Preventive Pediatrics

Celia T. Sy, M.D.Pediatric Pulmonologist

Department of PediatricsFatima Medical Center

Immunization Vaccinations Type of vaccine Route of administration Immune response Post- exposure drug prophylaxis

Immunization

Denotes the process of inducing or providing immunity artificially by administering an immunologic substances Active Passive

Active Immunization

When it produces the desired beneficial effects by stimulation of endogenous antibody production by the patient Tetanous toxoid MMR BCG

Passive Immunization

Administration of preformed human or animal antibodies to individuals already exposed or about to be exposed to certain infectious agents Tetanus antitoxins Immune globulins

Vaccination

Denotes the physical act of administrating any vaccine or toxoids

Immunobiologic Substances

Vaccine - a suspension of live or inactivated microorganism or fractions thereof administered to induce immunity and prevent infectious disease or its sequela

Toxoid – modified bacterial toxin that has been made nontoxic but retains the ability to stimulate the formation of antitoxins

Antitoxins – a solution of antibodies derived from the serum of animals immunized with specific antigens Passive immunization

Diphtheria antitoxin Tetanus antitoxin

Immune globulin (IG) - a sterile solution containing antibodies from human blood. Intended for IM use for passive immunization

Measles immune globulin hepatitis b immune globulin

IV IG – a product derived from blood plasma from the donor pools similar to the IG pool but prepared for IV used Used in primary antibody-deficiency

disorders- Kawasaki disease- ITP- Hypogammaglobulinemia

Immunologic Constituents Suspending fluids – sterile water, saline Preservatives, Stabilizers, Antibiotics

used to inhibit or prevent bacterial growth Stabilize the antigens or antibodies

albumin, phenols, neomycin, mercurial

Adjuvants – evoke suboptimal immunologic response To enhance immunogenicity

Al hydroxide, Al phosphate

Vaccines & Toxoids Live vaccines

BCG MMR Oral polio Varicella Oral typhoid

Killed antigens Toxoids

DPT Tetanus

Killed antigens Inactivated Virus

IPV (inactived polio virus)

Influenza Rabies Hepatitis A Hepatitis B

Killed antigens Bacterial

polysaccharide Hib

Route of Administration Intramuscular (IM)

DPT IPV (as DPT-IPV-

HIB combination)* Hep A & B HiB Influenza Pneumococcal Meningococcal Typhoid

Subcutaneous (SC) Measles Mumps Rubella MMR Varicella IPV Pneumococcal Meningococcal

Route of Administration Oral

OPV Typhoid

Intradermal BCG

Where to inject?

General rules: For children < 1 year old – lateral

thigh For children > 1 year old - deltoid Buttocks should not be used for active

vaccinations because of the potential risk of injury to the sciatic nerve

If the buttocks are to used – use only the upper outer quadrant

Fever:To give or not to give?

Minor febrile illness or malnutrition is not a contraindication to immunization

Immunization is deferred in the presence of severe febrile illness

Vomiting:What to Do?

Regurgitated oral vaccine If the child vomit or regurgitate within

5 – 10 mins after giving OPV – another dose should be given at the same visit

If repeated dose is not retained, re-administered at the next visit

Diarrhea:Could OPV be given?

Diarrhea should not be considered as a contraindication for OPV but to ensure full protection, doses given to children with diarrhea SHOULD NOT BE COUNTED as part of the series

Need to give 2 or more vaccines:How to give?

Multiple vaccinations Administer each vaccine at a different

site using different needles and syringes

If > 1 vaccine is to be used in a single limb, use the thigh muscle and given at 1 -2 inches apart

Interruption of ScheduleWhat to do?

Interruption with a delay between doses does not interfere with the final immunity achieved

No need to start the series again

Contraindications?

Live attenuated vaccines is contraindicated in: Pregnant woman Immunocompromised person –

leukemia, lymphoma, malignancy, therapy with steroids, alkylating agents, antimetabolites

Radiotherapy

Trivia

Which of the following are live vaccines?

DPT MeaslesTOPV PneumococcalIPV MeningococcalBCG Oral TyphoidHep BMMR

Guidelines for Giving Live vaccines and killed Antigens

2 or more killed antigens – may be administered simultaneously or at any interval between doses Example:

DPT and Hep B DPT and Hib Hep A and Hep B

Killed and live antigens – may be administered simultaneously or at any interval between doses Example:

DPT and OPV Hep b and MMR DPT and Measles DPT and varicella

2 or more live antigens – may administered simultaneously or at 4 week minimum interval if not given simultaneously Example:

Measles and varicella MMR and varicella

** OPV can be administered at any time before, with or after MMR if indicated

Guidelines for administration of IG & Vaccines

Simultaneous administration IG and killed antigen – given at the same

time or at any time between doses Hepatitis B immune globulin and hepatitis B

vaccine Tetanus antitoxins and anti-tetanus vaccine

IG and live antigen – should generally NOT BE ADMINISTERED simultaneously

Guidelines…IG & Vaccines

Non-simultaneous administrationFirst Second

IG Killed Ag No interval neededIG Live Ag dose relatedKilled Ag IG No interval neededLive Ag IG 2 weeks

