vaccinations
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BASIS OF VACCINE PROPHYLAXIS
Main Statements Vaccination is the most reliable measure of infectious diseases prophylaxis. Due to vaccination smallpox is eliminated in the world, morbidity and mortality
from such dangerous infections as poliomyelitis, measles, diphtheria, newborn tetanus, hepatitis B are considerably decreased.
All vaccines are divided into live, inactivated, recombinant and anatoxins. According to WHO terminology, all the diseases registered in vaccinated people are
divided into complicated course of postvaccination period and postvaccinal complications.
There are strict criteria which allow attribute unfavorable events after vaccination to postvaccination complications.
There is a strict schema of prophylaxis of postvaccination complications.
Vaccine prophylaxis is an artificial reproduction of specific immune
response with the goal of creation in human of nonsusceptibility to infectious
diseases by the method of vaccine application.
Currently about 40 diseases can be prevented with the usage of vaccines.
Medicine is capable to protect children from actually all the diseases against which
vaccines are developed. It became possible due to existence of national vaccination
schedule in almost every country. The schedule considers a lot of factors which
influence the scheme of vaccination in every separate country. Schedule of
prophylactic vaccines considers level of infectious morbidity, age particularities of
immunity formation in children, influence of maternal antibodies, side reactions,
complications and accessibility of vaccines.
Existence of unified standards in matters of immunization in some
particular countries allows provide considerable decrease of morbidity among
population with vaccine controlled infections. Such approach allowed defeat such a
wide-spread and dangerous disease of the past as smallpox. Currently vaccination
against smallpox is stopped, as circulation of causative agent is absent. In majority
of world countries, including Ukraine, poliomyelitis is eliminated. In majority of
American and European countries such severe diseases as measles, inborn rubella,
neonatal tetanus and diphtheria are not detected. Thanks to vaccination against
viral hepatitis B the frequency of hepatocellular carcinoma in children is
decreased.
Vaccination provides the possibility not only to prevent development of
infectious diseases, to decrease their severity and frequency of complications, to
minimize the risk of lethal outcome but it also has social and economical
significance. Thanks to vaccination the possibility of epidemics development is
excluded, stable tranquility of the whole society and parents of every concrete
child is established, the sureness of the doctors in the health of their patients is
provided. Besides, the number of hospitalizations, percentage of disabilities,
expenses on buying expensive drugs and causes of temporal incapacity to work are
decreased.
A very important issue in decreasing morbidity of infectious disease or
their elimination is the necessity to vaccinate maximal amount of children
population and every single child should follow the entire vaccination schedule.
Only in this case the appropriate level of population immunity is formed. If 95% of
the whole population is vaccinated, then the unvaccinated or partially vaccinated
people will also be protected from infections. It occurs due to formation of stable
population immunity. Vaccination of every individual person protects not only this
concrete person from infection but indirectly also protects all the members of
population.
If vaccination encompassing is not sufficient, the increased risk of the
infectious morbidity appears even in vaccinated people, as the vaccination does not
provide 100% resistance to the diseases. If the number of unvaccinated by different
reasons children will increase, there is a high probability of returning the
epidemics of infectious diseases. Due to vaccination in the world the morbidity and
mortality from many dangerous infections was considerably decreased, while such
fatal disease as smallpox was completely eradicated.
All the vaccines are divided into the following groups:
1. Live vaccines (against measles, rubella, mumps, varicella, poliomyelitis,
rotaviral infection, influenza, Q fever, tuberculosis, anthrax, tularemia, plague,
etc.).
2. Inactivated vaccines (against whooping cough, influenza, meningococcal
infection, pneumococcal infection, Haemophilus influenzae, viral hepatitis A,
poliomyelitis, rabies, typhoid fever, etc.).
3. Recombinant vaccines (against viral hepatitis B, papillomaviral infection).
4. Anatoxins (against diphtheria, tetanus).
There are monovaccines (against one infection) and combined vaccines
(against several infections). Combinant (combined) vaccines are two-component
(against diphtheria and tetanus, against hepatitis A and B), three-component
(against measles, rubella and mumps; against whooping cough, diphtheria and
tetanus), four-component (against measles, rubella, mumps and varicella; against
whooping cough, diphtheria, tetanus and hepatitis B), five-component (against
whooping cough, diphtheria, tetanus, poliomyelitis and haemophilic infection), six-
component (against whooping cough, diphtheria, tetanus, poliomyelitis,
haemophilic infection and hepatitis B).
