Immunisation Update By Sindy Lee & Eva Wong 27 th March 2003.
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Transcript of Immunisation Update By Sindy Lee & Eva Wong 27 th March 2003.
Immunisation UpdateBy Sindy Lee & Eva Wong27th March 2003
Case 1 Mr and Mrs Chan bring their 2 month
old daughter, Siu-yee for her first immunisation. They say that they have received a reminder letter from the government and ask what their child what their child requires.
Question 1 What immunisation does the child no
w require?
Question 2 How and in what sites are these immu
nisation given?
Question 3 How should these vaccines be
stored?
Question 4 Where and how should the
vaccination be recorded?
Question 5 The parents ask about possible
reactions to the vaccines. What advice would you give about possible adverse reaction?
Question 6 Mr Chan returns in 2 months for Siu ye
e’s sencond immunisation and tells you she had a fever after her last immunisation. She cried during the night. What questions would you ask Mr Chan? What would you advise about this immunisation?
Question 7 You next see Siu-yee at the age of 6 m
onths when she has a slight rhinitis but no fever and her chest is clear. Would you give her immunisation? What precaution would you take?
Case 2 Siu-ming, an 18 month old infant is br
ought for his fourth triple antigen immunisation. You have not seen him before.
Question 1 What information would you
requires before giving the injection?
Question 2 The parent informs you that Siu-ming
had his 12month booster at another private doctor’s clinic. The boy has not had an examination since relocating 12 months ago. What questions would you like to ask about his general health and development?
Question 3 What examination would you
perform?
Question 4 The parent informs you that although there
are no hearing problems in the family, Siu-ming does not seem to turn around when spoken to. Otoscopic examination reveals some mucosal swelling and a dull drum on the left side. He has a slight post-nasal drip but is afebrile.
Would you give his immunisation?
Question 5 What is your management of the
ear problem?
Case 1 Mr and Mrs Chan bring their 2 month
old daughter, Siu-yee for her first immunisation. They say that they have received a reminder letter from the government and ask what their child what their child requires.
Question 1 What immunisation does the child no
w require?
Question 2 How and in what sites are these immu
nisation given?
Case 1- answer 1, 2
Immunization programme in Hong Kong 2003Newborn BCG
Oral polio type IHepatitis B vaccine – first dose
1 month Hepatitis B vaccine – second dose
2-4 months Triple vaccine (diphtheria, tetanus & pertussis) – first doseOral polio trivalent – first dose
3-5 months Triple vaccine (diphtheria, tetanus & pertussis) – second doseHepatitis B vaccine – third dose
4-6 months Triple vaccine (diphtheria, tetanus & pertussis) – third doseOral polio trivalent – second dose
12 months MMR vaccine (measles, mumps, rubella) – first dose
18 months Triple vaccine (diphtheria, tetanus & pertussis) – booster doseOral polio trivalent – booster dose
Primary 1 Combined vaccine (diphtheria & tetanus) – booster doseOral polio trivalent – booster doseMMR ( measles, mumps & rubella) – second dose
Primary school student BCG after tuberculin testing
Primary 6 Combined vaccine (diphtheria & tetanus) – booster doseOral polio trivalent – booster doseSupplementary hepatitis B vaccination
Elderly > 65 years old in institutions
Influenza
intradermal
Immunization programme in Hong Kong 2003Newborn BCG
Oral polio type IHepatitis B vaccine – first dose
1 month Hepatitis B vaccine – second dose
2-4 months Triple vaccine (diphtheria, tetanus & pertussis) – first doseOral polio trivalent – first dose
3-5 months Triple vaccine (diphtheria, tetanus & pertussis) – second doseHepatitis B vaccine – third dose
4-6 months Triple vaccine (diphtheria, tetanus & pertussis) – third doseOral polio trivalent – second dose
12 months MMR vaccine (measles, mumps, rubella) – first dose
18 months Triple vaccine (diphtheria, tetanus & pertussis) – booster doseOral polio trivalent – booster dose
