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IMMUNIZATIONIMMUNIZATION
Prof. Dr. Muhammad Akbar Prof. Dr. Muhammad Akbar NizamaniNizamani
Liaquat University of Medical Liaquat University of Medical and Health Sciences Jamshoroand Health Sciences Jamshoro
Immunization Global Situation
Each year 130 million children are born, 91 million Each year 130 million children are born, 91 million of them in developing countriesof them in developing countries..
Almost 30 million children have no access to Almost 30 million children have no access to immunizationimmunization..
"Nearly 2 million children worldwide still die"Nearly 2 million children worldwide still dieneedlessly each year of vaccine-preventableneedlessly each year of vaccine-preventable
illnesses. illnesses. Success StorySuccess Story
Eradication of disease EX: smallpox Elimination of disease EX: polio Control of disease EX: diphtheria
Immunization
“The health of the people is the foundation upon which all their happiness and their power as state depends.”
“An ounce of prevention is worth a pound of cure”
diphtheriameaslespoliomyelitistetanusPertusishepatitis Byellow feverHibmeningitis ACrotaviruspneumococcaltotal
Infectious disease deaths 2001
4 000554 000
<100201 000285 000
300015 000
450 00012 000
338 000841 000
2 703 000
1 000191 000
100080 0001 000
518 00015 000
014 000
162 000768 000
1 751 000
5 000745 000
1000281 000286 000521 000
30 000450 000
26 000500 000
1 609 0004 454 000
WHO estimates
Immunization
PAKISTANPAKISTAN Infant Mortality rate: 67 per 1000 live birthsInfant Mortality rate: 67 per 1000 live births Under Five Mortality: 85 per1000 L. BirthsUnder Five Mortality: 85 per1000 L. Births Neonatal Mortality: 38 per 1000 L. BirthsNeonatal Mortality: 38 per 1000 L. Births What Kills:What Kills: approx 600000 per yearapprox 600000 per year
• Pneumonia 200000 per yearPneumonia 200000 per year• Diarrhea 200000 per yearDiarrhea 200000 per year• Vaccine preventable Vaccine preventable
120000 [20%] 120000 [20%] • ?ROUTINE EPI COVERAGE: 30 – 60 % , 80-85%UNICEF?ROUTINE EPI COVERAGE: 30 – 60 % , 80-85%UNICEF• IN 1990 OUR COVERAGE WAS > 90% IN 1990 OUR COVERAGE WAS > 90% One of the 5 countries in EMRO not on target to achieve MDG 4One of the 5 countries in EMRO not on target to achieve MDG 4• WHERE ARE WE GOING? WHERE ARE WE GOING? • WHERE WE SHOULD BE? WHERE WE SHOULD BE? • SHOULD LOOK AFTER OUR CHILDREN?SHOULD LOOK AFTER OUR CHILDREN?
Diseases covered by EPI Diseases covered by EPI immunizationimmunization
PoliomyelitisPoliomyelitis TuberculosisTuberculosis DiphtheriaDiphtheria PertusisPertusis TetanusTetanus Hepatitis BHepatitis B H.Influenzae: Pneumonia , MeningitisH.Influenzae: Pneumonia , Meningitis MeaslesMeasles
ROUTINE IMMUNIZATION: Every ROUTINE IMMUNIZATION: Every journey begins with a single stepjourney begins with a single step
At Birth : OPV , BCG (HEP B)At Birth : OPV , BCG (HEP B) 6 WEEKS : OPV1 ,PENTA 1 6 WEEKS : OPV1 ,PENTA 1 (PENTA: Diphtheria, Pertusis, Tetanus, (PENTA: Diphtheria, Pertusis, Tetanus,
Homophiles Influenza Type B, Hepatitis B)Homophiles Influenza Type B, Hepatitis B) 10 WEEKS : OPV 2 ,PENTA2 , HEP B 210 WEEKS : OPV 2 ,PENTA2 , HEP B 2 14 WEEKS : OPV 3 ,PENTA 3, HEP B 314 WEEKS : OPV 3 ,PENTA 3, HEP B 3 9 MONTHS : MEASLES 19 MONTHS : MEASLES 1 12 MONTHS: MEASLES 212 MONTHS: MEASLES 2 TT IMMUNIZATION for Child bearing age womenTT IMMUNIZATION for Child bearing age women Minimum two vaccines during pregnancy Minimum two vaccines during pregnancy
Active Immunization Types Live attenuated
• Virus OPV,Measles, mumps, rubella• Bacteria BCG
Killed• Virus IPV• Bacteria
Whole Pertusis Toxoid Tetanus Polysaccharide Meningococcal
Genetically Engineered• Hepatitis B
TT Immunization TT immunization for CBA women, pregnant womenTT immunization for CBA women, pregnant women
Most unfortunate to still see mothers and babies dying of Most unfortunate to still see mothers and babies dying of neonatal tetanus neonatal tetanus
TT 1: First contact with a girl reaching CBA or As early as