The regulation determining the age and sequence of prophylactic
vaccination performance is National schedule of prophylactic vaccines. In Ukraine,
according to National schedule of prophylactic vaccines, the obligatory vaccination
is performed against 10 infections: tuberculosis, viral hepatitis B, whooping cough,
diphtheria, tetanus, poliomyelitis, haemophilic infection, measles, rubella, mumps.
Besides obligatory vaccines the National schedule of prophylactic vaccines of
Ukraine also includes vaccines according to health conditions (against influenza,
pneumococcal infection, meningococcal infection, varicella, hepatitis A and
hepatitis B); according to epidemiological indications (against tularemia,
brucellosis, anthrax, leptospirosis, Q fever, tick-born encephalitis, plague, typhoid
fever, influenza, yellow fever, rabies, diphtheria, tetanus, hepatitis A,
poliomyelitis, measles, mumps, rubella, meningococcal infection and hepatitis B);
recommended vaccines (against varicella, hepatitis A, hepatitis B, influenza,
pneumococcal infection, meningococcal infection, rotaviral infection,
papillomaviral infection).
With considerable decrease of infectious morbidity and mortality reached
with modern programs of immunization, postvaccinal reactions and complications
acquire more and more significance. Besides antigens causing immune response,
vaccines contain a large amount of other substances, including solvents, stabilizers,
components of nutritive media, conservants, adjuvants, antibiotics. Any of these
components can provoke local or systemic side effect after vaccination injections.
According to WHO terminology (1991) all the diseases registered in
vaccinated are recommended to name as “unfavorable events” after vaccination.
They are divided into:
1. Complicated course of postvaccination period.
2. Postvaccinal complications.
Complicated course of postvaccinal period includes different diseases
simultaneous with vaccination but without cause-effect relation.
Postvaccinal complications (PVC) are conditions which develop as a
result of vaccination performance and have evident or proved connection to
vaccination and are not typical for usual course of vaccination process.
Postvaccinal complications are divided into:
- toxic (excessively strong);
- allergic (local and general);
- caused by infectious vaccination process (live vaccines).
Criteria according to which the “unfavorable events” can be attributed to
postvaccinal complications:
1. Proved relation in time with performance of vaccination.
2. Dose-dependent relation is detected.
3. Known tropism of live vaccines to certain tissues and organs.
4. Analysis of alternative causes is performed and degree of their non-
relation is proved.
5. After abandoning the usage of the vaccine, “unfavorable events” are not
registered any more.
6. Clinical presentation of the disease developed during postvaccinal
period is corresponding to clinical presentation typical for already known
postvaccination complications.
For postvaccination complications the following signs are typical:
• typical clinical signs of “standard case”;
• stereotypic terms of development.
Majority of specialists describe the following reasons of PVC appearance:
1. Vaccine reactogenicity.
• direct toxic effect of vaccine components;
• pharmacodynamic and immunologic activity of the vaccine;
• tropism of live vaccines to different tissues and organs;
• possible reversion of vaccine strain, acquisition of wild strain properties
(live poliomyelitis vaccine);
• contamination of vaccines by toxic substances.
2. Individual properties of macroorganism.
• pre-existing pathology which can be exacerbated in post-vaccination
period;
• sensitization, changes of immune reactions, perversion of endogenous
daily biorhythms in post-vaccination period;
• inborn or acquired defects of immunity, at which live vaccines can
cause a vaccine-associated disease;
• genetic predisposition of the child to given pathology (nervous system
disturbances, allergic, autoimmune diseases), which can develop in response to any
provoking factor. Vaccine, as a trigger, can be similar to any other outer influence,
e.g., acute viral infection.
3. Presence of program mistakes:
• violation of technique of immunization, when vaccines are injected
incorrectly. For example, vaccine against tuberculosis is injected subcutaneously
instead of intracutaneous injection. And the opposite, vaccines containing
aluminium hydroxide are injected intracutaneously (both these situations can cause
development of local pathological reactions);
• accidental usage of different medicinal drugs instead of solvents for
dried vaccines;
• violation of sterility requirements at vaccine injection which can lead to
development of abscess in place of vaccine injection;
• mistaken usage of some vaccines instead of others, in wrong dosage, to
children who should not be vaccinated with given vaccines according to age.