Primary 1 Combined vaccine (diphtheria & tetanus) – booster doseOral polio trivalent – booster doseMMR ( measles, mumps & rubella) – second dose
Primary school student BCG after tuberculin testing
Primary 6 Combined vaccine (diphtheria & tetanus) – booster doseOral polio trivalent – booster doseSupplementary hepatitis B vaccination
Elderly > 65 years old in institutions
Influenza
Immunization programme in Hong Kong 2003Newborn BCG
Oral polio type IHepatitis B vaccine – first dose
1 month Hepatitis B vaccine – second dose
2-4 months Triple vaccine (diphtheria, tetanus & pertussis) – first doseOral polio trivalent – first dose
3-5 months Triple vaccine (diphtheria, tetanus & pertussis) – second doseHepatitis B vaccine – third dose
4-6 months Triple vaccine (diphtheria, tetanus & pertussis) – third doseOral polio trivalent – second dose
12 months MMR vaccine (measles, mumps, rubella) – first dose
18 months Triple vaccine (diphtheria, tetanus & pertussis) – booster doseOral polio trivalent – booster dose
Primary 1 Combined vaccine (diphtheria & tetanus) – booster doseOral polio trivalent – booster doseMMR ( measles, mumps & rubella) – second dose
Primary school student BCG after tuberculin testing
Primary 6 Combined vaccine (diphtheria & tetanus) – booster doseOral polio trivalent – booster doseSupplementary hepatitis B vaccination
Elderly > 65 years old in institutions
Influenza
intramuscular
Immunization programme in Hong Kong 2003Newborn BCG
Oral polio type IHepatitis B vaccine – first dose
1 month Hepatitis B vaccine – second dose
2-4 months Triple vaccine (diphtheria, tetanus & pertussis) – first doseOral polio trivalent – first dose
3-5 months Triple vaccine (diphtheria, tetanus & pertussis) – second doseHepatitis B vaccine – third dose
4-6 months Triple vaccine (diphtheria, tetanus & pertussis) – third doseOral polio trivalent – second dose
12 months MMR vaccine (measles, mumps, rubella) – first dose
18 months Triple vaccine (diphtheria, tetanus & pertussis) – booster doseOral polio trivalent – booster dose
Primary 1 Combined vaccine (diphtheria & tetanus) – booster doseOral polio trivalent – booster doseMMR ( measles, mumps & rubella) – second dose
Primary school student BCG after tuberculin testing
Primary 6 Combined vaccine (diphtheria & tetanus) – booster doseOral polio trivalent – booster doseSupplementary hepatitis B vaccination
Elderly > 65 years old in institutions
Influenza
intramuscular
Immunization programme in Hong Kong 2003Newborn BCG
Oral polio type IHepatitis B vaccine – first dose
1 month Hepatitis B vaccine – second dose
2-4 months Triple vaccine (diphtheria, tetanus & pertussis) – first doseOral polio trivalent – first dose
3-5 months Triple vaccine (diphtheria, tetanus & pertussis) – second doseHepatitis B vaccine – third dose
4-6 months Triple vaccine (diphtheria, tetanus & pertussis) – third doseOral polio trivalent – second dose
12 months MMR vaccine (measles, mumps, rubella) – first dose
18 months Triple vaccine (diphtheria, tetanus & pertussis) – booster doseOral polio trivalent – booster dose
Primary 1 Combined vaccine (diphtheria & tetanus) – booster doseOral polio trivalent – booster doseMMR ( measles, mumps & rubella) – second dose
Primary school student BCG after tuberculin testing
Primary 6 Combined vaccine (diphtheria & tetanus) – booster doseOral polio trivalent – booster doseSupplementary hepatitis B vaccination
Elderly > 65 years old in institutions
Influenza
Subcutaneous
Question 3 How should these vaccines be
stored?
Case 1- answer 3 Stored 2-8C Upper deck:
oral polio, MMR, BCG, rebella Middle deck:
hepatitis B, DTP, flu Lower deck: emergency medication, NS Thermometer for monitoring Not to store with other foods Minimize opening New drug at the back
Question 4 Where and how should the
vaccination be recorded?
Case 1- answer 4 In practice record In child health record Immunization record Information:
Date Vaccine Adverse reaction Expiratory date and serial number
Question 5 The parents ask about possible
reactions to the vaccines. What advice would you give about possible adverse reaction?
