IMMUNISATION PRACTICE

Dr E O D ADDO-YOBO
MSc, DTCH MD, MWACP, FGCPS,

Dept of Child Health, KNUST-SMS/KATH, Kumasi, Ghana

2010

Outline
Basic Principles of Immunisation & Terminology Routine EPI vaccines Other vaccines New vaccines General Issues:

Vaccine Reactions Immunization Safety Issues Contraindications Immunization in Special situations

What is Immunisation?

Immunisation:
The biological process of conferring protection (artificially) in a human host against infectious agents in the environment .

Vaccination:
The act or practice of inducing in a non-immune person a primary response such that on first contact with the corresponding pathogen, a rapid secondary (memory response) is mounted, leading to prevention of disease symptoms.

Vaccine:
suspension of attenuated or killed micro-organisms or fractions thereof (i.e. purified protein sub-units, polysaccharides, conjugated PSs, or split virions ) administered (orally, in, id, im, sc) to induce specific immunity and prevent infectious disease prophylactic (i.e; EPI vaccines & therapeutic vaccines - i.e. cancer vaccines in development)

Major component of Child Survival Strategies

Battle for survival!

pathogen (human)

toxins

infection, disease & Complications /disability

immune response or death

vaccine

protective immune responses without majors adverse events

The Principles of Immunization

To To To

prime recipients immune response generate B and T memory cells

heighten immune response (humoral and cell mediated) to pathogens should have minimal adverse effects prevent/reduce severity of infectious diseases (effectiveness) be of assured quality and available for general use

Vaccine(s)

Structure of the Immune System

Substances, Cells, Tissues and Organs in different locations (central and peripheral) Complement each other in protecting the body Main organs include skin, spleen, thymus, and lymph nodes. Freely mobile cells from bone marrow, blood and lymphatics.

Important Definitions

Immune response
Development of resistance/immunity to a foreign substance eg. infectious agent. Can be humoral (Ab) or cell mediated (lymphoid) or both.

T & B lymphocytes, tolerance, hypersensitivity, immunodeficiency

Immunity The properties of host that confer resistance to a specific infectious agent. (The ability of the body to protect itself against disease causing organisms) Can be natural or acquired.

Natural Immunity - not acquired through contact with infectious agent.

Acquisition of Immunity

Natural acquisition of immunity: from infection with the microbe in nature, e.g. measles resulting in protection from future exposure (note notion of prior exposure) Artificial immunity: vaccine or immunoglobulin administration
Vaccine: organism or toxin, either killed or live but attenuated (organism) or inactivated (toxin). Live vaccines (BCG, polio, measles); killed vaccines (pertussis, polio), toxoids (tetanus, diphtheria), subunit (hep B).

Passive immunity: from mother or Ig infusions

Immunization process

Administration of vaccine: Potent immune response in a few weeks, several injections for some (DPT), some one shot (measles). Booster doses may be necessary (Hep. B).

Vaccines are safe, side effects (AEFI) rarer than complications of disease prevented. Vaccines are fragile (storage). AEFI: hypersensitivity, human errors (poor or absent training, or level).

Antibody Response following exposure to antigen

IgG Response

IgM Response

30 Primary encounter Secondary

60 3rd Time

1 yr.

10 yrs

Types of immunity

Non-specific (primary/innate):

First line defense, does not require prior exposure

Specific (adaptive):

Requires prior exposure, hallmarks (memory, specificity, recognition of self and non-self), antigen- antibody
Secondary, Acquired

Similarities between vaccines and other drugs

Vaccines Potential Multiple

are also medicines

for adverse effects

ingredients

Potential

for interaction with disease and other medicines

need to comply with standards of safety, efficacy and quality

Also

Categorization of current vaccines

Live attenuated:
Viruses (oral polio, measles, mumps, rubella, yellow fever), Bacteria (BCG, cholera)- long lasting immunity, very fragile (cold chain), mutation to pathogenicity

Killed vaccines:
Viruses (hep. A, Salk polio), bacteria (pertussis, cholera)intermediate immunity, several doses may be required

Sub-unit vaccines including toxoids:

Tetanus, Hep. B, acellular vaccines, conjugate polysacharide vaccines linked with suitable carrier proteins (Hib). Also single or polyvalent vaccines.