possible in pregnancy TT2: 4 weeks after TT1 TT3: At least 6 months after TT2 or in next pregnancy TT 4:At least one year after TT3 or in next pregnancy TT5: At least one year after TT 4
For Trauma/ wound in Immunized person single dose TT
Protection Protection
against against 55 diseasesdiseases
just just oneone injection:injection:
First do no harm: First do no harm: Hippocrates oathHippocrates oath
Hib
Hep B
Diptheria
Pertussis
Tetanus 55 inin
Plus… Plus… the Pentavalent the Pentavalent
AdvantageAdvantage
H. Influenza type b vaccineH. Influenza type b vaccine
H. Influenza type b is a common cause H. Influenza type b is a common cause of bacterial meningitis, pneumonia, of bacterial meningitis, pneumonia, epiglottis and sepsis in infants and epiglottis and sepsis in infants and childrenchildren
H. Influenza type b (Hib) vaccine is H. Influenza type b (Hib) vaccine is polysaccharide vaccine polysaccharide vaccine
Administered together with PENTA Administered together with PENTA vaccine vaccine
Dose is 0.5ml intramuscularlyDose is 0.5ml intramuscularly
Hib (Haemophilus influenzae type b)
A serious infectious disease causing meningitis and pneumonia in infants and
children• At least 3 million infected worldwide 1
• Children aged between 4 and 12 months most at risk 1,2
• 400,000 – 700,000 deaths worldwide each year 1
• Prevalence of Hib disease is 15-50% or more in developing countries 3
• 500,000 children die from Hib pneumonia every year 4
• 50,000 children die from Hib meningitis every year 4
3 McIntyre P. JAMA (SEA Suppl) 1993; 9: 5-10. 4 Shapiro ED, Ward, JI. The epidemiology and prevention of disease caused by Haemophilus influenzae type b. Epidemiologic Reviews 1991; 13:112-143.
1WHO position paper Wkly Epidemiol Rec 1998; 73: 64-68 2Cambell H. et al Drugs 1993; 46: 378-383
Hepatitis B key factsHepatitis B key facts
Over 2 billion people infected worldwide1
350 million chronic carriers worldwide1,2
4 million new acute hepatitis B cases per year3
1-2 million deaths annually directly related to HBV infection2,4
HBV is 100 times more infectious than HIV5
Around 62% of liver cancer cases in Pakistan are due to hepatitis B
HBsAg the seventh EPI antigenHBsAg the seventh EPI antigen
WHO, 1992
‘‘Only by mass vaccination of infants Only by mass vaccination of infants with HB vaccine as part of EPI with HB vaccine as part of EPI will the burden of HB infection will the burden of HB infection
be significantly reduced globally’be significantly reduced globally’
AVAILABLE VACCINES NOT AVAILABLE VACCINES NOT YET PART OF EPIYET PART OF EPI
Conjugated Pneumococcal Vaccine for IPD at 2 Conjugated Pneumococcal Vaccine for IPD at 2 ,4 and 6 months or with routine immunizatioin.,4 and 6 months or with routine immunizatioin.
MMR : 15- 18 MMMR : 15- 18 M Hepatitis A Vaccine 1 y , 2Hepatitis A Vaccine 1 y , 2ndnd Dose 3 – 6 M Dose 3 – 6 M Chicken Pox VaccineChicken Pox Vaccine Typhoid Vaccine 2 yearsTyphoid Vaccine 2 years Influenza Virus vaccine 1 y , Every YearInfluenza Virus vaccine 1 y , Every Year Yellow Fever VaccineYellow Fever Vaccine Rota Virus VaccineRota Virus Vaccine Meningococcal VaccinesMeningococcal Vaccines Rabies VaccineRabies Vaccine
Forghani et al, 1994
(Chickenpox Vaccine) (Chickenpox Vaccine) Primary infection: varicella Primary infection: varicella
Can develop in an estimated 95% of adults Can develop in an estimated 95% of adults in temperate climates by the age of 25 in temperate climates by the age of 25 yearsyears
is associated with complications in healthy is associated with complications in healthy children as well as high-risk groups, e.g. children as well as high-risk groups, e.g. immunocompromised patientsimmunocompromised patients
is the leading cause of vaccine-is the leading cause of vaccine-preventable deaths in children in the USApreventable deaths in children in the USA
Clinical presentation of herpes Clinical presentation of herpes zosterzoster
Reactivation: herpes zoster
Measles-Mumps-Rubella:Measles-Mumps-Rubella: what is the best choice for three in one?what is the best choice for three in one?