Case 1- answer 5 BCG: local reaction Polio: poliomyelitis (1/6.2million) DPT: fever, seizures HBV: rare MMR: fever, rash, joints pain
Question 6 Mr Chan returns in 2 months for Siu ye
e’s sencond immunisation and tells you she had a fever after her last immunisation. She cried during the night. What questions would you ask Mr Chan? What would you advise about this immunisation?
Case 1- answer 6 ? Body temperature Describe the crying If temp >40.5C or crying >3-4 hr, child
should preclude further pertussis vaccination
Consider prophylactic panadol
Question 7 You next see Siu-yee at the age of 6 m
onths when she has a slight rhinitis but no fever and her chest is clear. Would you give her immunisation? What precaution would you take?
Case 1- answer 7 Rhinitis not a contraindication Principles:
Careful education Management of fever Immunisation should not be inappropriat
ely deferred due to infection
Case 2 Siu-ming, an 18 month old infant is br
ought for his fourth triple antigen immunisation. You have not seen him before.
Question 1 What information would you
requires before giving the injection?
Case 2 – answer 1 Check previous immunisation record Any adverse reaction Allergies Past medical history Neurological diseases
Triple vaccine Contraindication:
Acute febrile illness Active or progressive neurological diseas
e Previous severe reaction e.g. encephalop
athy within 7 days after previous injection, immediate severe allergic or anaphylactic reaction
Triple vaccine Relative contraindications
Convulsion within 2 days Persistant, inconsolable screaming for m
ore then 3 hours within 2 days Collapse or shock like state within 2 days Unexplained high fever with 2 days Sever local reaction
Triple vaccine NOT contraindications:
Family history of adverse reaction Family history of convulsion Permaturity Asthma, eczema, allergies Stable neurological condition
Question 2 The parent informs you that Siu-ming
had his 12month booster at another private doctor’s clinic. The boy has not had an examination since relocating 12 months ago. What questions would you like to ask about his general health and development?
Case 2 – answer 2 Check previous health record Discuss developmental milestone
Question 3 What examination would you
perform?
Case 2- answer 3 Height and weight Strabismus Gait Abdomen and testis CVS
Question 4 The parent informs you that although there
are no hearing problems in the family, Siu-ming does not seem to turn around when spoken to. Otoscopic examination reveals some mucosal swelling and a dull drum on the left side. He has a slight post-nasal drip but is afebrile.
Would you give his immunisation?
Case 2- question 4 There is no contraindication
Question 5 What is your management of the
ear problem?
Case 2 – question 5 Dx: serous otitis media Take 3 months to resolve Conservative management Refer ENT if parents concern or persis
tent symptoms Prevent learning and language develo
pmental problem
Categorization of vaccines
BCG
Live or inactivated ?Live attenuated
Inactivated
Live attenuated Live attenuated
Live attenuated
Hep B surface anitigenD&T toxoid, killed P organismInactivated vaccine
InactivatedHaemophilus influenzae type B
Influenza
DPT
Hepatitis B
Chickenpox
MMROPVIPV
Are they contraindication for vaccination?
Family history of any adverse reactions following immunisation Family history of convulsion or epilepsy Prematurity Symptomatic HIV History of anaphylactic reaction Neurological conditions, such as cerebral palsy and Down’s syndr
ome Those on immunosuppressive agents eg. steroids Asthma. ezema, hay fever, rash to egg protein to receive MMR Those on antibiotic or inhaled steroid Pregnancy Child is being breastfeed Under a certain weight Chronic illness eg. congenital heart disease
No
NoNo
Yes
Yes
NoNo
NoNo
YesNo
NoNo
Routine immunization programme - BCGCharacteristicCharacteristic::Intradermal, papule will appear 2-6 wee
ks then dischargeEfficacy:Protect against disseminated disease a
nd TB meningitis in particular 80%About 50% protection against pulmona
ry TB
Routine immunisation – BCG Adverse reaction 1-2% Prolonged deep ulceration, subcutan
eous abscess Lymphadenitis 1-10% Osteomyelitis 5/100,000 in newb
orn Disseminated disease <2/1,000,000
Routine immunisation - BCG Contraindications
Children born to HIV-positive mothers Those at risk of severe immunodeficiency Symptomatic HIV (if asymptomatic, asses
sed by paediatrician for fitness) Those receiving immunosupressive agent
s Pregnancy
Routine immunisation – Poliovirus vaccine Immunogenicity and vaccine efficacy:Immunogenicity and vaccine efficacy:
Seroconversion
OPV IPV
3 doses >95% 99%
Inhibit acquisition-intestinal
+++ +
Routine immunisation – Poliovirus vaccine
How long did the faecal excretion of OPV last?6 weeks
What happen if the child vomit after ingestion of OPV? Repeat if vomiting within 10 minutes. If not retained, repeat 4 weeks later.