Clinical manifestations of post-vaccination complications. Toxic. Toxic
reactions are most commonly seen after immunization with killed vaccines,
particularly DPT, much more seldom after anatoxin injections, usage of
polysaccharide and recombinant vaccines. At vaccination with live vaccines toxic
reactions are most often registered after injection of measles vaccine. Terms of
development of toxic reactions correspond to those of usual reactions. After
injection of inactivated vaccines (DPT, polysaccharide, recombinant, anatoxins)
toxic reactions develop during the first three days after vaccination and most often
(95% of cases) during the first day. They are characterized by development of
prominent disturbance of general condition, intoxication: fatigue or restlessness,
decreased appetite, sleep disturbances, possible vomiting. The most common
symptom is fever till 39.50С and higher. Clinical signs remain during 1-3 days. At
injection of vaccine against hepatitis B and influenza split-vaccines the toxic
reactions can be accompanied by myalgia.
Toxic reactions after injection of measles, mumps and rubella vaccines can
include intoxication signs, fever, as well as catarrhal symptoms from upper
respiratory tract and other typical for these vaccines signs of postvaccination
process. Sometime nasal bleedings can develop. The terms of reaction appearance
are from 4-6th days till 12-14th days, that is, their development corresponds to
height of vaccination process. Symptoms of toxic reaction are preserved during
several days and disappear by the end of height vaccination period.
Allergic. Local allergic reactions. Local allergic reactions are most
commonly registered after injection of inactivated vaccines containing hydroxide
aluminium as a sorbent: DPT, anatoxins and others. At usage of live vaccines local
allergic reactions are seen more seldom and are also caused by additional
substances of the vaccine.
Local allergic reactions are characterized by appearance of hyperemia and
swelling more than 8 cm in diameter in the place of vaccine injection. According to
WHO classification, local reaction is considered to be edema and hyperemia
spreading beyond borders of nearest joint or covering more than half of body part
in the place of vaccination, as well as tenderness, hyperemia and edema (regardless
of size), which is present longer than 3 days. In rare cases after usage of vaccines
containing hydroxide aluminium, formation of aseptic abscess is possible.
Terms of appearance of local allergic reactions are within the first 1-3 days
after immunization with both killed and live vaccines.
General allergic reactions. Extremely rare general allergic reactions
include anaphylactic shock and anaphylactoid reaction.
Anaphylactic shock (IgE mediated acute reaction of immediate type
hypersensitivity). Typical, generalized form of shock has the periods of precursors,
height and recovery after shock. The shock usually develops during 3-30 min and
till 2 hours; at fulminant course it develops immediately (or several minutes later)
after injection of any vaccine.
At the precursor period the child develops inner discomfort, restlessness,
chills, weakness, dizziness, tinnitus, decreased vision, extremities and tongue
numbness, sometimes angioneurotic edema or urticaria. At fulminant form of
shock this period is absent.
The height period is characterized by:
• circulation insufficiency (decrease of arterial blood pressure lower than
90/60 mm Hg at mild form and till absence of blood pressure, weakness and
absence of pulse on periphery vessels, cold extremities, pale skin, increased
sweating, decreased urination till 20 ml/min and less);
• respiratory insufficiency (bronchospasm and/or laryngospasm, edema
of larynx);
• decreased consciousness (at mild form during several minutes, at severe
from during an hour and longer); possible development of seizures.
Period of shock recovery sometimes continues till 3-4 weeks. During this
time acute myocardial infarction, allergic myocarditis, glomerulonephritis,
hepatitis, serum sickness, disturbances of brain circulation and damage of nervous
system can develop.
Anaphylactoid reaction (acute reaction of hypersensitivity). It develops
acutely but its appearance is more prolonged in time than anaphylactic shock,
during the first two hours after vaccination. It presents with acute decompensation
of blood circulation, acute respiratory distress as a result of respiratory tract
obstruction. Additional clinical signs of anaphylactoid reaction are skin
involvement (spread urticaria, Quincke’s edema or generalized angioneurotic
edema) and gastrointestinal involvement (colic, vomiting, diarrhea).
The most common presentation of generalized allergic reactions is rash on
the skin: urticaria and Quincke’s edema, which appears within the first 1-3 days
after vaccination with killed vaccines and since 4 – 5th till 14th days after
vaccination with live vaccines (in height period of vaccination). It develops most
often by IgE-dependent type.
Urticaria is edema of epidermis and papillary layer of dermis, widening of
capillaries and arterioles; Quincke’s edema (giant urticaria, angioneurotic edema)
is the edema of deeper layers of dermis and subcutaneous tissue. Approximately in
half of patients urticaria is accompanied by Quincke’s edema. Quincke’s edema
can be localized on face and in oral cavity, or it can affect respiratory system,
which present with coarse voice, barking cough, attacks of cough, suffocation,
until asphyxia. In 30% of cases edema of gastro-intestinal tract is possible, which
presents clinically with nausea, vomiting, flatulence, intestinal obstruction. At
involvement of nervous system headache, dizziness, nausea, vomiting and
meningeal signs are possible.
