Cpm1st Childhood Tb

CHILDHOOD TUBERCULOSIS(1992)

PHILIPPINE PEDIATRIC SOCIETY

CHILDHOOD TUBERCULOSIS

223

CPM 1ST EDITION


PHILCAT - PPSThe Working Committee on Prevention andInitial Treatment of Childhood Tuberculosis

Estrella Paje - Villar, M.D. ChairJosefina C. Carlos, M.D. Co-Chair

CHILDHOOD TUBERCULOSIS CPM 1ST EDITION

225

Algorithm for the Prevention Therapy of Childhood Tuberculosis

2 3

1

TB Exposure (Class I)

(A)

Start 3 monthsIsoniazid

(B.D)

Patient< 5 yrs old?

(B)

5

TB Disease(Class III)

Multiple drugtherapy (G)

4

Repeat Mantoux

after 3 monthspositive

TB infection (Class II)

Continue Isoniazid>/ 6 months (F)

78

Y

YY

N

Repeat Mantoux

after 3 monthspositive

• discontinue H• if no BCG scar, give BCG

N6

N


226

CPM 1ST EDITION

Footnotes A. TB Exposure (Class I): includes persons with sig-

nificant contact with adolescent/adult source case but who are symptomatic, with negative Mantoux Test and normal radiologic findings.

B. Children particularly those under 5 years old, can develop severe TB in less than 3 months (6-8 weeks in meningitis and disseminated disease) because of the short incubation period of pulmonary, CNS and disseminated diseases. Hence, infants and children in the exposure stage should receive preventive therapy. In older children preventive therapy in TB exposure is more controversial since the disease is slower in progression. However, some experts recommend early treatment in the children to pre-vent establishment of infection after deposition of infected droplet nuclei in the alveoli, especially in the presence of risk factors like severe undemutri-tion and other immunocompromised states.

C. Mantoux test positive = ≥ 5 mm induration in those without BCG scar; >10 mm induration in those without BCG scar in the absence of any other find-ings suggestive of TB since BCG vaccination can cause increased reactivity to a subsequent tuberculin test. Virtually all children vaccinated at birth have non-reactive Mantoux test by 5 years of age.

D. For persons exposed to infectious TB but not yet infected isoniazid (H) is given to prevent estab-lishment of infection (primary chemoprophylaxis). In this case isoniazid is protective only while the person is receiving the drug.

E. Assuming that infector has been given inadequate multiple drug therapy.

F. TB infection: includes those positive with Mantoux test but without signs and symptoms and radiologic evidences suggestive of TB. Virtually all infected children should be treated to prevent development of TB disease in the near or distant future (sec-ondary chemoprophylaxis). The duration ranges from 6 months to 12 months. The AAP and CDC recommend a 9-month administration of Isoniazid, 5-10 mg/Kg/day, not exceeding 300 mg/day. In the immunocompromised host, the total duration of pre-ventive therapy is extended to 12 months. Isoniazid is extremely effective in preventing progression of TB infection to TB disease. It produces a 90% reduction in TB disease during the 1st year after treatment and the protective effect can last for at least 30 years. In the presence of primary isoniazid resistance, rifampicin is used instead.

G. TB Disease (Class III) - see algorithm (Figure 2).

Table 1. Guidelines for TB Chemoprophylaxis

Category Population at risk of infection/ Duration of Isoniazid (H) Use disease

Primary Newborn of an infected mother 3 months initially; after 3 months of PPD (-), chemoprophylaxis discontinue Isoniazid provided the infector PPD (-) infants and children under is under adequate therapy and give BCG; if 5 years exposed to TB PPD (+) continue Isoniazid for 9 months more; if abnormal chest x-ray, and 2 more drugs, e.g. Rifampicin and Pyrazinamide, and treat as diseaseSecondary HIV infection/persons with risk 12 monthsChemoprophylaxis factors for HIV infection whose HIV infection is unknown Recent tuberculin conversion (within 9 months 1-2 years) with negative chest x-ray PPD (+) not due to BCG with 9 months negative chest x-ray and no benefit to previous TB chemotherapy PPD (+) with stable or healed 9 months parenchymal lesions and no previous chemotherapy PPD (+) with stable or healed TB 1-2 months lesions with previous TB chemotherapy but are at risk of reactivation due to a. Measles/pertussis, etc. b. Conditions/drugs that induce immunosuppression (IDDM, for the duration of the chronic dialysis, leukemia) immunosuppression


227

Tabl

e 2.

Dos

age

Rec

omm

enda

tion

for

the

Initi

al T

reat

men

t of T

uber

culo

sis

Dos

age

(mg/

Kg)

Dru

gs

Dos

age

Form

s D

aily

2-

3x/W

eek

(DO

T)

</ 1

2 yr

s >

12 y

rs

</ 1

2 yr

s >

12 y

rs

Ison

iazi

d (H

)+

-100

mg,

300

mg

&

5-10

5

20-4

0 15

40

0 m

g ta

b (m

ax 3

00 m

g)

(Max

300

mg)

(m

ax 9

00 m

g)

(Max

900

mg)

-1

00 m

g &

200

mg

/5

mL

syr

Rifa

mpi

cin

(R)*

-1

50 m

g, 3

00 m

g, 4

50 m

g 10

-15

10

10-2

0 10

&

600

mg

tab/

cap

(max

600

mg)

(m

ax 6

00 m

g)

(max

600

mg)

(m

ax 6

00 m

g)

-100

mg

& 2

00 m

g/5

mL

su

spen

sion

-6

0 m

g/m

L, 1

0 m

L vi

al

(IV

infu

sion

)

Pyra

zina

mid

e (Z

) 50

0 m

g ta

b/ca

p 15

-30

15-3

0 50

-70

50-7

0

(m

ax 2

g)

(max

2 g

) (m

ax 4

g)

(max

4 g

)

15-2

5 15

-25

30 (3

x/w

k)

30 (3

x/w

k)Et

ham

buto

l (E)

0 20

0 m

g &

400

mg

tab

first

2 m

onth

s (m

ax 2

.5 g

) 50

(2x/

wk)

50

(2x/

wk)

(as H

Cl)

th

en 1

5 (m

ax 2

.5 g

)

(max

2.5

g)

(max

2.5

g)

Stre

ptom

ycin

(S)

1 g

vial

(IM

) 20

-30

15

25-3

0 25

-30

(as s

ulfa

te)

(m

ax 1

g)

(max

1 g

) (m

ax 1

.5 g

2x/

wk)

(m

ax 1

.5 g

2x/

wk)

(max

1 g

3x/

wk)

(m

ax 1

g 3

x/w

k)

+ H

abs

orpt

ion

is im

plie

d by

food

and

ant

acid

s; p

yrid

oxin

e is

reco

mm

ende

d in

chi

ldre

n w

ith n

utrit

iona

l defi

cien

cy, b

reas

tfeed

ing

infa

nt, p

regn

ant

w

omen

, and

in re

nal f

ailu

re.

* R

abs

orpt

ion

is im

paire

d by

food

; bio

avai

labi

lity

is v

ery

depe

nden

t on

the

form

ulat

ion.

0 E

is g

ener

ally

not

reco

mm

ende

d in

chi

ldre

n (<

yrs

) who

se v

isua

l acu

ity is

diffi

cult

to m

onito

r. H

owev

er it

shou

ld b

e co

nsid

ered

for a

ll ch

ildre

n w

ith

re

sist

ant o

rgan

ism

s whe

n su

scep

tabi

lity

to E

is li

kely

or h

as b

een

dem

onst

rate

d. A

bsor

ptio

n is

una

ffect

ed b

y fo

od b

ut d

elay

ed b

y al

umin

um h

ydro

xide

.