Routine immmunisation – Poliovirus vaccine
OPV IPV
Timing of Timing of vaccinationvaccination
2 separate doses (8 wks, min 6 wks) & a booster dose at 18 months ( min 2 mths after).
2 injections (8 wks, min 4 wks) & a booster dose 1 year after
Adverse effect:Adverse effect: Paralytic poliomyelitis (1/6.2 million) Contraindication:Contraindication: Anaphylactic reaction to a vaccine or any of its components (eg. Ne
omycin, streptomycin, polymyxin B)
Routine immunisation - DPT
Adverse event:Adverse event: Local and febrile reaction Bacterial or sterile abscesses 6-10/million Allergic reaction – anaphylaxis 2/100,000 Seizures – febrile seizures Hypotonic-hyporesponsive episode 4-291/100,000 Fever of 40.5 0.3%
Pertussis Diphtheria toxoid
Tetanus absorbed toxoid
Efficacy 50-90% 97% 100%
Routine immunisation – DPT Contraindication:Contraindication: An immediate anaphylactic reaction Encephalopathy within 7 days
Is history of febrile convulsion a contraindication for DPT vaccination?
How would you advise him?
Routine immunisation - DPT Management of Children with history of Management of Children with history of
febrile convulsion after DPTfebrile convulsion after DPT1. Administration of panadol at the time of DPT and at 4-8 ho
urs after immmunisation decreases the subsequent incidence of febrile and local reactions. Antipyretic prophylaxis every 4-6 hours for as long as 24 hours after vaccination may benefit children with increased risk of seizures, including febrile convulsions
2. Tepid sponging3. Regular checking of body temperature
Routine immunisation - MMRMeasles Rubella Mumps
EfficacyEfficacy 99% 99% 96%
Adverse Adverse reactionreaction
1. Fever 7-12 days after 5-15 %
2. Rash 5%3. Allergic reaction4. Seizures –
simple febrile5. Thrombocytope
nia 2-4/400,000 doses
6. Encephalitis - < 1 per million doses
1. Arthopathy 0.5%
2. Transient peripheral neurotic compliants
1. Rash2. Febrile
seizures3. Nerve
deafness4. Meningitis,
encephalitis
Routine immunisation - MMR Contraindication:
Anaphylactic reaction to a vaccine or its components ( eg gelatin, neomycin)
Immunodeficiency due to causes other the HIV Symptomatic HIV Pregnancy
Routine immunisation – Hep B Efficacy:Efficacy: 90-95% Immune memory remains intact for >13 years Schedule:Schedule:
Three doses at birth, 1 and 6 months Very low birth weight infants Infants < 2 kg respond poorly to vaccine If mother HbsAg pos : start HBV vaccination with HBIg at birth If mother HBsAg neg : start HBV vaccination when BW > 2 kg Children under 6 years with incomplete course of vaccination ( the 3 doses) Received 2 doses 3 wks to 3 mths apart and within 1 year after second dose –
give the third dose Supplementary Hep B vaccination for primary 6 students
Vaccine Storage and Handling
Protect MMR from light at all times
Freeze (-14 or lower)Freeze (-14 or lower) Refrigerate (2 – 8 )Refrigerate (2 – 8 )
OPVVaricella
MMRDPTHibHepA, HepBInfluenzaIPVPneumococcal
Polio vaccine
Oral polio vaccine VS inactivated polio vaccine
Polio vaccine Oral polio vaccine
Developed 1961 Live attenuated vaccine Cheap and easy to administer Humoral antibodies as well as intestinal immunity Short term shedding of vaccine in stool also result in “p
assive immunization” of persons with close contacts Risk of vaccine-associated paralytic poliomyelitis (VAPP) Declared polio-free in Oct 2000 in Western Pacific Risk of VAPP greater then risk of paralytic poliomyelitis fr