Rare but severe variant of general allergic reactions is toxic-allergic
dermatitis (syndromes of Stevens-Johnson, Lyell). Term of their appearance
coincide with height of vaccination process.
Involvement of nervous system. Seizure syndrome. The most frequent post-
vaccination complications from nervous system are seizure (encephalic) reactions
such as febrile seizures (at T >38.00С) or afebrile seizures (at Т <38.00С).
Seizure syndrome with hyperthermia (febrile seizures). These seizures
present as generalized tonic, tonic-clonic and clonic attacks, single or repeated,
usually of short duration. Febrile seizures can develop after all vaccines. The most
commonly they are provoked by DPT, on the second place by frequency is vaccine
against measles as monovaccine or in combination with other vaccines. Terms of
development are within 1st day, rarer 2-3rd days after vaccination with inactivated
vaccines. After live vaccines these seizures can develop on the 5-12 th days after
vaccination, at the height of vaccination reaction. Currently some authors do not
consider febrile seizures to be post-vaccination complication, as children of the
first three years are prone to seizure conditions at fever caused by different
reasons. These investigators consider febrile seizures after vaccination as reaction
of these children for fever. Older children develop hallucination syndrome as an
equivalent of seizure reaction during high fever.
Seizure syndrome with normal or subfebrile temperature with disturbances
of consciousness and behavior. Afebrile seizures are notable by polymorphic
features, from generalized seizures till small attacks (“absences”, “nods”, “pecks”,
“freezings”, fibrillations of separate muscle groups). Small attacks are usually
repeated, serial; they more often appear at falling asleep and wakening of the child.
Afebrile seizures are mostly seen after injection of pertussis vaccine and, unlike
febrile ones, they can appear later after vaccination, in 1-2 weeks. After measles
vaccination afebrile seizures are seen extremely seldom. Development of afebrile
seizures justifies pre-existing organic damage of nervous system in the child which
was not timely diagnosed before vaccination, and the vaccination in these cases is
a provoking factor (trigger) of already existent latent CNS disease.
Differential diagnosis of seizure syndrome (encephalic reaction):
• febrile seizures in post-vaccination period should be differentiated with
seizure attack at intercurrent infectious disease developed in the vaccinated child;
• afebrile seizures are differentiated with debut of epilepsy, other organic
diseases of nervous system with seizure syndrome (West syndrome, infantile
spasms, etc.); somatic diseases which can be accompanied by seizures
(spasmophilia, diabetes, etc.).
Differential diagnosis is based on:
•term of seizures development, at the height of vaccination process or
outside this time;
•presence or absence of intercurrent disease symptoms;
•data about presence of seizures in the patient earlier, as well as in
his/her relatives;
Laboratory investigations for exclusion of the etiology of seizures
(hypocalcemia, hypoglycemia, etc.).
Vaccine-associated diseases. The most severe ones from the group of
pathological process with involvement of nervous system are vaccine-associated
poliomyelitis, encephalitis and meningitis. This group of postvaccination
complications is observed rather rarely and only after usage of live vaccines.
Vaccine-associated poliomyelitis (VAP) or acute flaccid paralysis caused
by vaccine virus.
The disease is caused by damage of anterior horns of spinal cord. It
presents as a rule with damage of one extremity with typical neurological
disorders: decreased muscle tone, reflexes, trophies (atonia, areflexia, atrophy) but
with preservation of sensitivity. It lasts not less than 2 months, leaving afterwards
prominent residuals. It develops in vaccinated children on the 4-30th days after
immunization with live vaccine and in contacts with vaccinated people within 60
days. It mainly develops after first application of vaccine, in the mean frequency 1
per 2.5 million vaccine doses. Risk of the disease in immunodeficient people is
many times higher than in healthy ones.
Differential diagnosis of VAP is performed with acute flaccid paresis
(AFP):
• infectious AFP caused by viruses of “wild” strain of poliomyelitis,
enteroviruses of ECHO or Coxsackie groups;
• not infectious AFP caused by neuromyalgic syndrome, organic
neurological, bones, joint or vessel pathology, revealed or decompensated during
post-vaccination period.