N.B

. H a

nd R

mus

t be

give

n on

em

pty

stom

ach

(1 h

our b

efor

e or

2 h

ours

afte

r mea

ls


228

CPM 1ST EDITION

Algorithm for the Initial Treatment of Childhood Tuberculosis

2 3

1

N

Pulmonary TB (Class III PTB

(A)

Drug resistance likely

or unknown?(C)

5

7

Y Y

6Start

2 EHRZ or 2 SHRZ (E, F, J)

8

N

Legend:H - isoniazid C&S - culture and sensitivity testR - rifampicin Number before a group of letters - number of months of drug administrationZ - pyrazinamide Number after a group of letters - number of doses per weekE - ethambutol No number after a group of letters - group of drugs given dailyS - streptomycin

See Notes for the letters in paresthesis

C and Savailable?

Start 2 HRZ (D.E)

Continue 4 HR or 4 HR3

(D,E,H,I)

Continue 4 HR+/ E/S

or 4 HR +/ E/S(G,E,H,I,J)

Do C & SStart

2 EHRZ or 2 SHRZRevise regimenas appropriate

4

Figure 2


229

Footnotes

A. PTB disease based on at least three of the follow-ing:

• history of exposure to a source case • Mantoux test positive • suggestive symptoms and signs • suggestive Chest x-ray (PA and lateral views) • suggestive biopsy/histologic findings

N.B. Isolation of M. tuberculosis (positive smear and/or culture) is the gold standard but is very rarely present in infants and children

B. Based on • source case with fully susceptible M. tuberculosis • local prevalence of primary isoniazid resistance

(< 10%) • no history of previous use of anti-TB drugs

C. Drug resistance likely

• big bacillary population (e.g cavitary lesion) • previous use of anti-TB drugs • close contact with drug resistant source case • residence in a place with high primary isoniazid

resistance (≥10%)

D. For fully susceptible M. tuberculosis a 6 month regimen with 2 months isoniazid, rifampicin and pyrazinamide (HRZ) daily intensive therapy fol-lowed by 4 months isoniazid and rifampicin (HR) or 4 months isoniazid and rifampicin 3x a wk (HRg) continuation phase is adequate.

E. Supervised/direct observation therapy (DOT) is as effective and safe and is preferred. The health system must develop an infrastructure with the expertise and resources for strict implementation of the DOT programme.

F. A four-drug regimen for the intensive phase is rec-ommended where primary resistance is suspected or when the resistance status is unknown. S is preferred in infants and children (< 6 yrs) too young for moni-toring visual acuity and color perception. For older age group, E is preferred since monitoring of visual acuity and color perception will be less difficult and the pain and dangers of IM injections are avoided.

G. E or S may be continued in the continuation phase in patients with suspected primary drug resistance to delay further development of resistance.

H. Extrapulmonary tuberculosis is managed essentially the same manner as pulmonary tuberculosis except

that in serious life-threatening infections such as meningitis, miliary and bone and joint disease, the continuation phase is extended to a minimum of 10 months.

I. In immunocompromised patients (e.g. with HIV/AIDS), the continuation phase is extended to 7 months (i.e. total duration of 9 months chemo-therapy) or for at least 6 months after sputum con-version (if applicable) whichever is longer. If drug susceptibility results are not available, ethambutol or streptomycin should be given for the entire course of therapy because of the risk of rapid disease progres-sion while on inadequate therapy

J. In pregnant or nursing mothers, S and other aminoglycosides, ethionamide and prothionamide are contraindicated. The regimen recommended is 2 months ethambutol, isoniazid, rifampicin and pyrazinamide (EHRZ) intensive phase then 4 months isoniazid, rifampicin and ethambutol (HRE) or three doses a week of isoniazid, rifampicin and ethambutol (HREg) continuation phase.

References

1. Mitchison DA. The action of antituberculosis drugs in short course chemotherapy. Tubercle 1985; 66:219

2. Davies PDO (ed). Clinical tuberculosis. Chapman and Hall, London. 1994 pp. 129-156

3. Committee on Treatment of International Union Against Tuberculosis and Lung Disease Antitu-berculosis regimen of Chemotherapy. Bull Int. Un. Tubercle 1988; 63:60

4. Abemathy et. al. Short course chemotherapy for tu-berculosis in children. Pediatric 1983; 72:801-806

5. Biddulph J. Short course therapy for childhood tu-berculosis in children. Pediatrics 1990; 9:794-801

6. Jacobs R, Abemathy. The treatment of tuberculosis in children. Pediatrics 1985; 4:513-517

7. Jacobs RF, Sunakom P. Chotpitayasunonah et al. In-tensive short course chemotherapy for tuberculosis meningitis. Pedia. Infec. Dis. J. 1992; 11:194-198

8. Kumar C, Dhand R, Singh PD et al. A randomized trial of fully intermittent short course chemotherapy for childhood tuberculosis. Pediatr. Infect. Dis. J. 1990; 9:802-805

9. Starke JR, Taylor-Watts. Six month chemotherapy of intrathoracic tuberculosis in children. Am. Rev. Respi. Dis. 1989; 139 (suppi) A 314

10. Tsakilidis D, Pratsidou P, Hitoglou - Makedou A, et al. Intensive short course chemotherapy for treat-ment of Greek children with tuberculosis. Pediatr. Infect. Dis. J. 1992; 1036-1040

11. Starke JR: Multidrug therapy for tuberculosis in children, Pediatr. Infec. Dis J. 1990; 9:785


230

CPM 1ST EDITION

12. Starke JR and Correa AG. Management of myco-bacterial infection and disease in children. Pediatr Infect. Dis. J. 1995 14:455-70

13. American Academy of Pediatrics. Chemotherapy of tuberculosis in infants and children. Pediatrics 1992; 89:61-64

14. Centers for Disease Control and Prevention: Initial therapy of tuberculosis in the era of multidrug resistance: Recommendation of the A d v i s o r y Council for the elimination of tuberculosis. MMWR 1993; 42 (RR-7): 1-8

15. American Thoracic Society: Treatment of tuberculo-sis and tuberculous infections in adults and children. Am. J. Resp. Crit. Care Med. 1994; 149:1359-94

16. Treatment of tuberculosis: Guidelines for national programmes. World Health Organization, Geneva 1993

17. Jacobs RF: Pediatric tuberculosis in Rossman MD. Mac Gregor RR (eds). Tuberculosis Clinical Man-agement and New Challenges, McGraw-Hill, Inc. 1995; Chapter 8 pp. 129-144

18. First National Consensus in Tuberculosis. Chest Dis. 1989; 16:16-20

19. Starke JR. Tuberculosis in Behrman RE, Kleigman RM, Nelson W., Vaughan VC (eds). Nelson Text-book of Pediatrics WB Saunders Co. Philadelphia. 15th edition 1996. Chapter 199, pp. 834-847

20. Chaulet P, et al. Childhood tuberculosis still with us. Children in the Tropics, Review of the International Children's Centre. 1992; 53 57

21. A statement of the Committee on the Treatment of ILJATLD Bull. Int. Un. Tuberc 1987: 62:1-2:58-60

22. A statement of the Scientific Committees of the IUATLD Bull. Int. Un. Tuberc. 1991; 66:65-71

23. Udani PM: Tuberculosis in general Udani PM (ed) Textbook of Pediatrics. 1991, Jaypee Brothers Medical Publishers. New Delhi, India. Chapter 16 pp. 995-1175

24. Smith MHD, Starke ]R, Marquiz JR. Tuberculosis and opportunistic mycobacterial infections in Fei-gin RD and Cherry ]D (eds) Textbook of Pediatric Infectious Dis. WB Saunders Co. Philadelphia. 3rd edition 1992 Chapter 130 pp. 1321-1362

25. Seifart HI, Parkin DP. Donald PR: Stability of iso-niazid, rifampicin and pyrazinamide in suspension used for the treatment of tuberculosis in children. Pediatr. infect. Dis. J. 1991; 10-827-31

26. Acocella G et al: Bioavailability of isoniazid, ri-fampicin and pyrazinamide (in free combination of fixed triple formulation) in intermittent antitu-berculous chemotherapy. Monald Arch Chest Dis. 1993; 48:205-209

27. Leonin T, Leyson MO, Marfil LP, Tan GA et al: Multicenter clinical trial of short course chemo-therapy of pulmonary tuberculosis in the Philippines (unpublished)


