immunization presentation 3

8/3/2019 Immunization Presentation 3

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IMMUNIZATION

BY DR SHIBAMBU PATRICK

21 OCTOBER 2010


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IMMUNIZATION

Immunization is the process whereby a

person is made immune or resistant to an

infectious disease, typically by theadministration of a vaccine.

Vaccines stimulate the bodys own

immune system to protect the person

against subsequent infection or disease


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-

IMMUNIZATION

PASSIVE ACTIVE

Physiological /Natural

Mother Fetus

Breastmilk

ARTIFICIAL

Injections

ATTENUATED

VACCINES OR LIVE

INACTIVATED

VACCINES

(Killed vaccines)


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ACTIVE

IMMUNIZATION

ATTENUATED

Vaccines or lives

INACTIVATED

(Killed vaccines)

VIRAL BACTERIAL

VIRAL BACTERIAL

Measles,Mumps,

Rubella,Chickenpox,

Yellow fever,H1N1

BCG

TYPHOID

POLIO VACC

INFLUENZA

PERTUSIS

CholeraTyphoid vacc

Tissue culture,

embryonated eggs

Live animals


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EXPANDED PROGRAMME ON IMMUNIZATION- EPI (SA) APRIL

2009

AT BIRTH TOPV 0 BCG

6 WKS

TOPV1 DPT1 HBV1 Hib1 PCV1 RV1

10 WKS TOPV2 DPT2 HBV2 Hib2

14 WKS TOPV3 DPT3 HBV3 Hib3 PCV2 RV2

9 months PCV3 MEASLES1

18month TOPV4 DPT4 Hib4 MEASLES2

6 YRS Td 1

12 yrs Td 2


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RSA :WHO ESTIMATES OFIMMUNIZATION COVERAGE

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

BCG 81 81 81 81 81 81 81 84 86 89

DPT1 77 77 77 77 77 77 77 80 82 85

DPT3 69 69 69 69 69 69 69 70 71 73

Hepb3 67 67 67 67 67 67 67 68 69 71

Hib 3 67 67 67 67 67 67 67 68 70 71

Measl 62 62 62 62 62 62 65 69 72 75

Polio 70 70 70 70 70 70 70 71 71 71

Pcv

/rotavi

10/

19


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WHO: SA Reported cases

2009 2008 1981 1980

Diphther

ia

1 0 63 57

measles 5857 39 15805 19193

mumps 0 0 0 0

pertusis 4 _

polio 0 127 112

rubella 2975 1072

Neonata

l tetanus

1 1 214 166


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1.BCG( Bacillus calmette-Guerin)

Vaccine

Widely used in developing countries

Primarily effective in preventing disseminating TB

Consist of freeze dried live attenuated strains ofmycobacterium bovis.

Limited effectiveness in pulmonary TB (50 %)

More effective (80%) against severe childhood TB ie. Milliaryand Meningeal TB

Administered intradermally

NORMAL REACTION TO BCG

Raised papule at site of vaccination

4-6 wks post immunization Resolve spontaneously,may leave scar

NB. There is no association between the presence of BCG scarand immunogenicity or effectiveness of vaccine


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SIDE EFFECTS OF BCG

Prolonged alceration, with lymphadenitis(10%)

More common in HIV infected children who started HAART

in the first 2 yrs of life

MX.

Prednisone 2mg/kg 4 8 wks Continue ART

Rx with Anti-BCG antibiotics if evidence of disseminated BCGdisease ( INH ,Rimfapicin and Etionamide)

M. bovis is resistant to pyrazinamide

CONTRAINDICATION Symptomatic HIV infection

Other forms of impaired immunity


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2.POLIO VACCINE

2 Kinds: 1. TIPV Trivalent inactivated Polio vaccine

2.TOPV Live attenuated trivalent oral poliovaccine.

Both equally effective

TOPV preferred by WHO in its Polio eradicationstrategy

Most rich countries have to TIPV for routineimmunization because of the remote but serious risk

of vaccine associated Paralytic poliomyelitis ( 1: 2million doses) associated with TOPV

TOPV remain the publicly funded vaccine in RSA


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POLIO VACCINE CONT

WHO set a goal to eradicate Polioworldwide by 2005.

In South Africa, the last polio casedue to the wild poliovirus wasreported in 1989.

The final countdown to a polio free

South Africa was launched on 11April 2002.


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3.DIPHTHERIA TOXOID

Inactivated vaccine

Highly effective in inducing antibodies thatneutralize diphtheria toxins, thus protecting

against the disease. May not protect against acquisition or

carriage of Corynobacterium diphteriae

2 preparations available:

An absorbed, more immunogenic, high dosevaccine ( D) < 3YRS

A lower dose formula ( d) > 3YRS


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Diphtheria

Diphtheria caused by

Corynobacterium

diphtheriae

Dangers: upper airways

obstruction produced

by membranes in the

neck ( bull neck

diphtheria )

Myocarditis in the 1st or

2nd week of the disease

Nerve inflammation -

paralysis of muscle

Pharyngeal diphtheria with

membrane covering

tonsils and uvula


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4.TETANUS TOXOID

Inactivated ,yet antigenic preparation of

tetanus toxin

Protective antibodies develop in over 95% of

vaccine following primary series of3vaccines

TT every 10 yrs no longer recommended

Routine vaccine of pregnant women with TTduring 2nd trimester of pregnancy resulted

in decline incidence of neonatal tetanus by

passive transfer of maternal antibodies.


