Immunisation Update By Sindy Lee & Eva Wong 27th March 2003.

Immunisation Update By Sindy Lee & Eva Wong 27th March 2003

Case 1 Mr and Mrs Chan bring their 2 month old daughter, Siu-yee for her first immunisation. They say that they have received a reminder letter from the government and ask what their child what their child requires.

Question 1 What immunisation does the child now require?

Question 2 How and in what sites are these immunisation given?

Question 3 How should these vaccines be stored?

Question 4 Where and how should the vaccination be recorded?

Question 5 The parents ask about possible reactions to the vaccines. What advice would you give about possible adverse reaction?

Question 6 Mr Chan returns in 2 months for Siu yee’s sencond immunisation and tells you she had a fever after her last immunisation. She cried during the night. What questions would you ask Mr Chan? What would you advise about this immunisation?

Question 7 You next see Siu-yee at the age of 6 months when she has a slight rhinitis but no fever and her chest is clear. Would you give her immunisation? What precaution would you take?

Case 2 Siu-ming, an 18 month old infant is brought for his fourth triple antigen immunisation. You have not seen him before.

Question 1 What information would you requires before giving the injection?

Question 2 The parent informs you that Siu-ming had his 12month booster at another private doctor’s clinic. The boy has not had an examination since relocating 12 months ago. What questions would you like to ask about his general health and development?

Question 3 What examination would you perform?

Question 4 The parent informs you that although there are no hearing problems in the family, Siu-ming does not seem to turn around when spoken to. Otoscopic examination reveals some mucosal swelling and a dull drum on the left side. He has a slight post-nasal drip but is afebrile. Would you give his immunisation?

Question 5 What is your management of the ear problem?

Case 1 Mr and Mrs Chan bring their 2 month old daughter, Siu-yee for her first immunisation. They say that they have received a reminder letter from the government and ask what their child what their child requires.

Question 1 What immunisation does the child now require?

Question 2 How and in what sites are these immunisation given?

Case 1- answer 1, 2

Immunization programme in Hong Kong 2003
Newborn BCG Oral polio type I Hepatitis B vaccine – first dose 1 month Hepatitis B vaccine – second dose 2-4 months Triple vaccine (diphtheria, tetanus & pertussis) – first dose Oral polio trivalent – first dose 3-5 months Triple vaccine (diphtheria, tetanus & pertussis) – second dose Hepatitis B vaccine – third dose 4-6 months Triple vaccine (diphtheria, tetanus & pertussis) – third dose Oral polio trivalent – second dose 12 months MMR vaccine (measles, mumps, rubella) – first dose 18 months Triple vaccine (diphtheria, tetanus & pertussis) – booster dose Oral polio trivalent – booster dose Primary 1 Combined vaccine (diphtheria & tetanus) – booster dose MMR ( measles, mumps & rubella) – second dose Primary school student BCG after tuberculin testing Primary 6 Supplementary hepatitis B vaccination Elderly > 65 years old in institutions Influenza intradermal

Newborn BCG Oral polio type I Hepatitis B vaccine – first dose 1 month Hepatitis B vaccine – second dose 2-4 months Triple vaccine (diphtheria, tetanus & pertussis) – first dose Oral polio trivalent – first dose 3-5 months Triple vaccine (diphtheria, tetanus & pertussis) – second dose Hepatitis B vaccine – third dose 4-6 months Triple vaccine (diphtheria, tetanus & pertussis) – third dose Oral polio trivalent – second dose 12 months MMR vaccine (measles, mumps, rubella) – first dose 18 months Triple vaccine (diphtheria, tetanus & pertussis) – booster dose Oral polio trivalent – booster dose Primary 1 Combined vaccine (diphtheria & tetanus) – booster dose MMR ( measles, mumps & rubella) – second dose Primary school student BCG after tuberculin testing Primary 6 Supplementary hepatitis B vaccination Elderly > 65 years old in institutions Influenza

Newborn BCG Oral polio type I Hepatitis B vaccine – first dose 1 month Hepatitis B vaccine – second dose 2-4 months Triple vaccine (diphtheria, tetanus & pertussis) – first dose Oral polio trivalent – first dose 3-5 months Triple vaccine (diphtheria, tetanus & pertussis) – second dose Hepatitis B vaccine – third dose 4-6 months Triple vaccine (diphtheria, tetanus & pertussis) – third dose Oral polio trivalent – second dose 12 months MMR vaccine (measles, mumps, rubella) – first dose 18 months Triple vaccine (diphtheria, tetanus & pertussis) – booster dose Oral polio trivalent – booster dose Primary 1 Combined vaccine (diphtheria & tetanus) – booster dose MMR ( measles, mumps & rubella) – second dose Primary school student BCG after tuberculin testing Primary 6 Supplementary hepatitis B vaccination Elderly > 65 years old in institutions Influenza intramuscular