The diagnosis of VAP can be confirmed by:
• data about performed vaccination with live poliomyelitis vaccine or
contact with vaccinated people;
• typical terms of disease onset from the moment of vaccination;
• typical clinical presentation of acute flaccid paralysis;
• damage of anterior horns of spinal cord, proved by electromyogram
(EMG);
• data about immune deficient state of the patient;
• isolation of vaccine strain of poliomyelitis from the patients (confirmed
by genetic typing).
Vaccine-associated encephalitis are encephalitis caused by live viruses
tropic to nervous tissue (measles vaccine, rubella vaccine). In majority of cases it is
possible to prove intercurrent character of nervous system disease, which is only
connected to vaccination in time. Rare exclusions are immunocompromised people
when the virus of live vaccine can disseminate into all the organs, including the
brain.
Possibility of the development of vaccine-associated meningitis after
vaccination against mumps in some cases is proved by isolation of vaccination
strain from CSF.
However it is clear that not all the encephalitis and meningitis developed
during postvaccination period is vaccine-associated. It can be caused by other
causative agents not related to vaccines. That’s why every case of postvaccination
encephalitis or meningitis must be carefully examined.
Encephalitis after measles vaccine. Postvaccination encephalitis is a very
rare complication of measles vaccine. Its frequency is 1:1000000 vaccinated,
whereas after measles encephalitis develops in 1 per 1000 patients. Possible term
of disease onset is since 5 till 30 days after vaccination.
Clinical presentation is not specific and cannot be distinguished from the
one at viral encephalitis of other etiology. Morphological picture in case of fatal
outcome is described to be similar to one at other encephalitis.
Besides encephalitis, single cases of encephalomyelitis are described,
which is characterized by acute decrease of consciousness and multiple focal
neurological deficits developed several days after vaccination. On histological
examination the foci of periventricular inflammation and demyelination are seen,
more prominent in white matter of brain and spinal cord. The diagnosis is usually
made at pathomorphological examination.
However, none of the described in literature cases with fatal outcome
allowed isolation of measles vaccination strain from brain, which makes the
diagnosis of vaccine-associated encephalitis controversial.
Subacute sclerosing panencephalitis (SSPE). Cases of development of
SSPE after measles vaccine are well known. The disease is characterized by slow
progression. The process begins with disturbances of behavior and school
performance of the child, absence of appetite and weight loss. Later myoclonic
paroxisms appear at preserved consciousness. Further extrapyramidal dyskinesia
develop: athetosis, chorea, torsion dystonia. Gradually due to developing
chorioretinitis or atrophy of optical nerve vision is worsened.
Terminal stage is characterized by decortication and vegetative stage.
Length of SSPE development is from several weeks till several years with possible
periods of remission.
However, due to Advisory Committee on Immunization Practices (ACIP,
USA, 1997), in none of the cases direct interrelation of SSPE and vaccine strain of
measles is proved. Just the opposite, experts present the data that the frequency of
SSPE in vaccinated against measles children is much lower than after an episode
of measles. It is considered that SSPE develops in children vaccinated previously
against measles with non-efficacy of immunization, when they further develop
episode of measles.
Vaccine associated serous meningitis caused by mumps vaccine virus.
According to literature data, frequency of serous meningitis after mumps
monovaccines or combined vaccines containing mumps component depends on
used vaccine strain of the virus. So, for strain Uraba the frequency of
postvaccination meningitis is between 1:2000-1:20000; for strain Jeryl-Lynn it is
1:150000-800000. Due to obtained data the strain of Uraba was substituted with
Jeryl-Lynn strain in many countries. After this substitute the notifications about
vaccine associated meningitis became considerably rarer.
Guillain-Barre syndrome. It is an acute rapidly progressing ascending
symmetrical flaccid paralysis with loss of sensitivity, as a rule, without fever at the
disease onset. Case relation is not only proved after implementation of live
poliomyelitis vaccine; the syndrome is also described after usage of anatoxins,
vaccine against Haemophilus influenzae type B and influenza vaccines.
Development of Guillain-Barre syndrome after other vaccines is most possibly due
to previous disease before the vaccination.
Other post-vaccination complications.
Hypotensive-hyporesponsive syndrome. It is a rare complication
characterized by transitory acute cardiovascular insufficiency with arterial
hypotension, decreased muscle tone, shot-term loss or decrease of consciousness,
skin paleness.
Differential diagnosis of hypotensive-hyporesponsive syndrome is
performed with anaphylactoid post-vaccination reactions, syncopes caused by
other reasons (disturbances of cardiac rhythm, epileptic syndrome, hypoglycemia,
orthostatic reactions). The diagnosis can be confirmed with history data: presence
of syncopes before, orthostatic reactions, emotional instability in older age
children.
