Julita Chądzyńska

Milestones in Immunisation 429 BC Thucydides notices smallpox survivors did not get re-

infected

900 AD Chinese practise variolation

1700s Variolation reaches Turkey and rest of Europe

1796 Edward Jenner: from variolation to vaccination( vacca-cow)

1880s Louis Pasteur - sheep trials and rabies

1890 Emil von Behring discovers basis of diphtheria and tetanus vaccines

1920s Diphtheria, tetanus, pertussis (whooping cough) and BCG (against tuberculosis) vaccines widely available

1955 Polio immunisation programme begins

1980 Smallpox eradicated www.immunisation.nhs.uk

Goal of immunization

Disease Annual Morbidity Baseline 20th Century

2007 Morbidity

Smallpox 48 164 0

Diphtheria 175 885 0

Pertussis 147 271 10 454

Tetanus 1314 28

Poliomyelitis 16 316 0

Measles 503 282 43

Mumps 152 209 800

Rubella 47 745 12

Congenital rubella syndrome

823 0

Haemophilus infuenzae type b

20 000 22

Eradication or elimination of disease Prevention of disease in individuals

Red Book 2009

Types of vaccines

Attenuated-living pathogen with reduced virulence

Inactivated- whole dead pathogen

Toxoid- a toxin which underwent physical(heat) or chemical(fromalin) procedures to reduce its toxity

Component vaccines- contain purified parts of pathogen

Types of vaccines Live attenuated vaccines - Measles, Mumps, Rubella, Yellow fever, Polio, Chicken pox, Rotavirus, BCG, Influenza(intranasal live vaccine), Typhoid(oral), Varicella Inactivated viruses -Hepatitis A, Influenza, Japanese encephalitis, Poliovirus(IPV-s.c.), Rabies, Polysaccharide -Pneumococcal, Meningococcal, Typhoid( capsular polysaccharide) Polysaccharide protein conjugate -Pneumococcal, meningococcal, Hib Toxoid -tetanus, diphteria Recombinant viral antigen -Hepatitis B

Spacing of live and inactivated antigens Antigen combination Minimum interval between doses

2 or more inactivated NONE. Can be administered

simultaneously or at any

interval between doses

Inactivated or live NONE. Can be administered

simultaneously or at any

interval between doses

2 or more live 28-day minimum interval if not

administered at the same visit

A.A.P. Red Book 2009

Mininum interval between vaccine doses is 4 weeks(doses administered 5 or more days earlier should not be counted as valid(ACIP).

Longer than recommended intervals between doses do not reduce final antibody concentrations

Case 1 Parents of a two year old girl came to the ambulatory

to immunise their child. They missed the mandatory immunization with MMR and the booster dose of DTP. They are a very busy couple and they wondered if its possible to have both of these vaccines at one visit.

The parents would also like to immunise their child against chickenpox and would prefer to have it all done at the same visit.

What will you tell them? Does she have to start the DTP immunisation all over again?

Contraindication- a condition in a recpient that increases the risk for a serious adverse reaction. Precaution- a condition in a recipient that might increase the risk of serious adverse reaction or that might compromise the ability of the vaccine to produce immunity . ACIP

PERMANENT 1) History of a severe allergic reaction after a previous dose of

vaccine or to a vaccine constituent( unless the recipient has been desensitized)

2) Encephalopathy within 7 days after administration of a previous dose of diphtheria and tetanus toxoids and whole-cell pertussis vaccine(DTP), DTaP or Tdap should not receive further doses of vaccine

TEMPORARY 1) Severely immunocompromized persons should not receive

live vaccines 2) Pregnant women should not receive live- attenuated vaccines

ACIP

Genaral precautions TEMPORARY

1) Moderate or severe acute illness

2) History of receiving an antibody- containing blood product is a precaution to MMR and varicella containing vaccines

PERMANENT

1) Temperature >40,5 Cdeg. < 48 h after DTPw/DTaP

2) Collapse or shock-like state( hypotonic hyporesponsive

episode) /3 h

Contraindications 1. Anaphylaxis or a severe hypersensitivity reaction is an absolute contraindication to

subsequent doses of a vaccine. Persons with a known allergy to a vaccine component should not be vaccinated.

2. Do not give BCG or yellow fever vaccine to an infant that exhibits the signs and symptoms of AIDS.

The following are not contraindications. Infants with these conditions should be immunized:

• allergy or asthma (except if there is a known allergy to a specific component of the vaccine mentioned above);

• any minor illness, such as respiratory tract infections or diarrhea with temperature below 38.5°C;

• family history of adverse events following immunization;

• family history of convulsions, seizures, or fits;

• treatment with antibiotics;

• known or suspected HIV infection with no signs and symptoms of AIDS;

• signs and symptoms of AIDS, except as noted above (see 2_20);

• child being breastfed;

• chronic illnesses such as chronic diseases of the heart, lung, kidney, or liver

• stable neurological conditions, such as cerebral palsy or Down’s Syndrome;

• premature or low-birthweight (vaccination should not be postponed);

• recent or imminent surgery;

• malnutrition; and

• history of jaundice at birth

2004 Immunization in practice: a practical resource guide for Health workers – 2004 update_____Module 2: The vaccines WHO/IVB/04.06

Case 2 Parents came to the outpatient clinic with a six year

old boy for the mandatory DTP and OPV vaccination.

The boy was diagnosed of diabetes when he was 3 years old. At this momemnt his glucose levels are stable. Can he be vaccinated safely?

Case 3 Parents came with a 6 year old girl for DTP and OPV

vaccination. Two weeks ago she was hospitalised because of atopic dermatitis exacerbation and received prednisone 20 mg per /day 3 days.