Newborn BCG Oral polio type I Hepatitis B vaccine – first dose 1 month Hepatitis B vaccine – second dose 2-4 months Triple vaccine (diphtheria, tetanus & pertussis) – first dose Oral polio trivalent – first dose 3-5 months Triple vaccine (diphtheria, tetanus & pertussis) – second dose Hepatitis B vaccine – third dose 4-6 months Triple vaccine (diphtheria, tetanus & pertussis) – third dose Oral polio trivalent – second dose 12 months MMR vaccine (measles, mumps, rubella) – first dose 18 months Triple vaccine (diphtheria, tetanus & pertussis) – booster dose Oral polio trivalent – booster dose Primary 1 Combined vaccine (diphtheria & tetanus) – booster dose MMR ( measles, mumps & rubella) – second dose Primary school student BCG after tuberculin testing Primary 6 Supplementary hepatitis B vaccination Elderly > 65 years old in institutions Influenza Subcutaneous

Question 3 How should these vaccines be stored?

Case 1- answer 3 Stored 2-8C Upper deck: Middle deck:
oral polio, MMR, BCG, rebella Middle deck: hepatitis B, DTP, flu Lower deck: emergency medication, NS Thermometer for monitoring Not to store with other foods Minimize opening New drug at the back

Question 4 Where and how should the vaccination be recorded?

Case 1- answer 4 In practice record In child health record
Immunization record Information: Date Vaccine Adverse reaction Expiratory date and serial number

Question 5 The parents ask about possible reactions to the vaccines. What advice would you give about possible adverse reaction?

Case 1- answer 5 BCG: local reaction
Polio: poliomyelitis (1/6.2million) DPT: fever, seizures HBV: rare MMR: fever, rash, joints pain

Question 6 Mr Chan returns in 2 months for Siu yee’s sencond immunisation and tells you she had a fever after her last immunisation. She cried during the night. What questions would you ask Mr Chan? What would you advise about this immunisation?

Case 1- answer 6 ? Body temperature Describe the crying
If temp >40.5C or crying >3-4 hr, child should preclude further pertussis vaccination Consider prophylactic panadol

Question 7 You next see Siu-yee at the age of 6 months when she has a slight rhinitis but no fever and her chest is clear. Would you give her immunisation? What precaution would you take?

Case 1- answer 7 Rhinitis not a contraindication Principles:
Careful education Management of fever Immunisation should not be inappropriately deferred due to infection

Case 2 Siu-ming, an 18 month old infant is brought for his fourth triple antigen immunisation. You have not seen him before.

Question 1 What information would you requires before giving the injection?

Case 2 – answer 1 Check previous immunisation record
Any adverse reaction Allergies Past medical history Neurological diseases

Triple vaccine Contraindication: Acute febrile illness
Active or progressive neurological disease Previous severe reaction e.g. encephalopathy within 7 days after previous injection, immediate severe allergic or anaphylactic reaction

Triple vaccine Relative contraindications Convulsion within 2 days
Persistant, inconsolable screaming for more then 3 hours within 2 days Collapse or shock like state within 2 days Unexplained high fever with 2 days Sever local reaction

Triple vaccine NOT contraindications:
Family history of adverse reaction Family history of convulsion Permaturity Asthma, eczema, allergies Stable neurological condition

Question 2 The parent informs you that Siu-ming had his 12month booster at another private doctor’s clinic. The boy has not had an examination since relocating 12 months ago. What questions would you like to ask about his general health and development?

Case 2 – answer 2 Check previous health record
Discuss developmental milestone

Question 3 What examination would you perform?

Case 2- answer 3 Height and weight Strabismus Gait Abdomen and testis
CVS

Question 4 The parent informs you that although there are no hearing problems in the family, Siu-ming does not seem to turn around when spoken to. Otoscopic examination reveals some mucosal swelling and a dull drum on the left side. He has a slight post-nasal drip but is afebrile. Would you give his immunisation?

Case 2- question 4 There is no contraindication

Question 5 What is your management of the ear problem?