Thrombocytopenic purpura. It is an extremely rare post-vaccination
complication which present with acute decrease of platelets number in blood and
acute hemorrhagic syndrome. The cause-effect relation of thrombocytopenic
purpura and measles-containing vaccines is proved. The terms of development are
since 5th till 15th days after vaccination. The pathogenesis is based on infectious-
allergic and immune inflammatory mechanisms. Clinical presentations, disease
course, treatment and prognosis do not differ from those at thrombocytopenic
purpura of other etiology.
High-pitch cry. It is a persistent monotonous cry in children of the first six
months of age which develops several hours after vaccination and continues from 3
till 5 hours. It is registered mostly after vaccines containing whole-cell pertussis
vaccine. It is considered that development of high-pitch cry is due to possible
action of pertussis vaccine on changes in brain microcirculation. This leads to
increased intracranial pressure and appearance of headache.
Complications after BCG vaccine. Complications after BCG vaccine are
seen with frequency of 0.02%-0.004% from number of vaccinated newborns; after
revaccination they are even rarer and develop in 0.001%-0.0001% of revaccinated
children and adolescents.
Vast majority of complications present with local processes. They are
caused as a rule by violation of the technique of vaccination: the vaccine is injected
subcutaneously instead of intracutaneous; accidental use of higher dosage in
comparison to the one indicated in instructions; not sufficient sterile conditions of
vaccination. Presence of some (cellular or combined) forms of primary immune
deficiencies promotes development of certain local complications such as BCG-
lymphadenitis. According to WHO classification, suggested in 1984y.,
complications after anti-tuberculosis vaccine are divided into 4 categories:
• local complications, the most commonly seen;
• persistent and disseminated BCG infection without fatal outcome;
• disseminated BCG infection, generalized damage with lethal outcome
(2nd and 3rd variants are seen at inborn immune deficiencies);
• so called BCG syndrome. This disease develops soon after vaccination
or more often after revaccination and is characterized by allergic pathology:
nodular erythema, different allergic rashes. This category also includes formation
of colloid scar at the place of vaccine injection.
Local complications. Lymphadenitis, most commonly axillary and rarer
cervical. They develop 2-3 months later after vaccination. Lymphadenitis can be
closed or with fistula. They start to develop without symptoms. Lymph node
slowly begins to increase in size, is painless at palpation, intoxication can be
absent. In some cases purulent inflammation of the fistula develops with discharge
of pus. In these cases intoxication is prominent as a rule.
The pus is usually sterile, but sometimes vaccine strains of BCG can be
isolated. Reverse development of lymphadenitis is long-term and occurs within 1-2
years. At cytomorphological examination of lymph nodes caseous necrosis,
epithelioid cells and giant cells are seen. Similar morphological picture is seen at
tuberculosis lymphadenitis.
Lymphadenitis can progress to formation of calcifications in lymph node
more than 10 mm in diameter.
More rarely at the place of injection superficial or deep ulcer is formed.
Ulcers appear 2-4 weeks after vaccination and much rarer after revaccination.
Ulcer borders are elevated, granulation is poor.
Cold abscess develops 1-1.5 months after vaccination or revaccination. At
first hard subcutaneous infiltrate is formed, which is connected to nearest tissue
and is painless at palpation. Signs of inflammation are not seen: hyperemia, tissue
edema, pain at palpation. Intoxication, fever are also absent. Gradually the
infiltrate is softened, fluctuation appears, and fistula develops with discharge of
liquid sterile pus. Sometimes at the place of abscess deep ulcer appears. The course
is long-term. With the treatment the duration is 6-7 months long, without treatment
it can be prolonged till 1.5 years. Healing occurs with formation of star-like scar.
Majority of authors consider formation of the abscess to be a technical defect at
vaccination, subcutaneous injection of the vaccine.
At revaccination of female adolescents seldom formation of colloid scar is
observed. By the appearance this scar is not different from colloid scar of any other
origin – round or elliptical, hard, smooth, painless. If form of the scar is changed
and itching appears, this justifies its growth. Reasons of colloid scars formation are
not clear.
Sometimes local reaction is complicated by joining of secondary infection.
In these cases fistula is formed with discharge of pus. Usually common coccal
flora can be isolated from the pus.
Generalized complications. They are seen very seldom. Newborns with
primary immune deficiency can develop generalization of the infection with severe
damage of different organs and systems, including nervous system, with clinics of
serous meningitis.
