IMMUNIZATION

BY DR SHIBAMBU PATRICK 21 OCTOBER 2010

IMMUNIZATION
Immunization is the process whereby a person is made immune or resistant to an infectious disease, typically by the administration of a vaccine. Vaccines stimulate the bodys own immune system to protect the person against subsequent infection or disease

IMMUNIZATION

PASSIVE

ACTIVE

Physiological /Natural Mother Fetus Breastmilk

ARTIFICIAL Injections

ATTENUATED VACCINES OR LIVE

INACTIVATED VACCINES (Killed vaccines)

ACTIVE IMMUNIZATION

ATTENUATED Vaccines or lives

INACTIVATED (Killed vaccines)

Tissue culture, embryonated eggs Live animals

VIRAL

BACTERIAL

VIRAL

BACTERIAL

POLIO VACC INFLUENZA

PERTUSIS Cholera Typhoid vacc

Measles,Mumps, Rubella,Chickenpox, Yellow fever,H1N1

BCG TYPHOID

EXPANDED PROGRAMME ON IMMUNIZATION- EPI (SA) APRIL 2009

AT BIRTH

TOPV 0

BCG

TOPV1 6 WKS 10 WKS TOPV2 14 WKS TOPV3 9 months 18month TOPV4 6 YRS Td 1 12 yrs Td 2

DPT1 HBV1 DPT2 HBV2 DPT3 HBV3

Hib1 PCV1 RV1 Hib2 Hib3 PCV2 RV2 PCV3 MEASLES1 MEASLES2

DPT4

Hib4

RSA :WHO ESTIMATES OF

IMMUNIZATION COVERAGE
20 09 81 77 69 67 67 62 70 10/ 19 20 08 81 77 69 67 67 62 70 20 07 81 77 69 67 67 62 70 200 6 81 77 69 67 67 62 70 200 5 81 77 69 67 67 62 70 200 4 81 77 69 67 67 62 70 200 3 81 77 69 67 67 65 70 200 2 84 80 70 68 68 69 71 200 1 86 82 71 69 70 72 71 200 0 89 85 73 71 71 75 71

BCG DPT1 DPT3 Hepb3 Hib 3 Measl Polio Pcv /rotavi

WHO: SA Reported cases

2009 Diphther 1 ia measles 5857 mumps 0 pertusis 4 polio 0 rubella 2975 Neonata 1 l tetanus 2008 0 39 0 _ 1072 1 1981 63 15805 0 127 214 1980 57 19193 0 112 166

1.BCG( Bacillus calmette-Guerin) Vaccine

Widely used in developing countries Primarily effective in preventing disseminating TB Consist of freeze dried live attenuated strains of mycobacterium bovis. Limited effectiveness in pulmonary TB (50 %) More effective (80%) against severe childhood TB ie. Milliary and 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 scar and immunogenicity or effectiveness of vaccine

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 BCG disease ( INH ,Rimfapicin and Etionamide) M. bovis is resistant to pyrazinamide CONTRAINDICATION Symptomatic HIV infection Other forms of impaired immunity

2.POLIO VACCINE
2 Kinds: 1. TIPV Trivalent inactivated Polio vaccine 2.TOPV Live attenuated trivalent oral polio vaccine. Both equally effective TOPV preferred by WHO in its Polio eradication strategy Most rich countries have to TIPV for routine immunization because of the remote but serious risk of vaccine associated Paralytic poliomyelitis ( 1: 2 million doses) associated with TOPV TOPV remain the publicly funded vaccine in RSA

POLIO VACCINE CONT

WHO set a goal to eradicate Polio worldwide by 2005. In South Africa, the last polio case due to the wild poliovirus was reported in 1989. The final countdown to a polio free South Africa was launched on 11 April 2002.