Case 2 – question 5 Dx: serous otitis media Take 3 months to resolve
Conservative management Refer ENT if parents concern or persistent symptoms Prevent learning and language developmental problem

Categorization of vaccines
Live or inactivated ? Live attenuated BCG Inactivated IPV OPV Live attenuated MMR Live attenuated Chickenpox Live attenuated Hepatitis B Hep B surface anitigen DPT D&T toxoid, killed P organism Influenza Inactivated vaccine Haemophilus influenzae type B Inactivated

Are they contraindication for vaccination?
No Family history of any adverse reactions following immunisation Family history of convulsion or epilepsy Prematurity Symptomatic HIV History of anaphylactic reaction Neurological conditions, such as cerebral palsy and Down’s syndrome Those on immunosuppressive agents eg. steroids Asthma. ezema, hay fever, rash to egg protein to receive MMR Those on antibiotic or inhaled steroid Pregnancy Child is being breastfeed Under a certain weight Chronic illness eg. congenital heart disease No No Yes Yes No No No No Yes No No No

Routine immunization programme - BCG
Characteristic: Intradermal, papule will appear 2-6 weeks then discharge Efficacy: Protect against disseminated disease and TB meningitis in particular 80% About 50% protection against pulmonary TB

Routine immunisation – BCG
Adverse reaction 1-2% Prolonged deep ulceration, subcutaneous abscess Lymphadenitis 1-10% Osteomyelitis 5/100,000 in newborn Disseminated disease <2/1,000,000

Routine immunisation - BCG
Contraindications Children born to HIV-positive mothers Those at risk of severe immunodeficiency Symptomatic HIV (if asymptomatic, assessed by paediatrician for fitness) Those receiving immunosupressive agents Pregnancy

Routine immunisation – Poliovirus vaccine
Immunogenicity and vaccine efficacy: Seroconversion OPV IPV 3 doses >95% 99% Inhibit acquisition-intestinal +++ +

Routine immunisation – Poliovirus vaccine
How long did the faecal excretion of OPV last? 6 weeks What happen if the child vomit after ingestion of OPV? Repeat if vomiting within 10 minutes. If not retained, repeat 4 weeks later.

Routine immmunisation – Poliovirus vaccine
OPV IPV Timing of vaccination 2 separate doses (8 wks, min 6 wks) & a booster dose at 18 months ( min 2 mths after). 2 injections (8 wks, min 4 wks) & a booster dose 1 year after Adverse effect: Paralytic poliomyelitis (1/6.2 million) Contraindication: Anaphylactic reaction to a vaccine or any of its components (eg. Neomycin, streptomycin, polymyxin B)

Routine immunisation - DPT
Pertussis Diphtheria toxoid Tetanus absorbed toxoid Efficacy 50-90% 97% 100% Adverse event: Local and febrile reaction Bacterial or sterile abscesses /million Allergic reaction – anaphylaxis 2/100,000 Seizures – febrile seizures Hypotonic-hyporesponsive episode /100,000 Fever of %

Routine immunisation – DPT
Contraindication: An immediate anaphylactic reaction Encephalopathy within 7 days Is history of febrile convulsion a contraindication for DPT vaccination? How would you advise him?

Routine immunisation - DPT
Management of Children with history of febrile convulsion after DPT Administration of panadol at the time of DPT and at 4-8 hours after immmunisation decreases the subsequent incidence of febrile and local reactions. Antipyretic prophylaxis every 4-6 hours for as long as 24 hours after vaccination may benefit children with increased risk of seizures, including febrile convulsions Tepid sponging Regular checking of body temperature

Routine immunisation - MMR
Measles Rubella Mumps Efficacy 99% 96% Adverse reaction Fever 7-12 days after 5-15 % Rash 5% Allergic reaction Seizures – simple febrile Thrombocytopenia 2-4/400,000 doses Encephalitis - < 1 per million doses Arthopathy 0.5% Transient peripheral neurotic compliants Rash Febrile seizures Nerve deafness Meningitis, encephalitis

Routine immunisation - MMR
Contraindication: Anaphylactic reaction to a vaccine or its components ( eg gelatin, neomycin) Immunodeficiency due to causes other the HIV Symptomatic HIV Pregnancy

Routine immunisation – Hep B
Efficacy: 90-95% Immune memory remains intact for >13 years Schedule: Three doses at birth, 1 and 6 months Very low birth weight infants Infants < 2 kg respond poorly to vaccine If mother HbsAg pos : start HBV vaccination with HBIg at birth If mother HBsAg neg : start HBV vaccination when BW > 2 kg Children under 6 years with incomplete course of vaccination ( the 3 doses) Received 2 doses 3 wks to 3 mths apart and within 1 year after second dose – give the third dose Supplementary Hep B vaccination for primary 6 students