231

Ethambutol Ethambin..............................84 Odetol...................................84Isoniazid DLI-Isoniazid ........................8 UL Isoniazid ........................85Morphazinamide Piazolina ..............................85Pyrazinamide Braccopiral ..........................85 DLI-Pyrazinamide................85 Framed ................................85

Pharex-Pyrazinamide...........85 Pyrazinamide-Boie...............85 Py/amed................................85

PZA-CIBA...........................85 UL Pyrazinamide.................85 Zinastat ................................85Rifampicin AKT-S .................................86 Canarif..................................86 Crisarfam ............................86

Dipicin ................................86 DLI-Rifampicin ...................86 Flemodan ............................86 Koccifam .............................86 Medifam...............................86 Mycofam .............................86 Natridn ................................86 Patriot-Rifampicin................86 Pharex-Rifampicin...............86 PMI Rifampiein....................86 Rafromide ...........................86 Ramicin ...............................87 Refam...................................87 Resimin................................87 Ribosin.................................87 Ricyn....................................87 Rifadin..................................88 Rifastat.................................88 Rimactane.............................88 Rimaped Suspension............88 T-Bicin.................................88 UL Rifampiein......................88 USA Rifampiein...................88Streptomycin YSS Streptomycin Sulfate...............................88Drug Combination Abbutol-INH-B6..................88 Amyco .................................88

Drugs Mentioned in the Treatment GuidelineThis index lists drugs/drug classifications mentioned in the treatment guideline. Prescribing Information of thesedrugs can be found in the Philippine Pharmaceutical Directory (PPD) 1997. Opposite the brand name is its pagenumber in the PPD 1997.

Bisobutol..............................89 Combi Pack..........................89 Comprilex Pediatric Syrup.................................89 Continukit.............................89 Continupack..........................89 Coxiform ..............................89

4D.........................................89 Ebutol...................................89 Econokit ..............................89 Econopack............................90 EMB Forte ...........................90 Etham 500 ............................90

Ethambin-INH......................90 Ethamizid..............................90 Forbutol................................90 Genamzid/ Genamzid Forte................90 Isoetam ................................90 Koccid...................................90 Kyur Kit I.............................90 Kyur Kit II............................91 Lederrif-INH.........................91

Molecure l & 2......................91MOP/M-0 Compliance

Pack................................. 91 Myambutol+INH + B6 .................................92 Niretal...................................92 Odinah..................................92 Pacibutol...............................92 Pediambutol w/ INH-B6 Syrup...................92 Pharex-Isoniazid...................92 Primafort...............................92 Primafort-325 ......................92 Pyrifort..................................92 Pyrina ..................................93 Pyrobin-H.............................93 Quadpack..............................93 Rambutol..............................93 Ramicin-Iso..........................93 Resimin+H/ Resimin 225+H.................93 Rifater...................................93 Rifinah .................................93 Rimactazid 225/ Rimactazid 300/ Rimactazid 450..........94 Ronah-500............................94 Rotazid..................................94

SCC Kit................................94 Sthamizide............................94 Tres.......................................95 Tripack..................................95 Trisofort................................95 Trisovit..................................95 UL Ethambutol HCI.............95 UL Isoniazid 400 .................95 USA-Ethambutol + INH+B6........................... 95


232

CPM 1ST EDITION

DIARRHEAL DISEASESIN CHILDREN


233

Algorithm for the Management of Acute Respiratory Infection (ARI)/ Pneumonia for 2 mos. to 4 yrs. old

3 5

1

Y

Patients

Does patienthave severe

dehydration?

N

4

7

N

Assess

hydrationstatus


dehydration?

12

Patient has no dehydration

Plan CIV therapy

deficit/replacement

therapy

Plan BORS; encourage

to continuebreastfeeding

Plan AORS/

home fluidscontinue feeding


dehydration?

ContinuePlan C

Is therepersistent vomiting

or does patientrefuses to drink?

Insert NGT*

Does patientimprove?

Plan A

Plan C

Plan A or B

6

N

Y

2

8

Y

13

9 10 11

14N

15

16

Y

N

*NGT - Nasogastric Tube


234

CPM 1ST EDITION

USE THIS CHART FOR PATIENTS WITH: • loose or watery stools • loose stools with blood

Diagnosis 1. First, assess your patient for dehydration

Treatment Plan A B C1. LOOK AT; *Lethargic or Condition Well, alert *Restless, irritable* unconscious; floppy*

Eyes Normal Sunken Very sunken and dry

Tears Present Absent Absent

Mouth and Tongue Moist Dry Very dry

Thirst Drinks normally, *Thirsty, drinks *Drinks poorly or not not thirsty eagerly* able to drink*

2.FEEL: Skin Pinch Goes back quickly *Goes back slowly* *Goes back very slowly*

3. DECIDE: The patient has If the patient has two or If the patient has two NO SIGNS OF more signs including at or more signs, inclu- DEHYDRATION least one *sign*, there is ding at least one SOME DEHYDRATION *sign*, there is SEVERE DEHYDRATION

4. TREAT Use Treatment Weigh the patient, if Weigh the patient and Plan A possible, and use use Treatment Plan C Treatment Plan B URGENTLY

Guidelines for the Management of Patients with Diarrhea

2. Then, ask for other problems

ASK ABOUT BLOOD IF BLOOD IS PRESENTIN THE STOOL • Treat for 5 days with an oral antibiotic recommended for Shigella in your area • Teach the mother to feed the child as described in Plan A • See the child again after 2 days if: • under 1 year of age • initially dehydrated • there is still blood in the stool • not getting better • If the stool is still bloody after 2 days, change to a second oral antibiotic recommended for Shigella in your area. Give it for 5 days. ASK WHEN THIS IF DIARRHEA HAS LASTED AT LEAST 14 DAYS:EPISODE OF • Refer to hospital if:DIARRHEA BEGAN - the child is under 6 months old

- dehydration is present. (Refer the child after treatment of dehydration).


235

Treatment Plan A: To Treat Diarrhea at Home

Use this plan to teach the mother to:

• Continue to treat at home her child's current episode of diarrhea.

• Give early treatment for future episodes of di-arrhea.

A. Explain the 3 rules for treating diarrhea at home:

1. Givethechildmorefluidsthanusualtopreventdehydration:

• Use a recommended home fluid, such as a cereal gruel. If this is not possible, give plain

water. Use ORS solution for children described in the box below. • Give as much of these fluids as the child will

take. Use the amounts shown below for ORS as a guide.

• Continue giving these fluids until the diarrhea stops.

2. Give the child plenty of food to prevent unde-mutrition:

• Continue to breast-feed frequently. • If the child is not breast-fed, give the usual

milk. If the child is less than 6 months old and

• Otherwise, teach the mother to feed her child as in Plan A, except: - dilute any animal milk with an equal volume of water or replace it with a fermented milk product, such as yoghurt. - Assure full energy intake by giving 6 meals a day of thick cereal and added oil, mixed with vegetables, pulses, meat, or fish. • Tell the mother to bring the child back after 5 days: - if diarrhea has not stopped, refer to hospital - if diarrhea has stopped, tell the mother to: > use the same foods for the child's regular diet > after 1 more week, gradually resume the usual animal milk. > give an extra meal each day for at least 1 month. LOOK FOR SEVERE IF THE CHILD HAS SEVEREUNDERNUTRITION UNDERNUTRITION: • Do not attempt rehydration; refer to hospital for management. • Provide the mother with ORS solution and show her how to give 5mL/Kg/hr during the trip. ASK ABOUT FEVER IF TEMPERATURE IS 39°C OR GREATER:AND TAKE • Give paracetamol.TEMPERATURE IF THERE IS Falciparum malariae IN THE AREA, and the child has any fever (38° or above) or history of fever in the past 5 days. • Give an antimalarial (or manage according to your malaria programme recommendation).

not yet taking solid food, dilute milk or formula with an equal amount of water for 2

days. • If the child is 6 months or older, or alread

solid food: - Also give cereal or another starchy food, mixed,

if possible, with pulses, vegetables, and meat or fish. Add 1 or 2 teaspoonfuls of vegetable

oil to each serving. - Give fresh fruit juice or mashed banana to provide potassium. - Give freshly prepared foods. Cook and mash or grind food well. - Encourage the child to eat; offer food at least 6 times a day. - Give the same foods after diarrhea stops, and give an extra meal each day for two weeks.3. Take the child to the health worker if the child

does not get better in 3 days or develops any of the following:

• Many water stools • Repeated vomiting • Marked thirst • Eating or drinking poorly • Fever • Blood in the stool

Children should be given ORS Solution at home if: • They have been on Treatment Plan B or C • They cannot return to the health worker if the


236

CPM 1ST EDITION

diarrhea gets worse. • It is national policy to give ORS to all children who see a health worker for diarrhea.