3.DIPHTHERIA TOXOID
Inactivated vaccine Highly effective in inducing antibodies that neutralize 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 dose vaccine ( D) < 3YRS A lower dose formula ( d) > 3 YRS

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

4.TETANUS TOXOID
Inactivated ,yet antigenic preparation of tetanus toxin Protective antibodies develop in over 95% of vaccine following primary series of 3 vaccines TT every 10 yrs no longer recommended Routine vaccine of pregnant women with TT during 2nd trimester of pregnancy resulted in decline incidence of neonatal tetanus by passive transfer of maternal antibodies.

TETANUS
Dreaded disease acquired from contamination of wound or umbilical stump by Clostriduim tetani Convulsions Respiratory complication-freg cause of death Pronounced archind of back with clamping of jaws occurs during recurrent muscle spasm Fig1:child with painful muscle contraction due to tetanus Fig2:neonatal tet with complete rigidity

5.PERTUSIS VACCINE
Used against whooping cough Consist of whole-cell killed Bordetella pertussis organisms 50 80 % efficacy ,but immunity may wane in young adult High income countries prefer the use of acellular pertussis vaccine including SA Acellular pertussis vaccines cause fewer side effects than the whole cell pertussis vaccines Side effects-local swelling and redness,cyring , irritability

6.CONJUGATE HAEMOPHILUS INFLUENZAE Hib type b vaccine

Protect against Hib meningitis, pneumonia, epiglotitis and osteomyelitis. Does not protect against otitis media which is caused by unencapsulated non-type b H. influenzae Invansive Hib disease remain notifiable illness in SA Reduced invansive Hib disease by 90 % Less effective in HIVinfected children ,due to poor immune response or loss of immunity 1-3 yrs post immunization

Child with swollen face due to Hib infection

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.

HEP B Vaccines cont

Booster doses of Hep B vac are no longer recommended, regardless primary course was administered Immunity is long lasting NB:Infants born to HBsAg positive mothers should receive both 0.5 ml Hep B immune globulin and Hep B vac within 12 hrs of birth Thereafter same schedule as for other infants if followed. Given 6 ,10 and 14 wks EPI-SA

8.MEASLES VACCINE
Derived from Schwartz strains of measles virus Attenuated by multiple passage through both fertilized chicken eggs and chicken embryo fibroblast culture > 95% seroconversion rate when vaccine administered at the age of 15 month routine in rich countries Children are susceptible to measles at younger age in low and middle income countries ,with up to 3 rd of measles occurring in infants younger than 9 month of age, Therefore earlier immunization is necessary.

Measles vaccine cont

WHO recommend immunization at 9 month Immunity is long lasting Anaphylactic sensitivity to egg is no longer considered a contraindication to admin measles vaccine Measles vaccine can be used for post contact prophylaxis , provided administered within 72 hrs of exposure Fig Charac measle rash

9.PNEUMOCOCCAL CONJUGATE VACCINE ( PCV )

Currently available PCV( prevnar ) includes 7 of 90 pneumococcal serotypes 7 serotypes responsible for aprox 70% of all invasive pneumococcal 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

10.ROTAVIRUS VACCINE ( RV)

2 RV vaccine licensed for general use in SA are Rotarix and Rotateg Early generation RVV used in USA in 1998 was withdrawn because of association with intussusception 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

ESTABLISHED VACCINES NOT INCLUDED IN SA EPI PROGRRAME MMR INFLUENZA HEPATITIS A VARICELLA

Measles,mumps and rubella vaccine ( MMR )

Combination of live attenuated measles ,mumps and rubella viruses Administered at 15 month of age Not available at public wellbaby clinic Rubella is live attenuated vaccine grown in human diploid Fibroblasts Rubella is absolutely contraindicated during pegnancy Fig: charac maculopapular rash indicative of rubella

 In outbreak situation immunization of children living in the same home as susceptible pregnant mother is Child very swollen under often recommended jaws and in the cheeks to prevent infection due to mumps from reaching her