Similar generalized infection often has lethal outcome. From affected
organs BCG vaccine strain mycobacteria are isolated.
In later years there are reports about osteitis are a presentation of
generalized BCG vaccine infection in the literature. Osteitis develops 7-24 months
after vaccination. Clinically it presents as bone tuberculosis. Prognosis at timely
therapy is benign; the frequency of similar complication due to different sources is
from 0.1 till 30 per 100000 vaccinated.
As a very rare complication also related to disseminated vaccine strain of
mycobacteria tuberculosis, “lupus” is described which develops in the place of
vaccine injection or over regional lymph node. From affected skin mycobacteria of
BCG vaccine strain are isolated. Eye damage is also described which presents with
phlyctenular conjunctivitis, rarer iridocyclitis or scleritis.
Prophylaxis of postvaccination complications.
1. Usage of vaccines with complete cycle of pre-clinical and clinical trials
which are registered in Ukraine. Usage of modern types of vaccines (acellular
pertussis vaccine and inactivated poliomyelitis vaccine) plays an important part in
prophylaxis of postvaccination complications. So, implementation of inactivated
poliomyelitis vaccine in 2006 into National vaccination schedule of Ukraine
allowed exclude later such sever complication as vaccine-associated poliomyelitis.
2. To avoid post-vaccination complications, it is necessary to follow
strictly all the recommendations regarding storage, transport, doses, schema,
techniques of vaccine injection and contraindications to usage.
Besides contraindications described in regulations for every certain
vaccine, National vaccination schedule gives absolute contraindications for
vaccination usage and particularities of their usage at existence of temporal
contraindications.
The selection of children for vaccination is important in prophylaxis of
post-vaccination complications. With this goal, it is necessary to follow strictly
individual schedule of prophylactic vaccines for every child. Before vaccination
the child should be examined by a doctor, temperature must be measured as well as
history must be taken to exclude any disease which could be a contraindication for
vaccination. If the doctor has concerns about child’s health, specialist consultations
and laboratory investigations should be performed. Vaccination can only be
performed after exclusion of contraindications to vaccination. Children with
different chronic diseases with moderate and severe course in remission must be
vaccinated in hospital conditions with follow-up of corresponding specialists.
Important role belongs to obtaining allergy history. At the presence of
allergic reactions in the past for previous vaccine usage or components of vaccine,
the performance of given vaccination is contraindicated.
To exclude technical mistakes at vaccination, it is necessary to follow all
the rules of vaccine storage and transport. All the manipulations during
immunization must be done by specially trained personnel with strict adherence to
instructions of usage of every specific vaccine.
Correct technique of vaccination performance is important for prophylaxis
of post-vaccination pathology. During the first year of age, vaccines for
subcutaneous and intracutaneous injection are usually given to anterior-lateral
surface of thigh, whereas in older children and adults (if muscle layer is enough)
into deltoid muscle. Vaccines are not recommended to be injected into gluteus
muscle due to high risk of sciatic nerve damage and vaccine injection into fatty
tissue instead of muscles. In order not to inject accidentally the vaccine into blood
vessel, before vaccination the syringe plunger should be drown back to justify that
there is not blood in syringe.
In post-vaccination period medical personnel should perform active
follow-up to reveal timely all the disease cases in vaccinated children, to perform
monitoring and examination of every case suspected for postvaccination
complication.
Prophylaxis of vaccine-associated poliomyelitis
1. In close children groups (nurseries, boarding schools, etc.) it is necessary to
provide separate living of children who were vaccinated during the previous
3 weeks with live poliomyelitis vaccine and those who were not vaccinated.
2. During hospitalization of children to medical settings it is necessary to
collect carefully the vaccination history. Hospitalization of children and
unvaccinated children should be done into separate rooms.
3. Intramuscular injections (if not due to life-threatening situations) are
contraindicated during 2 weeks after vaccination with live poliomyelitis
vaccine.
4. Surgical procedures (including teeth extraction, tonsillectomy, adenectomy)
(if not due to life-threatening situations) are contraindicated during 2 weeks
after vaccination with live poliomyelitis vaccine.
5. Registration of contraindications of live poliomyelitis vaccine
administration.
Questions for self-control
1. Goals and tasks of immunoprophylaxis.2. National schedule of prophylactic vaccinations in Ukraine (vaccination according to age, health status, vaccinations on epidemiological indications, recommended vaccinations).3. Characteristics of vaccines for prophylaxis of diphtheria, pertussis and tetanus (DPT, DT, Tdap). Normal course of post-vaccination period and possible pathological reactions, their prophylaxis and treatment.