B. If the child will be given ORS solution at home, show the mother how much ORS solution to give after each loose stool &: give her enough packets for 2 days:

Age Amount of ORS Amount of ORS to give after each to provide for use loose stool at home

Less than 50-100 mL 500 mL/day24 months

2 up to 100-200 mL 1000 mL/day10 years

10 years or As much as 2000 mL/daymore wanted

• Describe and show the amount to be given after each stool using a Local measure.

C. Show the mother how to mix ORS:

D. Show her how to give ORS:

• Give a teaspoonful every 1-2 minutes for a child under 2 years. • Give frequent sips from a cup for an older child. • If the child vomits, wait 10 minutes. Then give

the solution more slowly (for example, a spoonful every 2-3 minutes). • If diarrhea continues after the ORS packets are used up, tell the mother to give other fluids as

described in the first rule above or return for more ORS.

Treatment Plan B: To Treat Dehydration

A.ApproximateamountofORSsolutiontogiveinthefirst4hours:

Age:* Less than 4 4-11 months 12-23 months 2-4 years 5-14 year 15 years or months older

Weight Less than 5 Kg 5-7.9 Kg 8-10.9 Kg 11-15.9 Kg 16-29.9 Kg 30 Kg or morein mL 200-400 400-600 600-800 800-1200 1200-2200 2200-4000

in localmeasure

* Use the patient's age only when you do not know the weight. The approximate amount of ORS required (in mL) can also be calculated by multiplying the patient's weight (in grams) times 0.075.

• If the child wants more ORS than shown, give more.

• Encourage the mother to continue breast-feeding. • For infants under 6 months who are not breast-fed,

also give 100-200 mL clean water during this period.

B. Observe the child carefully and help the mother give ORS solution:

• Show her how much solution to give her child. • Show her how to give it - a teaspoonful every 1-2

minutes for a child under 2 years, frequent sips from a cup for an older child. • Check from time to time to see if there are problems. • If the child vomits, wait 10 minutes and then

continue giving ORS, but more slowly, for example, a spoonful every 2-3 minutes. • If the child's eyelids become puffy, stop ORS and give plain water or breast milk. Give ORS according to Plan A when the puffiness is gone.

C. After 4 hours, reassess the child using the Assessment Chart. Then select Plan A, B or C to continue treatment. • If there are no signs of dehydration, shift to Plan A. When dehydration has been corrected, the child usually passes urine and may also be tired and fall asleep. • If signs indicating some dehydration are still present, repeat Plan B, but start to offer food, milk and juice as described in Plan A. • If signs indicating severe dehydration have appeared, shift to Plan C.

D. If the mother must leave before completing treat-


237

CPM 1ST EDITION

ment Plan B:

• Show her how much ORS to give to finish the 4-hour treatment at home.

• Give her enough ORS packets to complete rehydra-tion, and for 2 more days as shown in Plan A.

• Show her how to prepare ORS solution.• Explain to her the three rules in Plan A for treating

her child at home: - to give ORS or other fluids until diarrhea stops - to feed the child - to bring the child back to the health worker, if

necessary.

Use of Drugs for Children with Diarrhea

• ANTIBIOTICS should ONLY be used for dysen-tery and suspected cholera. Otherwise, they are ineffective and should NOT be given.

• ANTIPARASITIC drugs should ONLY be used for:

Amoebiasis, after antibiotic, treatment of bloody diarrhea for Shigella has failed or tro

phozoites of £. Histolytica containing red blood cells are seen in the feces.

Giardiasis, when diarrhea has lasted at least 14 days and cysts or trophozoites of Giardia are seen in feces or small bowel fluid.

• ANTIDIARRHEAL DRUGS and ANTIEMET-ICS should NEVER be used. None has been proven of practical value. Some are dangerous.


238

2

3

• Start IV fluids immediately. If the patient can drink, give ORS by mouth while the drip is set up. Give 100 mL/Kg Ringer's Lactate Solution (or, if not available, normal saline), divided as follows:

* Repeat once if radial pulse is still very weak or not detectable.

• Reassess the patient every 1-2 hours. If hydration is not improving, give the IV drip more rapidly.

• Also give ORS (about 5 mL/Kg/hour) as soon as the patient can drink: usually after 3-4 hours (infants) or 1-2 hours (older patients).

• After 6 hours (infants) or 3 hours (older patients), evaluate the patient us-ing the assessment chart. Then choose the appropriate Plan (A, B or C) to continue treatment.

Can you giveIV fluids

immediately!

N

First give Then giveAge 30 mL/Kg in: 70 mL/Kg in:Infants 1 hour* 5 hours

(under 12 mos) Older child 30 minutes* 2 1/2 hours

Is IV treatmentavailable nearby, (within 30 min)!

Are you trained to use a nasogastnc

(NG) tube for rehydration;

• Send the patient immediately for IV treatment.• If the patient can drink, provide the mother with ORS solution and show

her how to give it during the trip.

• Start rehydrationby tube w/ ORS solution: Give 20 mL/Kg/hr for 6 hours (total of 120 mL/Kg).

• Reassess the patient every 1-2 hours: - If there is repeated vomiting or increasing abdominal distension, give

the fluid more slowly. - If hydration is not improving after 3 hours, send the patient for

IV therapy.• After 6 hours, reassess the patient and choose the appropriate Treatment Plan.

• Start rehydration by mouth with ORS solution, giving 20 mL/Kg/hour for 6 hours (total of 120 mL/Kg).

• Reassess the patient every 1-2 hours: - If there is repeated vomiting, give the fluid more slowly. - If hydration is not improving after 3 hours, send the patient for IV therapy.• After 6 hours, reassess the patient and choose the appropriate Treatment

Plan.

Can thepatient drink?

URGENT:Send the patient

for IV or NG treatment

NOTES: • If possible, observe the patient at least 6 hours after rehydration to be sure the mother can maintain hydration giving ORS solution by mouth. • If the patient is above 2 years and there is cholera in your area, give an appropriate oral antibiotic after the patient is alert.

Reference World Health Organization Circular, Revised 1990


239

CPM 1ST EDITION

AntibacterialsAmpicillin Allidcil..................................60 Amibenz...............................60 Amopen................................60 Ampedia ..............................60

Ampidllin-Boie.....................60Ampicillin Sodium-YSS......60

Ampicin...............................60 Ampimydn...........................60 Amplivadi ...........................61

Apamadn..............................61 Apothecon Ampicillin..........61 Bactimed .............................61 Chrisolin...............................61 Cordroxyl ............................61

DLI-Ampidllin.....................61 Exdllin..................................61 Foramydn ............................61 Genaxin ...............................62 Knolidn ...............................62 Leoplex................................62 Metadyl................................62 Patriot-Ampidllin.................62 Penbritin...............................62 Pensyn .................................62 Pentrexyl...............................62 Pharex-Ampidllin ................62 Spedllin.................................62 Terampidn ...........................63 UL Ampidllin ......................63 Wyeth Omnipen...................63Ciprofloxacin Ciprobay...............................72Cotrimoxazole Atomexin ............................78

Baddal..................................78 Badam..................................78 BactilleTS ...........................78 Badrim ................................78 Bacxal................................. 80 Bestofens .............................80 Cotrimoxazole-Ashford.......80 Cotrimoxazole-Boie.............80 Cotrimoxazole-Varnsler.......80 Dhatrin.................................80 DLI-Cotrimoxazole..............80 Dodrimox ............................80 Elitrim,.................................80 Genoxzole/Genoxzole Forte.................................81


