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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