4. Characteristics of vaccines for prophylaxis of poliomyelitis: oral (live) and inactivated (killed).5. Normal course of post-vaccination period of vaccination against poliomyelitis. Possible pathological reactions, terms of their development and clinical presentations. What is vaccine-associated poliomyelitis?6. Characteristics of vaccines for prophylaxis of measles, mumps, rubella. Normal course of post-vaccination period of vaccination against measles, mumps, rubella. Possible pathological reactions, terms of their development and clinical presentations. 7. Clinics, diagnosis and emergency treatment of anaphylactic shock.8. Contraindications for prophylactic vaccinations.9. Prophylactic vaccinations by epidemiological indications in nidus of diphtheria, mumps, poliomyelitis, pertussis.
Tests for self-control
1. Vaccinations against which infectious diseases should be performed to children according to age, due to Schedule of vaccination:А. Poliomyelitis, tuberculosis, hepatitis A, diphtheria, measles, varicella, mumps, rubella, tetanus;В. Poliomyelitis, tuberculosis, hepatitis A, diphtheria, measles, pneumococcal infection, mumps, rubella, tetanus;С. Poliomyelitis, tuberculosis, hepatitis A, diphtheria, measles, haemophilus infection, mumps, rubella, tetanus, pertussis;D. Poliomyelitis, tuberculosis, diphtheria, measles, haemophilus infection, mumps, rubella, tetanus, meningococcal infection, pertussis;Е. Poliomyelitis, tuberculosis, hepatitis B, hepatitis A, measles, haemophilus infection, mumps, rubella, tetanus, meningococcal infection, pertussis, influenza.2. Which post-vaccination pathologic reaction in brain can develop after vaccination with DPT vaccine?А. Purulent meningitis;В. Serous meningitis;С. Subdural hemorrhage;D. Febrile or afebrile seizures;Е. All the answers are correct.3. What are the terms of local post-vaccination reactions development?А. Before 48 hour;В. Before 72 hours;С. During the first week after vaccination;D. Since 4th till 15th days after vaccination;Е. During 30 days after vaccination.4. At which age the child should be given the first vaccination against measles, mumps and rubella:А. 9 months;В. 12 months;С. 15 months;D. 18 months;Е. 6 months.5. Scheme of vaccination against poliomyelitis:А. 3 months, 4 months, 5 months, 18 months, 3 years, 6 years, 14 years;В. 3 months, 4 months, 5 months, 18 months, 7 years, 15 years;С. 3 months, 4 months, 5 months, 18 month, 6 years, 14 years;D. 3 months, 4 months, 5 months, 18 months, 3 years, 6 years, 15 years;
Е. 2 months, 3 months, 6 months, 18 months, 7 years, 15 years.6. At which age is the planned vaccination against diphtheria and tetanus with DT vaccine performed:А. 6 years;В. 18 months;С. 14 years;D. 18 years;Е. Every 10 years to adults vaccinated according to schedule.7. 4-years old child was not previously vaccinated against diphtheria, tetanus and pertussis. Which vaccine must this child be vaccinated with?А. Diphtheria tetanus anatoxin (DT);В. Adsorbed pertussis-diphtheria-tetanus vaccine (DPT);С. Adsorbed pertussis-diphtheria-tetanus vaccine with acellular pertussis component (DTaP);D. Diphtheria-tetanus anatoxin with decreased contain of antigens (Tdap);Е. Antidiphtherial serum (ADS) and tetanus anatoxin (T).8. Post-vaccination nervous system complications include everything except:А. Post-vaccination encephalitis;В. Meningoencephalitis;С. Encephalopathy;D. Brain abscess;Е. Afebrile seizures.9. The first revaccination of DPT is performed at the age:А. 2-3 years;В. 5 years;С. 6 years;D. 1-1.5 years after first vaccination;Е. Not performed.10. Vaccine-associated forms of poliomyelitis are characterized by all the listed signs except:А. Development of flaccid paralyses since 6 till 30 days after vaccination;В. Typical symptoms of the disease with development of persistent flaccid paralysis;С. Isolation of vaccine strain of poliomyelitis virus from the sick person;D. 4-fold increase of antibody titer to vaccine strain of the virus;Е. Development of sensitivity disturbances of affected skin dermatomes.
Test answers
1-С, 2- D, 3-А, 4-В, 5-С, 6-А, 7-А, 8- D, 9- D, 10-Е.
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