Can she be safely immunised?

www.who.int/immunization/policy

ACIP

I.M.

S.C.>12 months the recommended site over the triceps I.M.>3 years deltoid muscle ACIP

Route of administration I.M.- Dtap, DT,Td, Tdap, Hib, HepA, HepB, Influenza,

Meningococcal conjugate, Pneumococcal conjugate, HPV

S.C.-MMR, Meningococcal polysccharide, Varicella, Zoster

S.C/I.M- Pneumococcal polysaccharide, Polio inactive

Oral- Rotavirus, Polio attenuated, Typhoid

Intradermal- BCG

Case 4

You get a telephone from a mother of a 2 year old girl.

She wants to apply an anaesthetic cream before DTP+IPV+ Hib vaccination but she doesn’t know where to apply the cream. What will you tell her?

Simultaneous administration increases the probability that a child will be vaccinated at the appropriate age Simulataneously administering the most widely used live and inactivated vaccines produced seroconversion rates and rates of adverse effects similar to those observed when the vaccines are administered seperately ACIP

Suspending fluids may be sterile water or saline but could be a complex fluid containing small amounts of proteins or other constituents used to grow the immunobiologic. Preservatives, stabilizers, and antimicrobial agents are used to inhibit bacterial growth and to prevent degradation of the antigen. Such components may include gelatin, 2-phenoxyethanol, and specific antimicrobial agents. Preservatives are added to multidose vials of vaccines, primarily to prevent bacterial contamination on repeated entry of the vial.. Adjuvants are used in some vaccines to enhance the immune response. In the United States, the only adjuvants currently licensed by the Food and Drug Administration (FDA) to be part of vaccines are aluminum salts. Vaccines with adjuvants should be injected deep into muscle masses to avoid local irritation, granuloma formation, and necrosis associated with subcutaneous or intracutaneous administration. Conjugating agents- carrier proteins of proven immunologic potential combined to less immunogenic polysaccharide antigens. Their role is to enhance the type and magnitude of immune responses particularly in people with immature immune systems(

http://www.who.int/immunization/policy/immunization_tables/en/ http://vaccine-schedule.ecdc.europa.eu/Pages/Scheduler.aspx

http://www.who.int/immunization/policy/immunization_tables/en/http://www.who.int/immunization/policy/immunization_tables/en/http://www.who.int/immunization/policy/immunization_tables/en/

http://vaccine-schedule.ecdc.europa.eu/Pages/Scheduler.aspx

http://vaccine-schedule.ecdc.europa.eu/Pages/Scheduler.aspx

http://vaccine-schedule.ecdc.europa.eu/Pages/Scheduler.aspx

http://vaccine-schedule.ecdc.europa.eu/Pages/Scheduler.aspx

http://vaccine-schedule.ecdc.europa.eu/Pages/Scheduler.aspx

Adverse reactions I. LOCAL Swelling, pain, redness at the site of injection

Mild and self limited More common with inactivated vaccines II. SYSTEMIC Headeache, fever, myalgias, arthralgias, loss of apetite, malaise Mild form of the natural disease- after attenuated vaccines The pathogen must replicate to produce immunity, these symptoms occur 7-21 days after vaccination( e.g. typical rash) III. SEVERE ALLERGIC REACTION -vaccine antigen -cell culture material -stabilizer -preservative -antibiotic

Immunodeficiency and vaccination

ACIP

Post exposure immunization •Varicella 5 ys vaccine, unknkown-IG+ vaccine) •Rabies(10 days observation of the animal 0,3,7,14, 28) •Mumps and Rubella- doesn’t always prevent •Measles < 72 h vaccine, IG< 6 days (in some cases will prevent)

Managing Pain •Rapid plunge of the needle(without aspirating) •Limb in a postion which allows relaxation of the muscle •Pressure for 10 sec at the site of injection •Vapocoolant before injection •Local anaesthetic 30 to 60 minutes before injection •Administrationg sucrose solution before injection reduces crying time in infants •Distraction techniques •Breastfeeding?

Red Book 2009

Of children who become paralyzed by polio: 30% recover completely in the first weeks or months. 30% have mild paralysis. 30% have moderate or severe paralysis. 10% die (often because of difficulty breathing or swallowing).

Gregg’s Syndrome(Congenital Rubella Infection)

TRIAD Sensorineural deafness Cataract and microphthalmia Congenial heart disease(PDA)

http://www.sajch.org.za/index.php/SAJCH/article/view/461/358

Tuberculosis Miliary TB

Haemophilus influenzae type b ( Sepsis with gangrene of the hand, Periorbital cellulitis)

www.aap.org/immunization/illnesses/photos.htm

PEDIATRICS Vol. 109 No. 1 January 2002, pp. 124-129 Addressing Parents’ Concerns: Do Multiple Vaccines Overwhelm or Weaken the Infant’s Immune System? Paul A. Offit, MD*, Jessica Quarles, Michael A. Gerber,

1900 200(Smallpox)

1960 3217(DTP, Polio, Smallpox)

1980 3041(DTP, MMR, Polio)

2000 123-126(DTP, MMR, Polio, Hib, Pneumococcus, Varicella, HepB)

Number of Immunogenic Proteins and Polysaccharides Contained in Vaccines

PEDIATRICS Vol. 109 No. 1 January 2002, pp. 124-129 Addressing Parents’ Concerns: Do Multiple Vaccines Overwhelm or Weaken the Infant’s Immune System? Paul A. Offit, MD*, Jessica Quarles, Michael A. Gerber,