ROUTE OF ADMINISTRATION

Essence of Route: Elicit Immune Response with minimal risk

Deep IM for vaccines with adjuvants (depot effect, less granuloma formation) Intradermal (ID) - better for live vaccines, e.g. BCG

Intranasal influenza vaccine increased risk of Bells Palsy reported

New routes may have other safety risks

Who needs to be immunised?

High risk groups

Young children Elderly Malnourished

Leading causes of early childhood vaccine-preventable deaths

72% of 2.5m VPD deaths can be prevented with 5 vaccines
1. 2. 3.

Pneumococcal
Measles Rotavirus

28%
21% 16% 12% 8%
WHO/FCH/IVB/VAM, JUN04 (<5y, 2002 data)

4.
5. 6.
rota

Hib
Pertussis Tetanus

15%

7.
8. 9. 10.

Yellow Fever
Diphtheria Poliomyelitis

<1%
<0.5% <0.5%

Meningococcal <0.5%

Immunisation schedule for Ghanaian children: Expanded Programme on Immunisation (EPI)

Age
Birth 6 weeks 10 weeks 14 weeks 6 months 9 months 12 months BCG

Vaccines
OPV 0 OPV 1 OPV 2 OPV 3 Yellow fever DPT/HepB/Hib 1 DPT/HepB/Hib 2 DPT/HepB/Hib 3 Vit A Measles Vit A

Common Vaccine Types & Characteristics

EPI VACCINES
Tuberculosis Poliomyelitis Diphtheria, Tetanus, Pertussis Hep B Measles, Mumps, Rubella Hib Yellow Fever

BCG (Baccillus Calmette Gurin) -1

Disease = Tuberculosis Organism: Mycobacterium tuberculosis or M. bovis. Non-sporing, rod-shaped, acid-fast bacillus (neither gram positive or gram negative)

Vaccine: Live attenuated, freeze-dried Storage 2oC - 8oC. Never frozen. Do not shake to mix. Use with 2 hours. Shelf life 12 - 18 months. Vaccine Efficacy: 0 80% for PTB; 75-86% for Miliary and TB meningitis Indications: People at risk - infants, health personnel, contacts with sputum +ve cases. If exposure suspected, tuberculin test first then immunise. With contact: tuberculin test, repeat after 6 months, if positive => seroconversion, hence chemoprophylaxis.

Duration of immunity unknown. Evidence that wanes with time

[Tuberculin ]
Both Mantoux and Heaf = Purified Protein Derivative (PPD).

PPD = heat treated products of growth and lysis of mycobacterium. Results read 48 - 96 hours later. Positive result = induration of 5 mm in dia. with 0.1 ml 1 in 1000 dil. (If less => negative)

Heaf gun: 5-14 mm = Heaf Grade 2

15 mm = Heaf grade 4 or more => strongly positive.

POLIOMYELITIS
Organism: Polio virus type I, II, III. Inactivated at 55 oC for 30 minutes but this is inhibited by Mg++, milk, ice cream. Adults more prone to in-apparent paralytic infections.

Vaccine: Inactivated polio virus = Salk (1956) (IPV) Live attenuated vaccine = Sabin (1962) (OPV) OPV, eIPV (Enhanced potency Inactivated Polio Vaccine) Contain live strains of virus types I, II, III Establishes both local gut and blood immunity May be given at the same time with other inactivated or live vaccines EXCEPT typhoid.
Efficacy:
>90% in industrialised countries 72-98% in hot climates; lower protection against type III

Duration of immunity:

DIPHTHERIA:
Agent: Toxin producing Corynebacterium diphtheriae Vaccine = toxoid: Comes as liquid + adjuvant Tendency for lower antibody levels in adults due to less natural boosting. Efficacy: > 87% Duration of immunity: About 5 years. Longer in presence of natural boosting Schick Test: Used to test immunity after diphtheria immunisation. Test solution is the inactivated toxin. Done at least 3 months after immunisation. No reaction => test -ve => immune subject. Erythema lasting approx. 7 days => test +ve => nonimmune subject.