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TETANUS

Dreaded disease acquired fromcontamination of wound orumbilical stump by Clostriduimtetani

Convulsions

Respiratory complication-fregcause of death

Pronounced archind of backwith clamping of jaws occursduring recurrent muscle spasm

Fig1:child with painful musclecontraction due to tetanus

Fig2:neonatal tet with completerigidity


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6.CONJUGATE HAEMOPHILUS

INFLUENZAE Hib type b vaccine

Protect against Hibmeningitis, pneumonia,epiglotitis and osteomyelitis.

Does not protect againstotitis media which is caused

by unencapsulated non-typeb H. influenzae

Invansive Hib diseaseremain notifiable illness inSA

Reduced invansive Hibdisease by 90 %

Less effective in HIV-infected children ,due topoor immune response orloss of immunity 1-3 yrs postimmunization

Child with swollen face due

to Hib infection


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7.HEPATITIS B VACCINE

1st generation of Hep B vaccine was

prepared by extensive purification of

Hep B surface antigen particles derived

from blood donors who are carriers of

virus.

These vaccines no longer used in SA

2nd generation developed by

recombinant technology- the only

human vac produced by such means.


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HEP B Vaccines cont

Booster doses of Hep B vac are no longerrecommended, regardless primary coursewas administered

Immunity is long lasting NB:Infants born to HBsAg positive mothers

should receive both 0.5 ml Hep B immuneglobulin and Hep B vac within 12 hrs of birth

Thereafter same schedule as for otherinfants if followed.

Given 6 ,10 and 14 wks EPI-SA


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8.MEASLES VACCINE

Derived from Schwartz strains of measles virus

Attenuated by multiple passage through bothfertilized chicken eggs and chicken embryofibroblast culture

> 95% seroconversion rate when vaccineadministered at the age of 15 month routine in richcountries

Children are susceptible to measles at younger age

in low and middle income countries ,with up to3

rdof measles occurring in infants younger than 9month of age,

Therefore earlier immunization is necessary.


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Measles vaccine cont

WHO recommendimmunization at 9 month

Immunity is long lasting

Anaphylactic sensitivity toegg is no longer considered

a contraindication to adminmeasles vaccine

Measles vaccine can beused for post contactprophylaxis , providedadministered within 72 hrs of

exposureFig Charac measle rash


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9.PNEUMOCOCCAL

CONJUGATE VACCINE ( PCV )

Currently available PCV( prevnar ) includes 7 of 90pneumococcal serotypes

7 serotypes responsible for aprox 70% of all invasivepneumococcal disease ( meningitis and sepsis ) in

SA children Also prevent Otitis media

Effective in children immunized as early as 6 weeks

Given at 6 , 14 wks and 9 month of age EPI-SA

Less effective in HIV infected children ( 65% less ) Booster dose indicated at 15 18 month of age


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10.ROTAVIRUS VACCINE ( RV)

2 RV vaccine licensed for general use in SAare Rotarix and Rotateg

Early generation RVV used in USA in 1998was withdrawn because of association withintussusception

Live attenuated vaccines

administered at 6 and 14 wks EPI-SA

Both rotaviral vaccines are particularly

effective against severe form of disease , With no evidence of increase risk of

intussusception


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ESTABLISHED VACCINES NOT

INCLUDED IN SA EPI PROGRRAME

MMR

INFLUENZA

HEPATITIS A VARICELLA


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Measles,mumps and rubella

vaccine ( MMR )

Combination of liveattenuated measles ,mumpsand rubella viruses

Administered at 15 month ofage

Not available at public well-baby clinic

Rubella is live attenuatedvaccine grown in humandiploid Fibroblasts

Rubella is absolutelycontraindicated duringpegnancy

Fig: charac maculopapular rashindicative of rubella


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In outbreak situation

immunization of

children living in the

same home assusceptible

pregnant mother is

often recommended

to prevent infectionfrom reaching her

Child very swollen under

jaws and in the cheeks

due to mumps


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INFLUENZA VACCINE

Prepared by inactivated virus strains grownin fertilized chicken eggs

In USA Influenza vaccine is nowrecommended annually for all children ages6 - 59 month and all pregnant women.

