptimal immunologic response To enhance immunogenicity
Al hydroxide, Al phosphate
Vaccines & Toxoids Live vaccines
BCG MMR Oral polio Varicella Oral typhoid
Killed antigens Toxoids
DPT Tetanus
Killed antigens Inactivated Virus
IPV (inactived polio virus)
Influenza Rabies Hepatitis A Hepatitis B
Killed antigens Bacterial
polysaccharide Hib
Route of Administration Intramuscular (IM)
DPT IPV (as DPT-IPV-
HIB combination)* Hep A & B HiB Influenza Pneumococcal Meningococcal Typhoid
Subcutaneous (SC) Measles Mumps Rubella MMR Varicella IPV Pneumococcal Meningococcal
Where to inject?
General rules: For children < 1 year old – lateral
thigh For children > 1 year old - deltoid Buttocks should not be used for active
vaccinations because of the potential risk of injury to the sciatic nerve
If the buttocks are to used – use only the upper outer quadrant
Fever:To give or not to give?
Minor febrile illness or malnutrition is not a contraindication to immunization
Immunization is deferred in the presence of severe febrile illness
Vomiting:What to Do?
Regurgitated oral vaccine If the child vomit or regurgitate within
5 – 10 mins after giving OPV – another dose should be given at the same visit
If repeated dose is not retained, re-administered at the next visit
Diarrhea:Could OPV be given?
Diarrhea should not be considered as a contraindication for OPV but to ensure full protection, doses given to children with diarrhea SHOULD NOT BE COUNTED as part of the series
Need to give 2 or more vaccines:How to give?
Multiple vaccinations Administer each vaccine at a different
site using different needles and syringes
If > 1 vaccine is to be used in a single limb, use the thigh muscle and given at 1 -2 inches apart
Interruption of ScheduleWhat to do?
Interruption with a delay between doses does not interfere with the final immunity achieved
No need to start the series again
Contraindications?
Live attenuated vaccines is contraindicated in: Pregnant woman Immunocompromised person –
leukemia, lymphoma, malignancy, therapy with steroids, alkylating agents, antimetabolites
Radiotherapy
Trivia
Which of the following are live vaccines?
DPT MeaslesTOPV PneumococcalIPV MeningococcalBCG Oral TyphoidHep BMMR
Guidelines for Giving Live vaccines and killed Antigens
2 or more killed antigens – may be administered simultaneously or at any interval between doses Example:
DPT and Hep B DPT and Hib Hep A and Hep B
Killed and live antigens – may be administered simultaneously or at any interval between doses Example:
DPT and OPV Hep b and MMR DPT and Measles DPT and varicella
2 or more live antigens – may administered simultaneously or at 4 week minimum interval if not given simultaneously Example:
Measles and varicella MMR and varicella
** OPV can be administered at any time before, with or after MMR if indicated
Guidelines for administration of IG & Vaccines
Simultaneous administration IG and killed antigen – given at the same
time or at any time between doses Hepatitis B immune globulin and hepatitis B
vaccine Tetanus antitoxins and anti-tetanus vaccine
IG and live antigen – should generally NOT BE ADMINISTERED simultaneously
Guidelines…IG & Vaccines
Non-simultaneous administrationFirst Second
IG Killed Ag No interval neededIG Live Ag dose relatedKilled Ag IG No interval neededLive Ag IG 2 weeks
Interval between IG & Live Measles Vaccine
IVIG Interval ITP 400 mg/kg 8 month ITP 1000 mg/kg 10 months Kawasaki 11 months
Blood transfusion Whole blood & packed RBC 6 months Plasma/platelets 7 months
Interval…IG & live measles vaccine
IG measles prophylaxis Normal contact 0.25ml/kg 5
mons Immunocompromised 0.50ml/kg 6
mons
Trivia Which of the following vaccines
can be given simultaneously? Hep B & Measles BCG & DPT Oral polio & measles DPT & MMR Measles & MMR DPT & IPV + HiB
Immune Response
Immune response to one live virus vaccine might be impaired if administered within 30 days of another live virus vaccine
Only OPV and MMR can be administered at anytime before, with or after each other
Immune Response
Live virus vaccines can interfere with the response to a tuberculin test
Tuberculin testing can be done either on the same day that live virus vaccines are administered or 4 – 6 weeks later
Special Conditions…Special Considerations
Persons with hemophilia Increased risk of hepatitis B &
hematomas Assess the patient’s bleeding risk Use fine needle & apply pressure to
the site
Special considerations…
Altered immunocompetence Killed or inactivated vaccines can be
administered to all immunocompromised patients
OPV should not be given to any household contacts of an immunocompromised patient
IPV can be given
Special considerations….