Diphtheria antitoxin:
IM, IV - to treat suspected cases. Not for prophylaxis because causes intense sensitisation.

TETANUS

Agent:
Toxin producing Clostridium tetani

Vaccine =Toxoid Children & Adults: 3 doses one month apart: Reinforce at 10 year intervals x2 doses is enough for life. Booster dose considered at time of injury.

Rationale for Tetanus Toxoid immunisation for mothers of child bearing age

PERTUSSIS

Organism:-

mainly, Bordetella pertussis

(also B. parapertussis B. bronchoseptica) Vaccine: - Killed Bordetella pertussis Caution: Hx of febrile convulsion: - Advise on prevention of fever and give.

Hib (HAEMOPHILUS INFLUENZAE type b)

99% typeable strains causing disease are type b. Diseases: Meningitis + septicaemia - 60% Epiglotitis - 15 % Septicaemia - 10% Arthritis, osteomyelitis, cellulitis, pneumonia, pericarditis - 15% Infection rare under 3 months old, rapidly rises in 1st year with peak at 10 - 11 months, then declines till the age of 4 years after which infection is uncommon. Vaccine: Capsular polysaccharide + protein (to enhance immunogenicity in children less than 1 year old. Capsular polysaccharide alone is not immunogenic in children less than 18 months).

HEPATITIS B

Double stranded DNA virus (Hepadnavirus)

Carrier rate 2 - 10 %. chronic carriage more frequent in those infected as children. Higher still for those infected in the perinatal period. Among carriers those with HBeAg are most infectious. Those with anti- HBe are of low infectivity. A proportion of HBsAg carriers develop chronic hepatitis. Vaccine: HBsAg adsorbed onto adjuvant (alum). HbsAg prepared from recombinant DNA technique from yeast cells. Notes: Those older than 40 years are less likely to respond.

PENTAVALENT vaccine: DPT HepB + Hib

Introduced since 2001 Used in Ghana since March 2002

Supplied as liquid DPT-HepB in one vial and lyophilised Hib in a separate vial.
Lyophilised Hib can be stored at -20oC or refrigerated at +2 - +8 oC

Liquid DPT-HepB however must not be frozen

Contains preservative. Hence reconstituted vaccine can be reused over extended period

MMR - Measles Mumps Rubella

Measles, Mumps viruses = Paramyxoviruses (RNA virus)

Measles Vaccine:
Live attenuated Presentation: Freeze-dried Route: subcutaneous

Mumps (Parotis epidemica):

Live attenuated vaccine

Rubella = Togavirus
(the only togavirus that is not transmitted by arthropods)

(Single stranded) Primary purpose of vaccine = to prevent Congenital rubella Infection

Combined vaccine = MMR

YELLOW FEVER
Flavivirus, RNA Vector - Aedes aegypti Vaccine: Live attenuated, freeze-dried containing 17D strain Y. fever virus propagated in chick embryo.

Contains Neomycin, polymyxin

OTHER VACCINES

TYPHOID
Organism: Commonly, Salmonella typhi, S. paratyphi A, B, C. Gram negative. Cause systemic infection but most strains cause local infection in the gut. All patients excrete organism some time in the stool. 2.5% permanent carriers especially, females.

Vaccines: 1. Heat killed monovalent, phenol preserved 2. Capsular polysaccharide typhoid vaccine (of Vi polysacc of S typhi not live) Single dose leads to 3 years protection 3. Oral vaccine - attenuated S typhi strain TY 21a as enteric coated capsule.

VARICELLA ZOSTER
90% population already infected. Infection , however, severe in adults, especially pregnant women. Zoster = flaring up of dormant varicella.

NB: Congenital varicella syndrome.

Vaccine: Live attenuated (under development)

RABIES
Rhabdovirus, rod or bullet shaped, single stranded RNA Vaccine: Live attenuated, freeze dried (human dipliod vaccine)

Notes: Chloroquine prophylaxis suppresses Ab response of rabies vaccine especially if given intradermally. Guillian Barre Syndrome reported

Rabies -2
Post-exposure treatment Factors that should be taken into consideration:
vaccination status and clinical features of the animal type of vaccine used and the availability of the animal for observation

less efficient serological response to rabies in Individuals aged over 50 years.