Genzaprim/Genzaprim Forte..................................81 Groprim/Groprim Forte........81 Lagatrim................................81 Lextrizole ............................81 Macromed ...........................81 Microbid/Microbid DS.........81 Pharex-Cotrimoxazole..........82 Septrim.................................82 Servitrim ..............................82 Sulfotrim .............................82 Syltrifil..................................82 Syndal...................................82 Thoprim ...............................82 Triforam................................82 Trimetazole...........................82 Trimezol-Scanpharm............84 Trizole Suspension...............84 UL Cotrimoxazole ...............84 USA-Cotrimoxazole.............84Doxycycline Atrax.....................................74 Doryx....................................74 Doxiron ...............................74

Doxin 100.............................74 Scrvidoxyne..........................74 Vibramydn ...........................74Erythromycin Ditron ................................. 50 DLI-Erythromydn................50 Erydn....................................50 Ery-Max...............................50 Erythrodn/ Erythrodn DS ...................52 Erythromydn-Allied.............52 Ethiodn ................................52 Gentrodn...............................52 llosone .................................52 Macrodn ..............................52 Phamaco-Erythromycin........52 Pharex-Eryhtromycin...........52 Romaxin ..............................53 Sarazine................................53 Servitrodn.............................53 UL Erythromycin .................53 USA-Erythromycin .............53Tetracyline Cydabid ...............................76 DLI-Tetracyline ...................76 Hostacydine .........................76 Tetracydine-B.......................76

Tetracycline HC1- Upjohn...............................76 UL Tetracycline....................76 Unimycin .............................76AntiprotozoalsDiloxanide furoate Entamizole.........................272 Furamide............................269Etofamide Kitnos.................................269Furazolidone Furoxone ...........................264Metronidazole Anerobia.............................269 DLI-Metronidazole.............270 Elizol..................................270 Flagyl.................................270 Histox ................................270 Metroxyn............................270 Metronidazole-Boie............270 Metroxyn............................271 Patriot-Metronidazole .......271 Pharex-Metronidazole....... 271 Servizol...............................271 USA-Metronidazole...........271 Vermoxzole .......................271Paromomycin Humagel ............................266Secnidazole Flagentyl.............................271Tinidazole Fasigyn ......................271, 281Intravenous Fluids Lactated Ringer's Solution-Euro-Med.........248Oral Rehydration Solution Allyte I & II........................246 Cholyte-50..........................246 Elotrans..............................246 Glucolyte............................246 Glucost ..............................246 Hydrite ..............................247 Pedialyte 45/90...................247 ServidratLS.........................247


240

IMMUNIZATIONS

Philippine Pediatric Society, Inc.Committte on Handbook of Infectious Diseases,

1996-1998

Josefina C. Carlos, M.D., ChairMargaret L. Fong, M.D., Co-ChairMelba V. Masigan, M.D., Co-Chair


241

CPM 1ST EDITION

Definition

Prevention of infectious disease can be achieved in two ways:

I. Active Immunization - entails the giving of an anti-gen usually prior to natural exposure to an infectious agent to stimulate the individual to develop his own antibody.

II. Passive Immunization - entails the giving of pre-formed human or animal antibody to temporarily protect the recipient.

ACTIVE IMMUNIZATION

1. Involves the administration of all or part of a micro-organism or a modified product of the microorganism (e.g. toxoid) to elicit an immunological response simulating that of natural infection but which presents little or no danger to the recipient.

2. Types of protection induced:

• Complete protection for life • Partial protection so that booster doses are administered at intervals.

3. Efficacy is assessed by the evidence of protection against the particular disease. Antibody formation is an indirect measure of protection, but in some instance the immunologic response responsible for protection is poorly understood and serum antibody concentration is not always predictive of protec-tion.

4. Characteristics of an ideal immunizing agent: • Easy to produce • Potency is durable and easily measured • Easy to adminster

• Does not in itself produce disease in the recipient or susceptible contacts • Induce long-lasting (ideally permanent) immunity that is measurable using common and inexpensive technique. • Free of contaminating substances • Adverse reactions should be minimal (ideally absent). Except for the available immunizing

agents, all of these objectives are rarely, if ever met, hence, incomplete immunization may

occur, undesirable side effects or reactions may occur in small number of subjects, and infrequently, morbid effects may be encountered.

5. Types of antigen for active immunization: • Live attenuated virus or bacteria • Killed microorganisms

• Inactivated exotoxins (toxoid) - incapable of replicating in the host, hence must contain a sufficient antigenic mass to stimulate the desired response provided by live attenuated

agents; maintenance of long- lasting immunity often requires periodic administration of booster doses.

6. Fluid may contain proteins or other constituents derived from the medium in which the vaccine was produced, preservatives, stabilizers, antibiotics, and selective adjuvants (e.g. aluminum) to retain the antigen at the depot site to prolong its stimulating effect.

7. Timing: critical for the success of the procedure. In general, vaccines are recommended for the young-est age group at risk for the natural infection and its complications that will demonstrate an acceptable level of immune response following vaccine admin-istration.

8. Recommended dose: derived from theoretical considerations, experimental vaccine trials and significance; exceeding the recommended dose volume may be hazardous because of excessive local or systemic concentrations of immunizing antigens; underdosage may result in an inadequate serologic response and protection.

9. Route of administration: may determine the type and duration of immunologic response; recommended routes are based on clinical trials demonstrating safety and efficacy. Injectable vaccines (intramus-cular and subcutaneous) should be administered in areas unlikely to cause local neural, vascular or tissue injury e.g. anterolateral aspect of the upper thigh in infants and the deltoid muscle of the upper arm in older children.

Immunizations


242

TAB

LE

I. A

CT

IVE

IMM

UN

IZAT

ION

OF

INFA

NT

S A

ND

CH

ILD

RE

N Im

mun

izin

g A

gent

s A

ge

Dos

e R

oute

C

ontr

aind

icat

ions

Adv

erse

Rea

ctio

nsB

CG

N

ewbo

rn

0.05

mL

Intra

derm

al

Imm

une

defic

ienc

y, p

rogr

essi

ve

Abs

cess

or u

lcer

s at t

he si

te o

f inj

ectio

n

>1

mon

th

0.1

mL

derm

atos

es

axill

ary

lym

phad

enop

athy

whi

ch m

ay

case

ate,

dis

sem

inat

ed B

CG

0.1

/100

,000

va

ccin

ees;

BC

G o

stei

tis 0

.1-0

.3/1

00,0

00

va

ccin

ees

Dip

hter

ia -

teta

nus

2,4,

6 m

onth

s 0.

5 m

L IM

A

cute

febr

ile il

lnes

s. C

onvu

lsio

ns

Feve

r; at

tim

es a

ssoc

iate

d w

ith so

mno

lenc

e &

/an

d pe

rtuss

is v

acci

ne

18 m

onth

s

or

oth

er se

vere

reac

tions

(ana

phyl

axis

or

con

vuls

ions

attr

ibut

ed to

per

tuss

is(D

TP)

4-6

year

s

or

col

laps

e) to

pre

viou

s dos

e of

DTP

va

ccin

e; p

rolo

nged

cry

ing

gi

ve D

T in

stea

d Tr

ival

ent O

ral

2,4,

6 m

onth

s 0.

5 m

L PO

A

ltere

d im

mun

e st

ates

(leu

kem

ia,

Para

lysi

s (0.

06 m

illio

n do

ses a

mon

gPo

lio-V

irus

18 m

onth

s

ly

mph

oma,

mal

igna

ncy,

ther

apy

with

re

cipi

ents

0.1

4 m

illio

n do

ses a

mon

gVa

ccin

e (T

OPV

) 4-

6 ye

ars

alky

latin

g dr

ugs,

antim

etab

olite

s,

cont

acts

of r

ecip

ient

s)

ster

oids

or r

adia

tion;

pre

gnan

cyD

TP +

Inac

tivat

ed

2,4,

6 an

d 18

0.