Altered immunocompetence MMR is not contraindicated to close
contacts of immunocompromised persons
MMR vaccine is recommended for all asymptomatic HIV-infected persons and should be considered for all symptomatic HIV-infected persons
Special consideratios…
Preterm infants Regardless of birth weight should be
vaccinated at the same chronological age and according to the same schedule
Use full recommended dose except BCG
OPV should be deferred until discharge from the nursery
Special considerations…
Pregnancy Combined tetanus and diphtheria
toxoids ARE THE ONLY vaccine indicated
Vaccines BCG (Bacille-Calmette-Guerin)
Attenuated bovine strains of tubercle bacilli
Route: intradermal Dose: 0.05 ml preterm 0.1 ml term Complications
Abscess Indolent ulcer lymphadenopathy
BCG Normal course
Wheal diappear in 30 mins
Induration – after 2-3 wks
Pustular formation – after 4 – 6 wks
Full scarification – after 6 – 12 wks
Accelerated reaponse – 91-100% correlation with TB infection Induration – after
2 – 3 days Pustular formation
– after 5 – 7 days Scar – after 2 -3
wks
Polio vaccine
OPV – live attenuated vaccine IPV – inactive polio virus Combination vaccine:
DPT + IPV + Hib
DPT
Toxoids of diphtheria & tetanus; inactivated pertussis component adsorbed into aluminum salts
Dose: 0.5 ml Route: IM Side effect: swelling at injection
site
DTaP
Diphtheria, tetanus, acellular pertussis component
Decrease risk of neuroparalytic reactions due to component of pertussis
Measles Live attenuated vaccine Freeze dried Dose: 0.5 ml SQ Side effects: fever between 5th-14th day
after injection, rashes, arthritis Prophylaxis: may be given within 72
hours after measles exposure Measles IG – 0.25 ml/kg IM may be
within 6 days of exposure
Hepatitis B Vaccine
Infant born to HBs Ag-positive mother should received: Hep b Vaccine + Hep B immune
globulin (HBIG) within 12 hours of birth at different site
Next dose: Hep B at 1-2 months of age and 3rd dose at 6th month of age
Schedule: 0, 1, 6
Hepatitis B Vaccine
Infant born to mother whose HBsAg status is unknown: Hep B vaccine within 12 hours of birth Request for mother’s HBsAg status –
if (+)Infant should received HBIG
Asap (no later than 1 week of
age)
Recommended Schedule BCG
DPT, TOPV, IPV, Hib
Hepatitis B
Measles
At birth or anytime after birth
2, 4, 6 month of age
0, 1, 6 month of age 0, 1, 3 month of age
(endemic country)
9 month of age ( can be given at 6
month of age)
Schedule…. MMR Hepatits A Pneumococcal
(IPD 7 valent) Pneumococcal
(23-valent) Meningococcal Typhoid
15 month of age After 1 year of age 2, 4, 6 months up
to 9 years of age 2 years of age
2 years of age 3 years of age
Post-exposure Drug Prophylaxis Diphtheria Erythromycin Pertussis Erythromycin Cholera Tetracycline Plasmodia Chloroquine N. gonorrhea
Amoxicillin/Penicillin Meningococcemia Rifampicin
Sulfisoxazole Ceftriaxone
Tuberculosis Isoniazid
Case 1A 3 y/o child was exposed to a person with measles. Past
immunization hx: he had received 1 dose of BCG, 3 doses of DPT, TOPV & Hepatitis B. If you are the attending physician, how are you going to manage the patient?
Give measles vaccine if the exposure is within 72 hours Give measles immunoglobulin if the exposure is more
than 72 hours Give MMR if the exposure is within 72 hours Give Mesles vaccine and immune globulin at the same
time Observe the patient
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