Regimen depends on vaccine type

INFLUENZA
Orthomyxovirus, single standed RNA (8 stranded) High antigenic change rate

HEPATITIS A
Picorna virus (RNA) No carrier state, little likelihood of chronic liver disease. Hepatitis A vaccine: Formaldehyde inactivated

NEW VACCINES

Pneumococcal Vaccine Spectrum of Pneumococcal Disease Mode of transmission and Carriage

Direct contact with respiratory secretions from patients and carriers. Persons exposed to pneumococci would normally have transient nasopharygeal colonization (not disease). Nearly all children have nasopharygeal carriage of pneumococci (S. pneumoniae) at one time or the other

Disease: Non-Invasive disease: (More common)

Otitis media Sinusitis Bronchitis Non-bacteraemic pneumonia

Invasive Pneumococcal disease (IPD):

(i.e. any condition in which S. pneumoniae is present in blood, cerebrospinal fluid or another normally sterile body site)

Pneumonia with empyema/and or Bacteraemia, Febrile Bacteraemia (CF: 5 20%), or Meningitis (CF: 50 50%)

Blood Spread

Pneumococcal Vaccines- History

1977:

14-valent Polysaccharide vaccine licensed

1983 : 23-valent polysaccharide vaccine(PPV23) licensed

Pneumococcal polysaccharide vaccine 50 to 60% against invasive disease among children 24 to 59 months of age (not pneumonia) Never been recommended for children < 2yr (due to poor T cell-independent immune response). Recommended for children 2 years with underlying medical conditions that increase the risk for pneumococcal disease e.g. SCD, Asplenia, Chronic renal disease/ Nephrotic syndrome, Lung disease, Chronic liver disease including cirrhosis, diabetes mellitus.

Conflicting result on efficacy testing Short-lived immunity Not associated with induction of immunological memory, Requiring periodic re-vaccination to maintain protective efficacy.

2000:

7-valent Pneumococcal Conjugate Vaccine (PCV)

The pathogen

Gram positive diplococcus

90+ serotypes based on capsular polysaccharide

Approximately 20 serotypes account for >70% of invasive disease; Approximately 10 serotypes commonly associated with pediatric infections Serotypes, antimicrobial resistance profile, and pneumococcal molecular type (clone) are strongly associated Variations on global distribution of serotypes varies. Some serotypes common in developing countries (particularly types 1 and 5) are no longer common in industrialized countries. Serotypes associated with invasive infections among HIV infected children are similar to serotypes that infect healthy children.

Vaccine Composition of PCV

Vaccine
7 Valent (Prevnar) 9-Valent 10-valent 13-valent

Serotype Composition
4,6B, 9V, 14, 18C, 19F and 23F conjugated to an immunogenic mutant diphtheria (non-toxic) toxin, CRM197 PCV7 + polysaccharide from serotypes 1 and 5. 7-valent + 1, 5, 7F 10-valent + 3, 6A, 19A

PCV Administration

Dose: 0.5mls Route: Intramuscular Recipients: Infants Regimen: 3 doses at 4 weeks intervals

Recommended to start at 6 weeks, Hence 6, 10, 14 weeks

Booster at 12 months improves immune response

Meningococcal Vaccine
Meningococcal disease epidemiology:

death-to-case ratio 10% in developing world especially in <1yr olds.

1020% of survivors develop permanent sequelae such as epilepsy, mental retardation or sensori-neural deafness. Neisseria meningitidis also responsible for meningitis occurring beyond the neonatal and childhood period.

. 4 out of 13 serogroups of N.
meningitidis (N. meningitidis. A, B, C and W135) recognized to cause epidemics. Serogroup A has shown to cause the epidemics in the meningitis belt, which extends across Africa from Senegal to Ethiopia occurring at intervals of 7-14 years.

Neisseria meningitidis also responsible for meningitis occurring beyond the neonatal and childhood period.

MENINGOCOCCUS
Organism: Neisseria meningitidus Gram negative diplococci, non motile; Serotypes BCAY W135, Groups A and C usually associated with epidemics Carriage rate in normal population 10 - 25% Short incubation period of 2-3 days.