5 m

L IM

A

cute

febr

ile il

lnes

ses

Feve

r loc

al re

actio

n er

ythe

ma,

pai

n,Po

lio V

irus

mos

, 4-6

yea

rs

ed

ema

(IPV

) Vac

cine

Atte

nuat

ed m

easl

es

6 m

onth

s 0.

5 m

L SC

A

ltere

d im

mun

e st

ate

as li

sted

abo

ve

Loca

l rea

ctio

n si

mul

atin

g an

Arth

usva

ccin

e (E

dmon

dsto

n

A

cute

febr

ile il

lnes

s ph

enom

enon

, 1-8

day

s afte

r vac

-Za

greb

stra

in) o

r

Unt

reat

ed a

ctiv

e tu

berc

ulos

is

cina

tion;

feve

r with

or w

ithou

tLi

ve fu

rther

atte

nuat

ed

9 m

onth

s

SC

Imm

unog

lobu

lin a

dmin

istra

tion

mea

sles

- lik

e m

anife

stat

ions

abo

ut(S

chw

artz

stra

in)

w

ithin

3 m

onth

s 6t

h-12

th d

ays a

fter v

acci

natio

nm

easl

es v

irus v

acci

ne

M

arke

d hy

pers

ensi

tivity

to v

acci

ne

Mea

sles

, Mum

ps,

co

mpo

nent

s;

Feve

r, m

alai

se, e

ncep

halit

is, s

kin

erup

tions

;R

ubel

la v

acci

ne

A

llerg

y to

egg

s;

Feve

r, hy

pers

ensi

tivity

reac

tions

, ras

h,(M

MR

)

Preg

nanc

y un

ilate

ral n

erve

dea

fnes

s; tr

ansi

ent

arth

ralg

ia a

nd p

erip

hera

l neu

ritis

Li

ve m

umps

viru

s 15

mon

ths

0.5

mL

SC

vacc

ine*

11

-12

year

sLi

ve ru

bella

viru

s 15

mon

ths

0.5

mL

SCva

ccin

e*

D

ipht

heria

-

14-1

6 ye

ars

0.5

mL

IM

Acu

te fe

brile

illn

esse

s Fe

ver

teta

nus t

oxoi

ds

& e

very

adul

t typ

e (T

d)

10 y

ears

th

erea

fter

* If

mea

sles

vac

cine

is n

ot in

dica

ted

NO

TE: I

nter

rupt

ion

a/sc

hedu

le, w

ith a

del

ay b

etw

een

dose

s, do

es n

ot in

terf

ere

with

the

final

imm

unity

ach

ieve

d no

r doe

s it

nece

ssita

te s

tarti

ng w

ith th

e se

ries

affli

n,

rega

rdle

ss o

fth

e le

ngth

of t

ime

elap

sed.


243

CPM 1ST EDITION

TAB

LE

I. A

CT

IVE

IMM

UN

IZAT

ION

OF

INFA

NT

S A

ND

CH

ILD

RE

NIm

mun

izin

g A

gent

s A

ge

Dos

e R

oute

C

ontr

aind

icat

ions

A

dver

se R

eact

ions

Hep

atiti

s A V

acci

ne

>2 y

ears

Fo

llow

IM

H

yper

sens

itivi

ty to

any

com

pone

nt

Loca

l rea

ctio

ns in

clud

e er

ythe

ma,

man

ufac

ture

r's

of th

e va

ccin

e sw

ellin

g an

d

reco

mm

enda

tion

war

mth

.H

epat

itis B

Vac

cine

B

irth

Follo

w

IM

Hyp

erse

nsiti

vity

to a

ny c

ompo

nent

Sy

stem

ic c

ompl

aint

s inc

lude

feve

r,

man

ufac

ture

r's

of th

e va

ccin

e m

alai

se, f

atig

ue, h

eada

che,

reco

mm

enda

tion

dizz

ines

s, m

yalg

ia a

nd n

ause

a.H

emop

hilu

s infl

uenz

ae

B v

acci

ne (H

ib)

a.

HB

OC

2,

4,6

mon

ths

IM

N

one

Non

e

(con

juga

ted

with

bo

oste

r

Dip

hthe

ria to

xoid

)*

15 m

onth

s

b.PR

P-O

MP

2,

4 m

onth

s

IM

Non

e N

one

(c

onju

gate

d

with

N. m

emny

tidis

) bo

oste

r Fo

llow

12

mon

ths

man

ufac

ture

r'

c.PR

P-T

(con

juga

ted

2,

4,6

mon

ths

IM

N

one

Non

e

with

teta

nus t

oxoi

d)

boos

ter

inst

ruct

ions

15 m

onth

s

Live

atte

nuat

ed v

aric

ella

≥9

mon

ths

1 SC

A

ltere

d im

mun

e st

ate

as li

sted

Lo

cal p

ain

and

eryt

hem

a va

ccin

e

abov

e

A

cute

febr

ile il

lnes

s G

ener

al re

actio

ns: F

ever

, pap

ulov

esic

ular

Unt

reat

ed a

ctiv

e TB

re

actio

ns n

oted

7-2

1 da

ys a

fter

Imm

unog

lobu

lin a

dmin

istra

tion

im

mun

izat

ion

with

in 3

mon

ths

*1. W

hen

imm

uniz

atio

n is

initi

ated

at 7

-11

mon

ths,

reco

mm

ende

d re

gim

ens/

or to

th H

BOC

and

PRP

-OM

P an

d PR

P-T

are

iden

tical

viz

. 3 d

oses

-firs

t 2

dose

s yve

n at

1 m

onth

s int

erva

l, 3r

d do

se p

ven

at 1

5-18

mon

ths o

fay.

Any

conj

ugat

e va

ccin

e fo

r 3rd

dos

e. 2

. Whe

n im

mun

izat

ion

is in

itiat

ed a

t 11-

li m

onth

s, th

e re

com

men

ded

regi

men

s for

thes

e th

ree

vacc

ines

are

iden

tical

viz

. 2 d

oses

gi

ven

at 2

-3 m

onth

s int

erva

l. 3

. W

hen

imm

uniz

atio

n is

initi

ated

at 1

5 m

onth

s or o

lder

, the

reco

mm

ende

d re

gim

en is

a si

ngle

dos

e of

any

lice

nsed

con

juga

te v

acci

ne

(HBO

C o

r PRP

-OM

P, P

RP-T

).


244

TABLE II.RECOMMENDED IMMUNIZATION SCHEDULE FOR CHILDREN

NOT IMMUNIZED IN THE FIRST YEAR OF LIFE

Recommended Time Immunizations Comments

Less than 7 years old

First visit DTP, TOPV or DTP MMR - if child ≥ 5 months old; IPV, MMR, Hib* HBV tuberculin testing (TT) should be

done; if TT negative, give BCG

Interval after first visit

2 months DTP, TOPV or DTP Second dose of HIB is indicated IPV; HBV (Hib) only in infants whose 1st dose was received <15 months.

4 months DTP, TOPV or DTP IPV

10-16 months DTP, TOPV or DTP IPV HBV Age 4-6 years DTP, TOPV or DTP DTP, not necessary if the fourth(at or before school entry) IPV dose was given after 4th birthday; not necessary if 3rd dose was given after 4th birthday.

Age 11-12 years MMR

Age 14-16 years Td Repeat every 10 years throughout life

7 years old and older

First visit Td; TOPV or IPV, MMR, HVB

Interval after first visit

2 months Td, TOPV pr IPV

8-14 months Td, TOPV or IPV

11-12 years MMR

10 years later Td Repeat every 10 years throughout life

* HBCV - Hemophilus influenzae type B conjugate vaccine


245

CPM 1ST EDITION

TAB

LE II

I. A

CTI

VE

IMM

UN

IZAT

ION

NO

T R

OU

TIN

ELY

GIV

EN T

O IN

FAN

TS A

ND

CH

ILD

REN

Imm

uniz

ing

Age

nt

Dos

e R

oute

In

dica

tions

C

ontr

aind

icat

ions

A

dver

se R

eact

ions

Cho

lera

Vac

cine

a.