INFLUENZA VACCINE
Prepared by inactivated virus strains grown in fertilized chicken eggs In USA Influenza vaccine is now recommended annually for all children ages 6 - 59 month and all pregnant women. < 9 yrs children : to receive 2 full doses separated by 1 month <3 yrs : to get half adult dose in 2 occasion separated by month Vaccine efficacy varies between 60 90 % in young children

H1N1

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

VARICELLA VACCINE
A live attenuated varicella vaccine (var) now part of the routine immunization schedule in most high income countries Var given as single dose ideally between 1224 months of age Adolescents over 13 years to receive 2 doses 4-8 weeks apart if they have not had the disease or vaccine Contraindicated in individual with advance immunosuppressive disorder and in pregnancy (as other live vaccine)

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 vaccination particularly when they are still immunocompetent

CHILDREN WITH SPECIAL VACCINATION REQUIREMENTS

1. HIV INFECTED CHILDREN Immunization of the HIV infected children poses some problems: Immune response to vaccines may be inadequate Theoretical risk that some live vaccines may themselves cause progressive infection High risk of disseminated BCG disease in HIV infected Antibody responses to HiB conjugate vaccine, Hep B &Pneumococcal conjugate vaccine have been shown to be poorer in HIV infected infants Measles cause severe disease in HIV children

2. Preterm babies
Should be vaccinated according to EPI schedule commencing at birth, provided that they are well and there is no contraindications. No correction of preterm birth is necessary Preterm infants mount adequate antibody responses and they are not at great risk of adverse events

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 and immunoglobulin prophylaxis against RSV(Palivizumab)

4. Immunodeficiency owing to disease or

treatment Live vaccines are usually contraindicated in immune suppressed individuals: 1. Receiving high dose of steroids and other immunosuppressive treatment 2. Living with malignant conditions like lymphoma 3. Recipient of bone marrow and other organ transplant

-Such patients should be given appropriate preparation of immunoglobulin ASAP after exposure to the disease such as measles(measles immune globuline) and chickenpox(zoster immune globuline) -Pertussis, diphtheria, tetanus, Hib and hepatitis B vaccines can be given safely to pt receiving immunosuppressive therapy but may be less effective -HIV and severe malnutrition although immunodeficient can be given live vaccines

5. Delayed or unknown immunization

status CATCH UP vaccination is available BCG may be given if Tuberculin test is negative and there is no immunosuppression Spaced 4 6 weeks apart

Storage and handling of vaccines ( cold chain )

Vaccines lose their potency if not stored and transported correctly Heat sensitive vaccines include OPV,yellow fever and measles Some vaccines (eg BCG & reconstituted MMR) lose potency if exposed to light Reconstituted Measles vaccine detoriorates rapidly at room 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 or clarity

Common minor adverse ff immunization

Local swelling Redness Crying Irritability Low grade fever

TRIGGER ADVERSE EVENTS REQUERING REPORTING

1 .Local reactions severe local reaction (swelling extending >5cm, redness and swelling >3day) lymphadenitis injection side abscess 2. Systemic reactions all cases of hospitalization thought to be related to immunization 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

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

FALSE CONTRAINDICATIONS
Family hx of any adverse rxns ff vaccination Fhx of convulsions Previous MMR or pertusis like illness Preterm birth Hx of jaundice after birth Stable neurological conditions such as CP and trisomy 13 Contact with infectious disease Minor illness(without sistemic illness and temp < 38.5) Treatment with antibiotics Asthma, eczema ,hay fever Treatment with local acting steroids Childs mother is pregnant Child being breastfed Underweight,but otherwise healthy child Over the age recommended in the vaccination schedule Recent or imminent surgery Parental belief in homoepathy

BARRIERS TO IMPROVE VACCINATION IN SA

No weekend or after hour services at clinic to enable working parents to immunize their children Limited family practitioner or paediatrician involvement in the vaccination administration Unavailability of vaccine at hospitals ( to allow immediate catch-up for unvaccinated children Health workers citing false contraindications in denying children vaccinations Exposure of some parents to global antivaccination lobby