Vaccine: Purified, heat stable lyophilised (frozen, dehydrated) extract of polysaccharide capsule of N. meningitidus effective against Group A and C.

Meningococcal Vaccines

Current internationally marketed meningococcal vaccines are based either on combinations of group-specific capsular polysaccharides (A and C, or A, C, Y, and W135) or on a conjugate between certain groups and a protein carrier. The polysaccharide vaccines are safe and highly immunogenic, although the group C component is ineffective in children under 2 years of age. On the other hand, the serogroup C conjugate vaccine is safe and efficacious even in the youngest children. (Monovalent polysaccharide vaccines are not readily available) Vaccines against group B meningococci have shown modest efficacy in both children and adults

ROTAVIRUS VACCINES

Rotavirus Infection:
Most common cause of severe diarrhoea in young children
All children infected by age 2-3 years of age First infections are symptomatic and re-infections are common Rotavirus strains in circulation

Improvements in water and sanitation will not prevent infection

Way forward rotavirus vaccines

Clinical Symptoms & Rotavirus infection

Primary

infection is associated with: severe dehydration and fever profuse watery diarrhoea and vomiting Associated with >1/3 of all hospitalizations due to diarrhoeal disease Approx 2m hospitalizations globally due to rotavirus infection Associated with high mortality due to the acute & severe dehydration

Rotavirus vaccine Immunization Schedule

(1)

Rotarix : (GSK lyophilised human G1P8 strain - monovalent)

2 doses; oral live attenuated vaccine Children approx 2-4 months 1st dose given from 6 weeks but not later than 12 weeks Interval between 2 doses not more than 4 weeks 2nd dose by 16 weeks not later than 24 weeks
(G serotypes - human G1, G2, G3 and G4; bovine G6; human P1A[8] and bovine P7[5])
cross-protective of multiple strains

(2) Rotateq : (Human-bovine reassortant, live-attenuated, oral)

3 doses; given at 2, 4, 6 months 1st dose given 6-12 weeks (dont initiate vaccination to infants > 12 weeks) All doses by 32 weeks

(3) RotaShield (Wyeth): License withdrawn Trails stopped due to increased incidence of Intususception

CHOLERA

Organism: Vibrio cholerae; Gram negative curved rod. Old Vaccine: Heat killed, phenol preserved Inaba, Ogawa,
serotypes of V. cholerae 01. No longer recommended by WHO because of limited personal protection afforded.

New Oral Cholera Vaccines (OCVs):

Orochol-E: Live attenuated single-dose cholera vaccine CVD 103-HgR, Protective efficacy reached 8 days after administration Possible use once an outbreak has started Dukoral Killed WC B subunit cholera vaccine (WC/rBS) Derived from mixtures of WC killed strains. Given in two doses, 10-14 days apart. Protective efficacy is reached 10 days after the second dose. Currently not indicated for use once an outbreak has started. Neither of the two vaccines protects against Vibrio cholerae O139.

Cervical Cancer Prevention Small, double-stranded DNA viruses that infect the cervical epithelium neoplasia. High risk oncogenic types: 16, 18 causing 70% cervical cancers 2 vaccines available: Quadrivalent Vaccine: HPV types 6, 11, 16, 18 Produced in Yeast Bivalent Vaccine: HPV types 16,18 Ideal age group to vaccinate:10-13 year old girls not a standard target population adolescent vaccination. Can be implemented for girls in last year of primary school/first year of secondary school. Catch-up vaccination in older adolescents and adult women? Not recommended in a public health programme

Human Papilloma Virus Vaccines

VACCINE REACTIONS

Vaccine Reactions

Common, minor reactions

Part of immune response to vaccine, Generally, Fever, local reactions (pain, redness, swelling), irritability malaise and non-specific symptoms Commonly associated with DPT (up to 60% cases) Symptoms much less common (up to 10%) with all the other EPI vaccines. Settle on their own Warn parents and advise how to manage
e.g. fever, malaise etc.

Rare, more severe reactions

Usually require clinical management, e.g., severe allergic reaction (such as anaphylaxis), Vaccine specific reactions (e.g. BCG osteitis)

ANAPHYLAXIS

Reported less from developing countries

Less sensitization?, Less reporting?