om wild-type poliovirus
Inactivated polio vaccine Global eradication targeted at
2005 Change to IPV?
Inactivated polio vaccine (IPV) Developed 1955 Immunogenicity is low Replaced by enhanced-potency IPV No risk of VAPP Disadvantages:
Expensive Needs additional injections IPV vaccinee is infected by wild polio, virus can s
till multiply and shed in stool risking continued circulation among the community
Inactivated polio vaccine (IPV) During polio outbreak: OPV WHO recommendation:
Countries currently involved in polio eradication should not consider using IPV at this moment and OPV is required for actual eradication
Recently or currently endemic countries should continue EXCLUSIVE OPV
Is HK ready to switch to IPV? Last case of poliomyelitis caused by
wild poliovirus occurred in HK in 1985
Some Nearby areas still endemic South Asia countries reported 80% of
global cases of polio in 1998 Indian subcontinent Sub-Sahara Africa
Lack of data about risk of VAPP
Polio vaccination in HK Oral trivalent vaccine introduced in 1963 Resurgence of polio type 1 in 1965 Oral polio type 1 to newborn in 1966 1971: Booster doses of trivalent vaccine
at 18mo 1979: booster doses at P.1 and P.6 Strategy need review after global
eradication of polio
Influenza vaccine
Influenza vaccine Epidemiology:
Two peaks: Jan-Mar, Jun-Aug 2- 3 types of influenza viruses
Multivalent Component will be determined each year fo
r northern and southern hemisphere 97/98: Bayern(H1N1), Wuhan(H3N2) 98/99: Sydney(H3N2), Beijing(H1N1)
Influenza vaccine Inactivated vaccine Safe Efficacy
age and immunocompetence of recipient degree of match/similarity between vacci
ne strains and virus in season If antigenicity similar, prevents illness in
70% - 90% of healthy persons <=65years
Influenza vaccine- how to use? Different strain each year Annual vaccination 1998: annual immunization of
residents in elderly homes in HK Given 2-4 months before its peak
October to December Route: IM, 0.25-0.5ml
Influenza vaccine- who should receive it? DH
All persons >65years Residents of nursing home
HA Children with hemodynamically significant conge
nital heart disease, chronic lung disease (+/- asthma), children on long-term aspirin, hemoglobinopathies, psychogeriatric inpatients, institutionalized mental handicapped patients
Private: Anyone who wishes to reduce risk of influenza
Intranasal influenza vaccine Trivalent, live attenuated cold adapte
d vaccine Effective (93% effective in preventing
culture-positive influenza) and safe Protective even in the second year wit
h serotype mismatch (86% effective) No injection needed
Hepatitis A vaccine
Hepatitis A- epidemiology Incidence decreasing due to better
hygiene Fecal-oral route: hygiene >
vaccination Usually has a benign course 51% of Guangzhou province and
15% HK has HA antibodies Expensive
Hepatitis A Two inactivated hepatitis A vaccines
available Approved for persons > 2 years of age Pediatric formulation available
Different units but 0.5ml IM for both 2 doses (initial and at least 6 months later)
Hepatitis A 88-100% seroconverted after 1st dose,
100% after 2nd dose Protective efficacy for clinical hepatiti
s A of 94-100% Need for booster dose not known yet,
kinetic models suggest that protective levels will persist for > 20years
Hepatitis A Routine immunization for areas with rates >
=20/100000 in the US Hong Kong
Limited to high risk groups: travellers to endemic areas, chronic liver disease, laboratory workers, food handlers, health care workers
Not routinely recommended for children “personal decision” Not a substitution for high standard of hygiene
Varicella vaccine
Varicella vaccine Epidemiology:
Over 90% of children infected by 8 years Highly communicable Complications uncommon but serious Great economic impact Treatment of acyclovir remains in doubt
Varicella vaccine Routine pre-exposure administration