Interval between IG & Live Measles Vaccine

IVIG Interval ITP 400 mg/kg 8 month ITP 1000 mg/kg 10 months Kawasaki 11 months

Blood transfusion Whole blood & packed RBC 6 months Plasma/platelets 7 months

Interval…IG & live measles vaccine

IG measles prophylaxis Normal contact 0.25ml/kg 5

mons Immunocompromised 0.50ml/kg 6

mons

Trivia Which of the following vaccines

can be given simultaneously? Hep B & Measles BCG & DPT Oral polio & measles DPT & MMR Measles & MMR DPT & IPV + HiB

Immune Response

Immune response to one live virus vaccine might be impaired if administered within 30 days of another live virus vaccine

Only OPV and MMR can be administered at anytime before, with or after each other

Immune Response

Live virus vaccines can interfere with the response to a tuberculin test

Tuberculin testing can be done either on the same day that live virus vaccines are administered or 4 – 6 weeks later

Special Conditions…Special Considerations

Persons with hemophilia Increased risk of hepatitis B &

hematomas Assess the patient’s bleeding risk Use fine needle & apply pressure to

the site

Special considerations…

Altered immunocompetence Killed or inactivated vaccines can be

administered to all immunocompromised patients

OPV should not be given to any household contacts of an immunocompromised patient

IPV can be given

Special considerations….

Altered immunocompetence MMR is not contraindicated to close

contacts of immunocompromised persons

MMR vaccine is recommended for all asymptomatic HIV-infected persons and should be considered for all symptomatic HIV-infected persons

Special consideratios…

Preterm infants Regardless of birth weight should be

vaccinated at the same chronological age and according to the same schedule

Use full recommended dose except BCG

OPV should be deferred until discharge from the nursery

Special considerations…

Pregnancy Combined tetanus and diphtheria

toxoids ARE THE ONLY vaccine indicated

Vaccines BCG (Bacille-Calmette-Guerin)

Attenuated bovine strains of tubercle bacilli

Route: intradermal Dose: 0.05 ml preterm 0.1 ml term Complications

Abscess Indolent ulcer lymphadenopathy

BCG Normal course

Wheal diappear in 30 mins

Induration – after 2-3 wks

Pustular formation – after 4 – 6 wks

Full scarification – after 6 – 12 wks

Accelerated reaponse – 91-100% correlation with TB infection Induration – after

2 – 3 days Pustular formation

– after 5 – 7 days Scar – after 2 -3

wks

Polio vaccine

OPV – live attenuated vaccine IPV – inactive polio virus Combination vaccine:

DPT + IPV + Hib

DPT

Toxoids of diphtheria & tetanus; inactivated pertussis component adsorbed into aluminum salts

Dose: 0.5 ml Route: IM Side effect: swelling at injection

site

DTaP

Diphtheria, tetanus, acellular pertussis component

Decrease risk of neuroparalytic reactions due to component of pertussis

Measles Live attenuated vaccine Freeze dried Dose: 0.5 ml SQ Side effects: fever between 5th-14th day

after injection, rashes, arthritis Prophylaxis: may be given within 72

hours after measles exposure Measles IG – 0.25 ml/kg IM may be

within 6 days of exposure

Hepatitis B Vaccine

Infant born to HBs Ag-positive mother should received: Hep b Vaccine + Hep B immune

globulin (HBIG) within 12 hours of birth at different site

Next dose: Hep B at 1-2 months of age and 3rd dose at 6th month of age

Schedule: 0, 1, 6

Hepatitis B Vaccine

Infant born to mother whose HBsAg status is unknown: Hep B vaccine within 12 hours of birth Request for mother’s HBsAg status –

if (+)Infant should received HBIG

Asap (no later than 1 week of

age)

Recommended Schedule BCG

DPT, TOPV, IPV, Hib

Hepatitis B

Measles

At birth or anytime after birth

2, 4, 6 month of age

0, 1, 6 month of age 0, 1, 3 month of age

(endemic country)

9 month of age ( can be given at 6

month of age)

Schedule…. MMR Hepatits A Pneumococcal

(IPD 7 valent) Pneumococcal

(23-valent) Meningococcal Typhoid

15 month of age After 1 year of age 2, 4, 6 months up

to 9 years of age 2 years of age

2 years of age 3 years of age

Post-exposure Drug Prophylaxis Diphtheria Erythromycin Pertussis Erythromycin Cholera Tetracycline Plasmodia Chloroquine N. gonorrhea

Amoxicillin/Penicillin Meningococcemia Rifampicin

Sulfisoxazole Ceftriaxone

Tuberculosis Isoniazid

Case 1A 3 y/o child was exposed to a person with measles. Past

immunization hx: he had received 1 dose of BCG, 3 doses of DPT, TOPV & Hepatitis B. If you are the attending physician, how are you going to manage the patient?

Give measles vaccine if the exposure is within 72 hours Give measles immunoglobulin if the exposure is more

than 72 hours Give MMR if the exposure is within 72 hours Give Mesles vaccine and immune globulin at the same

time Observe the patient