Anaphylaxis is rare (1/1 000 000 vaccinats)

Fainting is common and untrained staff may misdiagnose fainting/dizziness for anaphylaxis or vice versa Administration of adrenaline during a faint may be dangerous
PROMPT MANAGEMENT IS VITAL!

ADVERSE EFFECT FOLLOWING IMMUNIZATION

(AEFI)
A medical incident that takes place after an immunization, causes concern, and is believed to be caused by immunization

Vaccine reaction - caused by vaccines inherent properties Programme error - caused by error in vaccine preparation, handling, or administration Coincidental - happens after immunization but not caused by the vaccine or vaccination process (a chance association) Injection reaction - anxiety about or pain caused by the injection not vaccine/vaccination Unknown - cause cannot be determined

IMMUNISATION SAFETY ISSUES

Immunisation Safety -1

Vaccine Quality: Quality of biological process Character of each batch subject to variation - Hence batch numbers Diluent Characteristics Are specific for vaccine in relation to volume, pH, chemical properties Sensitivity to Heat Cold Chain
All vaccines are sensitive to heat BCG, measles, Polio can be kept in freezers DILUENTS MUST NOT BE FROZEN (e.g. Liquid vaccines containing adjuvants (aluminium salts) e.g. TT, DPT) Cool to < 8oC before reconstitution to prevent vaccine shock from sudden temperature change Previously frozen vaccines reactions and reduced immune response

Sensitivity to light Shelf life:

Immunisation safety Issues -3

Multidose vial policy

Previous policy: Discard all opened vaccines vials after immunisation sessions irrespective of vaccine type and remainder. NOW OBSOLETE
Current Policy: Mulltidose vials of OPV, DPT (DT) and TT, Hep B and liquid formulations of Hib vaccines from which one or more doses have been removed during an immunisation session may be used in subsequent immunisation sessions for up to 4 weeks PROVIDED THAT - Expiry date not expired - Vaccines stored under approp. cold chain conditions (2 8 oC) - Vaccine vial septum not submerged in water - Aseptic technique used to withdraw all doses - VVM if present has not reached discard point However, for RECONSTITUTED Vaccines e.g. BCG, Measles, Yellow Fever and some formulations of Hib (Except Pentavalent vaccine), DISCARD AFTER 6 HOURS OR AFTER IMMUNISATION SESSIONS which ever comes first.

VACCINE VIAL MONITOR

Examples of real safety issues

Disasters" due to faulty production - Rare; True vaccine reactions

Vaccine-associated paralytic polio Mumps vaccine-associated aseptic meningitis Rotavirus and intussusception Bell's palsy following intranasal flu Influenza vaccine and oculorespiratory syndrome

Unproven Associations And Public Concern

Influenza vaccine and Guillain Barr Syndrome MMR and autism, Crohns disease Polio and HIV Hepatitis B and multiple sclerosis DTP and permanent brain damage DTP and increased risk of mortality Aluminium and macrophagic myofasciitis Bovine spongiform encephalopathy (BSE) Thimerosal and autism, neurodevelopmental problems Multiple vaccines given simultaneously

Can vaccines overload the immune system?

Giving multiple vaccines at the same time is safe

People are exposed daily to hundreds of antigens

Multiple vaccines work with the immune system to boost it

Simultaneous vaccination protects against several diseases quickly

Combo vaccines reduce discomfort and costs

CONTRAINDICATIONS

True contraindications are rare Current serious febrile illness: delay vaccine
History of severe reaction after previous dose (e.g. anaphylactic reaction) Evolving neurological disease (e.g. uncontrolled epilepsy) - avoid whole cell pertussis vaccine
No DPT or DPT/HepB/Hib to child with convulsion/shock within 3 days of the most recent dose of DPT or DPT/HepB/Hib. No DPT or DPT/HepB/Hib to child with recurrent convulsions or active CNS disease.

Type 1 hypersensitivity to egg - avoid yellow fever & influenza, can use vaccines made in chick fibroblasts

Contraindications to vaccinations - 2

No live vaccine to:

Pregnant women for risk of teratogenic effect Patients with malignant disease e.g. leukaemia, Hodgkins disease, Malignant disease of the RES, Patients with immune suppression, Patients on chemotherapy - defer for 6 months after stopping treatment.