MMRMMRPRIORIXPRIORIX
Measles –complicationsMeasles –complications
Otitis media: 1/10 childrenOtitis media: 1/10 children
Pneumonia: 1/20 childrenPneumonia: 1/20 children
Encephalitis: 1/1000 childrenEncephalitis: 1/1000 children
Sub-acute sclerosingSub-acute sclerosingpanencephalitis (SSPE):panencephalitis (SSPE):1/100,000 children1/100,000 children
Other complications: Other complications: blindness, miscarriages, blindness, miscarriages, premature births and premature births and congenital malformationscongenital malformations
Encephalitis
Pneumonia
Mumps – complicationsMumps – complications
Meningo-encephalitis:Meningo-encephalitis:5–15%5–15%
Deafness: 0.5–5/100,000Deafness: 0.5–5/100,000
Orchitis: 30–40% of adult Orchitis: 30–40% of adult menmen
Mastitis: approx. 30% of Mastitis: approx. 30% of women after pubertywomen after puberty
Oophoritis, miscarriage, Oophoritis, miscarriage, pancreatitispancreatitis
Encephalitis
Congenital rubella syndrome (CRS) – Congenital rubella syndrome (CRS) – clinical features and complicationsclinical features and complications
• Rubella during pregnancy: Rubella during pregnancy: up to 80% chance of baby up to 80% chance of baby born with CRSborn with CRS
• Growth retardation, eye Growth retardation, eye problems, deafness, heart problems, deafness, heart defects, mental retardationdefects, mental retardation
• Many other organs and body Many other organs and body systems can be affectedsystems can be affected
• Onset of signs, symptoms Onset of signs, symptoms and abnormalities may be and abnormalities may be delayeddelayed
Thrombocytopenia in a baby born with CRS
Meningococcal Vaccines:Meningococcal Vaccines:
• Meningococcal polysaccharide Meningococcal polysaccharide vaccine A/C/Y/W-135vaccine A/C/Y/W-135
• Recommended to children older than Recommended to children older than 2 years AND at risk (terminal 2 years AND at risk (terminal complement component deficiency, complement component deficiency, asplenia, military recruits ,traveling asplenia, military recruits ,traveling
• Meningococcal conjugate vaccine A/C Meningococcal conjugate vaccine A/C used in Europe for infantsused in Europe for infants
• Minor side effectsMinor side effects
3434
Opportunities: Best way of escaping from a problem is to solve
it Vaccines are safe Immunization is among
the safest of modern medical interventions.
Vaccines are easier and safer to administer than ever before.
Being immunized is much safer than risking infection and disease.
Immunization can save money
Immunization is one of the most cost-effective health interventions.
Investing in vaccines SAVES more money than it costs.
Immunization saves lives
Immunization saves the lives of approximately 3 million people each year, all over the world.
EPI : Current Status in Pakistan Started in 1978 Promising start Coverage Rates in 80s reached >80% Fully immunized rates now only 47% Wide spread provincial differences in coverage:
Punjab 53%, KPK 47%, Sindh37%,Balochistan 35%.
Campaign districts in 2009 reported coverage of BCG 93%, Polio 86%, Penta 86%, Measles 85% and TT 55% and over all coverage of 86%.
UNICEF state of the world children reports 80-85%
Challenges to EPI Poor routine coverage Poliomyelitis eradication still serious issue Outreach capacity of vaccinators Service structure of EPI staff Attitude of doctors in health facilities Private sector involvement Political interference in management of EPI staff;
absenteeism Maintenance of vaccine stock and quality “ he
who should do good to another must do it in the Minute Particulars. William Black”
Challenges to EPI Maintenance of cold chain ( A desk is dangerous place from where to view the world)
Lack of accountability
Monitoring , evaluation and information management (Not every thing that counts can be counted and not everything that can be counted, counts. A . Einestein).
Poor disease surveillance “ All interest in disease and death is only another expression of interest in life”.
Demand creation, behavior change “ Knowing is not enough we must apply, willing is not enough we must do. Goethe’
Lack of political will ,commitment and proper planning
“We tackle 20 year problems with 5 year plans, staffed by two year personnel working with one year appropriation. It is simply not good enough”
Questions to be answered Why we are not able to eliminate poliomyelitis in spite of so
many rounds? Inject able polio vaccine versus oral vaccine. Alternative to BCG; when will be more effective vaccine
available? Should we start Hepatitis B vaccine at birth now? Why Pertusis resurgence? A cellular Pertusis versus whole cell Pertusis!! Booster of penta !! Which should be ninth vaccine of EPI: Pneumococcal,
Typhoid, Hepatitis A, MMR ,Chicken Pox??? Measles at months ? Why are our newborns still dying in tetanus?
References and more reading UNICEF state of the world’s children 2011 Immunization essentials. A practical field guide US AID
2003 ,2010 Immunization Basics:
www.immunizationbasics.jsi.com.resources.general.htm www.who.int/pmnch/topics www.who.int/vaccine_research www.path.org/vaccineresources www.cdc.gov/vaccines/ www.vaccines.org www.niaid.nih.gov www.immunizationinfo.org/vaccines/hepatitis B