Cla

ssic

(Oga

wa

&

1.0

mL

R

esid

ence

in e

ndem

ic a

reas

, thr

eat

Age

: bel

ow 1

yea

r

In

aba

stra

ins)

ev

ery

6 m

onth

s SC

of

epi

dem

ic

Acu

te fe

brile

illn

ess

b.

El T

or

Trav

el to

& fr

om c

ount

ries w

here

St

rong

reac

tion

to p

revi

ous i

mm

uniz

atio

n

ch

oler

a is

ram

pant

c. A

ttenu

ated

stra

in

V

ibrio

cho

lera

e 1

sach

et

Ora

l

Age

: bel

ow 2

yea

rs; c

onco

mita

nt

Tran

sien

t mild

dia

rrhe

a, n

ause

a,

CV

D10

3-H

gR

(2x1

02 v

iabl

e

antib

iotic

use

; hyp

erse

nsiti

vity

to th

e ab

dom

inal

cra

mps

orga

nism

s

va

ccin

e an

d th

e bu

ffer c

ompo

nent

s;

of

atte

nuat

ed

cong

enita

l or a

cqui

red

imm

une

stra

in)

deffi

cien

cy, c

onco

mita

nt tr

eatm

ent w

ith

imm

unos

uppr

essi

ve o

r ant

imito

ticC

hole

ra -

Typh

oid

0.

5 m

L, 2

dos

es,

SC

Res

iden

ce in

end

emic

are

as

drug

s

Vacc

ine

1 m

o ap

art y

early

Rab

ies V

acci

ne

Rab

ies p

ost-e

xpos

ure

prop

hyla

xis

a.

Hum

anD

iplo

id

1.0

mL

on th

e IM

is

reco

mm

ende

d fo

r all

pers

ons 1

.)

Ana

phyl

actic

, neu

ropa

ra-ly

tic

Cel

l Vac

cine

da

y of

the

bite

itten

or s

crat

ched

by

wild

or

re

actio

ns (r

are)

(

HD

CV

) (D

O) &

repe

ated

dom

estic

ani

mal

s tha

t may

be

Fe

ver,

naus

ea

do

ses a

t D3,

D7,

infe

cted

, 2.)

who

repo

rt ha

ving

an

In v

iew

of g

ravi

ty o

f dis

ease

all

Pain

, ery

them

a &

indu

ra-ti

on a

t

D14

& D

28(D

90

op

en w

ound

or m

ucou

s mem

bran

e co

ntra

indi

catio

ns a

re se

cond

ary

in

site

of i

njec

tion

optio

nal)

co

ntam

inat

ed w

ith sa

liva

or o

ther

ca

seso

f sus

pect

ed ra

bies

Fe

ver,

mal

aise

, mya

lgia

b.

Inac

tivat

ed

0.5m

LDO

,D3,

IM

po

tent

ially

infe

ctio

us m

ater

ial (

eg

cont

amin

atio

n Se

rum

sick

ness

R

abie

s D

7,D

14,

br

ain

tissu

e) fr

om a

rabi

d an

imal

,

Neu

ropa

raly

tic re

actio

ns (r

are)

(

vero

cel

l) D

30(D

90 o

ptio

nal)

SC

3.) w

ho re

port

a po

ssib

ly in

fect

ious

ex

posu

re (e

g bi

te, s

crat

ch, o

r ope

n

c. D

uck

Embr

yo

1.0m

LDO

,D3,

SC

w

ound

or m

ucou

s mem

bran

e

Vac

cine

(DEV

) D

7,D

14,

co

ntam

inat

ed w

ith sa

liva

or o

the

D28

.D90

IM

in

fect

ious

mat

eria

l) to

a h

uman

with

rabi

es.

Typh

oid

Vacc

ine

a.

Pare

nter

al

1-4

year

s: 0

.25

mL

SC

>

5 ye

ars:

0.5

mL

R

esid

ence

in e

ndem

ic a

reas

A

ge: b

elow

2 y

ears

Pa

in a

t site

of i

njec

tion

2 do

ses,

1 m

onth

A

cute

febr

ile il

hess

; pro

tein

uria

, Fe

ver,

conv

ulsi

ons o

r chi

lls,

apar

t,

pr

ogre

ssiv

e di

seas

e; P

regn

ancy

he

adac

he, m

alai

se

ev

ery

3 ye

ars

b.

Ora

l 1

cap

to b

e ta

ken

O

ral

Res

iden

ce in

end

emic

are

as

Acu

te in

test

inal

& fe

brile

infe

ctio

ns

Mild

gas

troin

test

inal

1 ho

ur b

efor

e a

Imm

une

defic

ienc

y-

dist

urba

nces

, rar

ely

mea

l on

Dl,

D3,

D5

cong

enita

l or a

cqui

red


246

TAB

LE

IV. E

XPA

ND

ED

PR

OG

RA

M O

N IM

MU

NIZ

ATIO

N (E

PI) O

F T

HE

DE

PAR

TM

EN

T O

F H

EA

LTH

Vacc

ine

Min

imum

Age

D

ose

Num

ber

Rou

te o

f Si

te o

f M

inim

um In

terv

al

Rem

arks

of

Dos

e A

dmin

istr

atio

n A

dmin

istr

atio

n be

twee

n do

ses

BC

G 1

B

irth;

any

tim

e 0.

05 m

L fo

r 1

Intra

derm

al

Rig

ht d

elto

id

Va

ccin

e de

stro

yed

afte

r or 6

wee

ks

new

born

s; 0

.1

regi

on o

f the

arm

by h

eat a

nd su

n

mL

for o

lder

lig

ht

infa

nts

DTP

6

wee

ks

0.5

mL

3 IM

up

per o

uter

4

wee

ks

Vacc

ine

dam

aged

by

heat

porti

on o

f thi

gh

an

d fr

eezi

ng; D

TP n

ot

gi

ven

to >

6 y

ears

old

-

gi

ve T

d if

avai

labl

e

Polio

6

wee

ks

2 dr

ops o

r 3

3 PO

M

outh

4

wee

ks

Vacc

ine

easi

ly d

amag

ed

depe

ndin

g on

by

hea

t

man

ufac

ture

r's

inst

ruct

ions

Hep

atiti

s M

inim

um a

ge

Follo

w

3 IM

A

nter

o-la

tera

l 4

wee

ks

Vacc

ine

dest

roye

d by

B V

acci

ne

Birt

h m

anuf

actu

rer's

as

pect

, thi

gh

fr

eezi

ng a

nd h

eat

in

stru

ctio

ns

(infa

nts)

M

easl

es

Min

imum

age

0.

5 m

L 1

SC

Out

er p

art o

f

Vacc

ine

easi

ly d

amag

ed

6

mon

ths

by

hea

tB

CG

2 at

scho

ol e

ntry

0.

1 m

L 1

Intra

derm

al

left

delto

id

Va

ccin

e de

stro

yed

by h

eat

whe

ther

or n

ot

an

d su

nlig

ht

ch

ild h

as B

CG

sc

arTe

tanu

s W

omen

of c

hild

0.

5 m

L 5

IM

delto

id re

gion

TT

l at 1

st c

onta

ct,

Vacc

ine

dam

aged

by

heat

toxo

id

bear

ing

age

TT2

at le

ast 4

wks

an

d su

nlig

ht

afte

r TTl

TT3

at le

ast 6

wks

afte

r TT2

,

TT

4 at

leas

t 1 y

ear

For t

hose

not

giv

en p

rimar

y

af

ter T

T3,

imm

uniz

atio

ns in

infa

ncy

TT5

at le

ast 1

yea

r an

d ch

ildho

od

af

ter T

T4


247

CPM 1ST EDITION

PASSIVE IMMUNIZATION

1. Indications for the administration of preformed antibody to provide temporary protection to an unimmune recipient.

• Congenital or acquired 6-lymphocyte cell defects alone or in combination with other immunodeficiencies. • When no vaccine for a given disease is avail

able and prevention or modification is possible by anti body. • When time does not permit adequate protection by active immunization alone (e.g. postexpo-

sure to measles, rabies, hepatitis B or tetanus prophylaxis).