< 9 yrs children : to receive 2 full dosesseparated by 1 month


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H1N1


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HEPATITIS A VACCINE

2 doses of vaccines administered im

injection separated by at least 6 month

Provides long lasting protection Other than children, it should be

administered to individuals at risk of

exposure to Hep B such as health

workers ,lab personnel and employees

of nursing homes and institutions


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VARICELLA VACCINE

A live attenuated varicella vaccine (var)

now part of the routine immunizationschedule in most high income countries

Var given as single dose ideally between 12-24 months of age

Adolescents over 13 years to receive 2 doses4-8 weeks apart if they have not had thedisease or vaccine

Contraindicated in individual with advanceimmunosuppressive disorder and inpregnancy (as other live vaccine)


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Varicella vaccine cont

Efficacy single dose var is 90%in healthy

children and 70% in healthy adults

Immunity persist beyond 20 years

Vaccines is registered in SA

Potentially immuno-compromised

children(e.g HIV infected & leuckemia)

should be considered for vaccinationparticularly when they are still

immunocompetent


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CHILDREN WITH SPECIAL

VACCINATION REQUIREMENTS

1. HIV INFECTED CHILDREN

Immunization of the HIV infected children poses someproblems:

Immune response to vaccines may be inadequate

Theoretical risk that some live vaccines maythemselves cause progressive infection

High risk of disseminated BCG disease in HIVinfected

Antibody responses to HiB conjugate vaccine, Hep B&Pneumococcal conjugate vaccine have beenshown to be poorer in HIV infected infants

Measles cause severe disease in HIV children


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2. Preterm babies

Should be vaccinated according to EPIschedule commencing at birth,provided that they are well and there is

no contraindications. No correction of preterm birth is

necessary

Preterm infants mount adequateantibody responses and they are not atgreat risk of adverse events


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3. Children at special risk of infection

Chronic lung disease

Congenital lung disease

Asplenia

Trisomy 21

To be vaccinated according to std schedule

and in some cases may require additional

vaccines like influenza vaccine andimmunoglobulin prophylaxis against

RSV(Palivizumab)


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4. Immunodeficiency owing to disease ortreatment

Live vaccines are usually contraindicated

in immune suppressed individuals:

1. Receiving high dose of steroids andother immunosuppressive treatment

2. Living with malignant conditions like

lymphoma

3. Recipient of bone marrow and other

organ transplant


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-Such patients should be given appropriatepreparation of immunoglobulin ASAP afterexposure to the disease such asmeasles(measles immune globuline) and

chickenpox(zoster immune globuline)-Pertussis, diphtheria, tetanus, Hib and

hepatitis B vaccines can be given safely topt receiving immunosuppressive therapybut may be less effective

-HIV and severe malnutrition althoughimmunodeficient can be given live vaccines


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5. Delayed or unknown immunizationstatus

CATCH UP vaccination is available

BCG may be given if Tuberculin test is

negative and there is noimmunosuppression

Spaced 4 6 weeks apart


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Storage and handling of vaccines

( cold chain ) Vaccines lose their potency if not stored and transported

correctly

Heat sensitive vaccines include OPV,yellow fever andmeasles

Some vaccines (eg BCG & reconstituted MMR) losepotency if exposed to light

Reconstituted Measles vaccine detoriorates rapidly atroom temperature

Vaccines should not be frozen,do not place at freezer Keep fridge between 2 to 8 degree C

Check signs of detorioration such as change in colour orclarity


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Common minor adverse ff

immunization

Local swelling

Redness

Crying Irritability

Low grade fever


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TRIGGER ADVERSE EVENTS

REQUERING REPORTING

1 .Local reactions

severe local reaction (swelling extending >5cm, redness andswelling >3day)

lymphadenitis

injection side abscess

2. Systemic reactions

all cases of hospitalization thought to be related toimmunization

encephalopathy with 7 days

collapse or shock like state within 48 hours

fever or >40.5 degree within 48 hours

seizures within 3 days

all death thought to be related to immunization


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CONTRAINDICATIONS

The only absolute contraindication to

childhood vaccine are: Anaphylactic sensitivity to any of

particular vaccine component

Anaphylactic events following previous

dose of any vaccine


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FALSE CONTRAINDICATIONS

Family hx of any adverse rxnsff vaccination

Fhx of convulsions

Previous MMR or pertusis likeillness

Preterm birth

Hx of jaundice after birth

Stable neurological conditionssuch as CP and trisomy 13

Contact with infectious disease

Minor illness(without sistemicillness and temp < 38.5)

Treatment with antibiotics

Asthma, eczema ,hay fever

Treatment with local actingsteroids

Childs mother is pregnant Child being breastfed

Underweight,but otherwisehealthy child

Over the age recommended inthe vaccination schedule

Recent or imminent surgery

Parental belief in homoepathy


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BARRIERS TO IMPROVE VACCINATION

IN SA

No weekend or after hour services at clinic toenable working parents to immunize theirchildren

Limited family practitioner or paediatrician

involvement in the vaccinationadministration

Unavailability of vaccine at hospitals ( toallow immediate catch-up for unvaccinated

children Health workers citing false contraindicationsin denying children vaccinations

Exposure of some parents to global anti-vaccination lobby


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immunization presentation 3

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