Overall 80-85% protection from infection Milder disease for clinical disease
Post-exposure prophylaxis Varicella-zoster immunoglobulin (VZIG)
within 96 hours of exposure: efficacy 50%, protection period unknown
Oral acyclovir: inadequate studies Post-exposure immunization: encouragin
g results in Japan and US
Varicella vaccine- post-exposure use Prevention of disease about 95-
100% Milder clinical presentation Susceptible children with 72 hours
and possibly up to 120hrs after exposure
Varicella vaccine Live attenuated viral vaccine US:
Institutional settings Teachers Non-pregnant women of childbearing age (avoid pre
gnancy for 3 months afterwards) International travellers Health care workers Family members of immunocompromised patients
NOT needed for those with reliable hx of chickenpox
Varicella vaccine HK:
Epidemiology and burden largely unknown
? Cost-effectiveness of universal immunization
Selective immunization Healthcare workers
Varicella vaccine-specific contraindications Allergic reaction to neomycin, gelatin or pri
or dose Pregnancy Immunodeficiency or those on immunosup
pressive therapy On aspirin (stopped for 6 weeks) Moderate or severe acute illness Malignant neoplasms affecting bone marro
w or lymphatic systems
Meningitis- children killer?
Meningococcal, pneunococcal and hemophilus influenza type B
Meningococcal vaccine Quadrivalent polysaccharide vaccine
(A,C,Y, W-135) and monovalent polysaccharide vaccines, efficacy <100%
Men A vaccine in China (large outbreak in 1970s)
Meningococcal vaccines US: 33% serogroup B, 28% group C, 34
% group Y (1995-8) College students 0.6/100000 Freshmen in dorm 4.6/100000 Children 2-5yr 1.7/100000 Not cost-effective
Meningococcal vaccines UK: Growing burden of serogroup C in late 90s <1 yr: 31.5/100000 1-4 yr: 16/100000 Nov 1999, incorporated MenC conjugate va
ccine into routine infant immunization (3 doses for <2m, 2 doses of 5-12mo)
National campaign offering vaccine to everyone <18yr (1 dose)
Meningococcal vaccine for HK? 1995-97: 17 cases of infection (meningitis a
nd septicemia) reported to DH Incidence of 0.03-0.08/100000 81% local cases, 38% children <4 yrs 4 serogroup B, 2 group A, 2 nonB
Jan 2000 – July 2001 24 cases reported 79% local, same age distribution 8 serogroup W-135
Indication for use Outbreak control caused by strains wi
th a capsular group contained in the vaccine
High risk group: Complement deficiency Hyposplenia Travellers to highly endemic areas
Conjugated pneumococcal vaccine Heptavalent conjugated pneumococcal vac
cine trial involving >37000 children followed for 24 months found protective against both invasive disease (meningitis, pneumonia, septicemia) and acute otitis media Serotype-specific efficacy was 94% against inva
sive disease 85% against bacteremic pnuemonia
Licensed in Feb 2000 in US
Conjugated pneumococcal vaccine Heptavalent vaccine Serotypes (4, 6B, 9V, 14, 18C, 19F, 23F) In various sites of body (nasopharyng
eal, mucosal and invasive)
Should we use it in HK? Lack of documentation of disease bur
den Very few lab diagnosed bacteremia or
meningitis in HA hospital No pneumococcal disease in HK?
Haemophilus influenza type B Meningitis associated with high
mortality and morbidity in Europe and North America
Annual incidence: 22-109/100000 of age <5 yr
Annual incidence in HK: 2.67/100000 ? Cost effectiveness ? Combined vaccine
Combination vaccine Simplify administration and promote
compliance Technical difficulties and decreased i
mmunogenicity Whole cell DTP-Hib, DTaP-Hib, DTaP-
Hib-IPV, HepatitisB-Hib
DTaP (acellular pertussis vaccines) VS DTwP (whole-cell pertussis vaccine) DTwP is effective but well known for post-v
accination fever (48hr) and local reatogenicity (swelling and induration) of injection site
DTaP causing less adverse effects and as effective as, if not more effective than DTwP
Cost-effective? Combination vaccines in future?
The end