• When a specific toxic effect of venom is best managed by antibody administration (e.g. poisonous snake bite). • Therapeutically, when a disease is already present, and antibody may ameliorate or aid in suppressing the toxin effects (e.g. botulism, diphtheria, tetanus). N.B. Passive immunization must be given as soon as possible after exposure to be able to prevent the infection.2. Types of products available for passive immuniza-

tion • Normal (standard) human immunoglobulin for

general use (gamma globulin) a. Intramuscular immunoglobulin (IGIM) b. Intravenous immunoglobulin (IGIV) • Specific (special) human immunoglobulin (for intramuscular use only) - e.g. Hepatitis B,

Varicella-Zoster, Rabies, Tetanus immunoglobu lins, etc.

• Human plasma/blood • Animal sera and antitoxins - Tetanus antitoxin,

Diphtheria antitoxin. Rabies immune serum, Botulism antiserum, Black widow spider anti venin. Snake bite antivenin, etc.


248

TABLE V. PASSIVE IMMUNIZATION IN INFANTS AND CHILDREN

Disease Preparation Goal and Dose Indications/Comments

Antibody IGIM Treatment: 0.7 mL/Kg Double dose at onset of therapy;Immunodeficiency every 2-4 weeks give at multiple sites.

IGIV Treatment: 2 mL/Kg of Also for ITP& Kawasaki disease; 5% preparation; 3.3 mL/ more predictable blood levels Kg of 3% preparation but more frequent side effects and higher cost.

Diphtheria Diphtheria Prevention: 5,000 units For symptom-free, positiveAntitoxin culture and positive Schick test.

Treatment: See below* 40,000-120,000 units

Hepatitis A IGIM Prevention: Single Household contacts: higher dose exposure - 0.04 mL/Kg in adults with heavy exposure. Continuous exposure: Repeat in 4-5 months if exposure 0.02 - 0.06 mL/Kg continues.

Hepatitis B IGIM Prevention: Use if HBIG is unavailable or 0.06 - 0.12 mL/Kg exposure is uncertain.

Hepatitis B Postexposure prophylaxis For newborns delivered from Immuno- in newborns: 0.5 mL at mothers with Hepatitis B birth within 12 hours (HBsAg+globulin(HBIG) Others: 0.06 mL/Kg or 5 especially those with HBeAg+). mL for adults within 24 Accidental puncture of skin by hours; repeat 4 weeks later contaminated needle. for those who choose not to Splashing of infected blood into receive Hepatitis B vaccine mucous membrane. Accidental injection of infected

blood.

Hepatitis C IGIM Prevention: 0.12 mL/Kg Use with transfusions under (non A, non B) special circumstances.

Measles IGIM Prevention: Susceptible normal infants & 0.25 - 0.50 mL/Kg children** Prevention: 0.50 mL/Kg Susceptible (max 15 mL) immunocompromised patients Modification: 0.05 mL/Kg

Measles Prevention: 0.04 mL/Kg For susceptible normal infants Immuno- and children

* Suggested doses: Mild nasal or pharyngeal -40,000units Moderately severe pharyngeal - 80,000 units Severe pharyngeal or laryngeal or extensive diseases > 48 hour duration, or brawny swelling of the neck -120,000 units** If modified measles did not occur, vaccinate with live attenuated measles vaccine after 3 months.


249

CPM 1ST EDITION

* As antitoxin to neutralize circulating toxin: Tetanus Immune Globulin (TIG) is preferred, 3,000 - 6,000 units, intramuscularly, although some experts claim that 500 units is just as effective as a larger dose (part may be infiltrated around the wound); repeated doses are not reauired.

As control measure in Passive Immunization: TIG, 250 - 500 units, intramuscularly or Tetanus antitoxin, 3,000 - 5,000 units, intramuscularly (after careful screening and testing for sensitivity to it.

** Alternative drug: Tetanus Antitoxin (ATS), 500 units/Kg BWor 5,000 units to newboms, 10,000 units to children, 20,000 units to adults; 1/2 intravenously and the rest intramuscularly. Intradermal test must be done one hour before serum administration except in newborns in whom sensitivity testing can be dispensed with.

As control measure in Passive Immunization: TIG, 250 - 500 units, intramuscularly or Tetanus antitoxin, 3,000 - 5,000 units, intramuscularly (after careful screening and testing for sensitivity to it).

Reference Handbook on Infectious Diseases, Philippine Pediatric Society, Inc., 1992 Edition, pp. 2-11

TABLE V. PASSIVE IMMUNIZATION IN INFANTS AND CHILDREN

Disease Preparation Goal and Dose Indications/Comments

Varicella VZIG Modification: 2-5 mL Newboms whose mother developed varicella prior to or soon after delivery; patients on corticosteroids, altered immune status.

IGIM Modification: Use in high risk patients if VZIG is 0.6 -1.2 mL/Kg unavailable or unaffordable.

Rabies Rabies human Prevention: 20.0 iu/Kg Multiple bites regardless of the immunoglobulin 1/2 IM 1/2 around presence or absence of signs of (RIG) wound rabies in animals; single bites in whom rabies cannot be ruled out.

Anti-rabies Prevention: 40.0 iu/Kg Use only if RIG is unavailable or equine serum unaffordable. (ARS)

Rubella IGIM Prevention: 0.55 mL/Kg Use only during pregnancy; or 20 mL efficacy unreliable Tetanus Tetanus human Prevention: 250 units Susceptible infants and children* immunoglobulin Treatment: 500 units (TIG)

Tetanus antitoxin Prevention: 3,000-5,000 Use when TIG is unavailable or (ATS) units unaffordable** Treatment: 500 units/Kg

or 5,000 units to newborns, 10,000 units to children, 20,000 units to adults

Poliomyelitis IGIM Prevention: 0.15 mL/Kg Rarely indicated


250

Active ImmunizationBCG Lyophilized BCG Vaccine...........................120Diphtheria, Tetanus,Pertussis, Polio Myelitis(DPTIOPV) Anatetall.............................113 Difpertetall.........................113 Diftetall Ped/Diftetall Adult Use........................113 Dite Anatoxal Berna (Chldn)/DiteAnatoxal Bema (Adult)..................113 Diteper Anatoxal Bema...............................113 D.P.T.................................. 113 Pentact-HIB........................113 Polioral/Polio Vaccine............................113 Polio Sabin.........................113 Poliovirus Vaccine Live Oral Trivalent..................113 Te Anatoxal Bema..............114 Tetavax...............................114 Tetracoq..............................114 Tetract-HIB........................114 Tritanrix............................NP*Influenza Act-Hib..............................120 Hibtiter................................120 Inflexal Berna ....................120 Vaxigrip..............................120Measles, Mumps, Rubella(MMR) Biviraten Bema...................114

Ervevax .............................114 Gunevax.............................114 Lirugen...............................114 MMR II..............................114

Moraten Bema....................116 Morbilvax...........................116 Morupar..............................116 Mumaten Bema..................116 MumeruVax........................116 Rimevax ............................116 RubeatenBema...................116 Trimovax Merieux ............116


Triviraten Bema ................116Hepatitis B Engerix-B...........................116 Tritanrix............................NP* H-B-Vax II..........................118 Hepavax-B..........................118 RecomvaxB........................118Passive ImmunizationDiphtheria, Tetanus IG Tetano/Tetanus Immune Globulin (Human)..........................120 Purified Tetanus Antitoxin.........................120 Tetaglobuline......................121 Tetanus Antitoxin Bema...............................121 Tetuman Berna ..................121 Tosuman Bema...................121 Hepatitis A &B GlobumanBema..............121 Globuman Hepatitis Bema...............................121 Hepabig...............................121Measles MorumanBema...................121Rabies Imogam Rabies...................121 Pasteur Antirabies Serum..............................121Rabies Antiserum Bema..................................121 Rabuman Berna..................121Other Immunologicals GlobumanBema..................122 IG Gamma..........................122 Sandoglobulin.....................122

*NP - Product Information can be found in PPD 19971st Supplement

Cpm1st Childhood Tb

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