Symptomatic HIV
Avoid BCG and YF Consider withholding measles vaccine in severely IC (monitor immune status) Measles not recommended if person is seriously ill

Live vaccine virus should not be given within 3 months of giving immunoglobulin because of inhibition of immune response.

Immunizing the immunocompromised

Patients may be immunocompromised due to HIV , congenital immune deficiencies, immuno-suppression, e.g. steroids, chemotherapy, etc., malnutrition May not respond adequately to vaccination Risk of disseminated infection from live attenuated vaccines In some cases, recommended to weigh risk of exposure to disease (e.g., BCG in asymptomatic HIV +ve children)

Important Non-contraindications to vaccinations:

Allergy(except to egg), asthma, allergic rhinitis URTI with diarrhoea and mild fever temp < 38.5oC Prematurity Malnutrition Family history of convulsions Stable neurological conditions e.g. Cerebral palsy, Down Syndrome Treatment with antibiotics, low dose corticosteroids History of jaundice after birth

IMMUNISATION FOR PRE-TERM INFANTS -1

Theory:

Much of the immune system development occurs about the 1st and 2nd trimester. Known deficiencies in new born immune system appeared to mature as quickly in preterm infant as in term infant. Response to antigen in preterms is not significantly different from term babies (response is related to exposure and not to gestation. CMI is also demonstrable in preterms babies).

IMMUNISATION FOR PRE-TERM INFANTS PRECAUTIONS

There may be uncertainties about CNS development of the prem infant, therefore need to weigh the risk of giving against the benefits or risk of postponing. Baby at risk of convulsion may convulse with an immunisation and so with pertussis vaccine. If you need to suspend pertussis then postpone the whole DPT (might not get single pertussis vaccine).

IMMUNISATION FOR PRE-TERM INFANTS -3

Recommendations:
Consider

all prems for full immunisation

course.
Start

immunisation in 2nd month of age irrespective of degree of prematurity. OPV in neonatal unit since there is a small chance of transfer of OPV virus to other babies. Hence give OPV on discharge from nursery - not while still on admission.

Delay

Notes on vaccine use -1

All vaccines stored at 2 - 8 oC, not frozen; Except OPV, eIPV which are stored at 0-4oC. Usual dose - 0.5ml IM/deep SC except oral vaccines. Except BCG, OPV, other oral vaccines e.g. Salmonella, all vaccines given either IM or deep SC. BCG --> intradermal Rabies, typhoid, cholera, MAY be given intradermally. Wrong method reduces efficacy

Notes on vaccine use -1

Interrupted immunisation course resume, do not restart. EXCEPT for HIB (use same brand or restart with different brand)
No contraindications to the immunisation of the sick child if he/she is well enough to go home. Children with diarrhoea who are due for OPV: give but dont count, then repeat after 4 weeks and record this one as given. Dont give OPV 0 after 15 days (GHS recommendation: disturbs regular immunisation visits)

Immunizing special populations: Pregnant women

Safety concerns: Potential teratogenicity and induction of abortion, vaccination generally deferred to 3rd trimester Vaccinate only if indicated Live viral vaccines usually not recommended Birth defect unrelated to the vaccine may be falsely attributed to the vaccine Newer vaccines/regimens may have unknown effects - use with caution Women (especially adolescents) may not be aware of or disclose pregnancy , screen?

EPI TARGET DISEASES Current challenges and strategies to boost EPI

MDG (Millennium Development Goals):

- 4th Goal: Reduce by two thirds the Mortality Rate among children <5 - 5th Goal: Improve Maternal Health

GIVS (Global Immunization Vision & Strategy): - Protecting more people

- Introducing new vaccines and technologies - Integrating immunization in the health systems context - Interdependence

RED (Reaching Every District): reaching unreached as an

operational strategy

END OF PRESENTATION

QUIZ

Parents of 8 month old baby weighing 8kg, born in USA, seek your professional advise on immunisation for their child. How will you proceed? What if baby weighed 4.5kg What if baby was born prematurely and currently weighs 5kg? What if baby was adopted from HIV positive mother?