Vaccine Storage and Handling
Freeze (-14 or lower) Refrigerate (2 – 8 ) OPV Varicella MMR DPT Hib HepA, HepB Influenza IPV Pneumococcal Protect MMR from light at all times

Oral polio vaccine VS inactivated polio vaccine

Polio vaccine Oral polio vaccine Developed 1961
Live attenuated vaccine Cheap and easy to administer Humoral antibodies as well as intestinal immunity Short term shedding of vaccine in stool also result in “passive immunization” of persons with close contacts Risk of vaccine-associated paralytic poliomyelitis (VAPP) Declared polio-free in Oct 2000 in Western Pacific Risk of VAPP greater then risk of paralytic poliomyelitis from wild-type poliovirus

Inactivated polio vaccine
Global eradication targeted at 2005 Change to IPV?

Inactivated polio vaccine (IPV)
Developed 1955 Immunogenicity is low Replaced by enhanced-potency IPV No risk of VAPP Disadvantages: Expensive Needs additional injections IPV vaccinee is infected by wild polio, virus can still multiply and shed in stool risking continued circulation among the community

Inactivated polio vaccine (IPV)
During polio outbreak: OPV WHO recommendation: Countries currently involved in polio eradication should not consider using IPV at this moment and OPV is required for actual eradication Recently or currently endemic countries should continue EXCLUSIVE OPV

Is HK ready to switch to IPV?
Last case of poliomyelitis caused by wild poliovirus occurred in HK in 1985 Some Nearby areas still endemic South Asia countries reported 80% of global cases of polio in 1998 Indian subcontinent Sub-Sahara Africa Lack of data about risk of VAPP

Polio vaccination in HK
Oral trivalent vaccine introduced in 1963 Resurgence of polio type 1 in 1965 Oral polio type 1 to newborn in 1966 1971: Booster doses of trivalent vaccine at 18mo 1979: booster doses at P.1 and P.6 Strategy need review after global eradication of polio

Influenza vaccine

Influenza vaccine Epidemiology: Multivalent
Two peaks: Jan-Mar, Jun-Aug 2- 3 types of influenza viruses Multivalent Component will be determined each year for northern and southern hemisphere 97/98: Bayern(H1N1), Wuhan(H3N2) 98/99: Sydney(H3N2), Beijing(H1N1)

Influenza vaccine Inactivated vaccine Safe Efficacy
age and immunocompetence of recipient degree of match/similarity between vaccine strains and virus in season If antigenicity similar, prevents illness in 70% - 90% of healthy persons <=65years

Influenza vaccine- how to use?
Different strain each year Annual vaccination 1998: annual immunization of residents in elderly homes in HK Given 2-4 months before its peak October to December Route: IM, ml

Influenza vaccine- who should receive it?
DH All persons >65years Residents of nursing home HA Children with hemodynamically significant congenital heart disease, chronic lung disease (+/- asthma), children on long-term aspirin, hemoglobinopathies, psychogeriatric inpatients, institutionalized mental handicapped patients Private: Anyone who wishes to reduce risk of influenza

Intranasal influenza vaccine
Trivalent, live attenuated cold adapted vaccine Effective (93% effective in preventing culture-positive influenza) and safe Protective even in the second year with serotype mismatch (86% effective) No injection needed

Hepatitis A vaccine

Hepatitis A- epidemiology
Incidence decreasing due to better hygiene Fecal-oral route: hygiene > vaccination Usually has a benign course 51% of Guangzhou province and 15% HK has HA antibodies Expensive

Hepatitis A Two inactivated hepatitis A vaccines available
Approved for persons > 2 years of age Pediatric formulation available Different units but 0.5ml IM for both 2 doses (initial and at least 6 months later)

Hepatitis A 88-100% seroconverted after 1st dose, 100% after 2nd dose
Protective efficacy for clinical hepatitis A of % Need for booster dose not known yet, kinetic models suggest that protective levels will persist for > 20years

Hepatitis A Routine immunization for areas with rates >=20/ in the US Hong Kong Limited to high risk groups: travellers to endemic areas, chronic liver disease, laboratory workers, food handlers, health care workers Not routinely recommended for children “personal decision” Not a substitution for high standard of hygiene

Varicella vaccine

Varicella vaccine Epidemiology:
Over 90% of children infected by 8 years Highly communicable Complications uncommon but serious Great economic impact Treatment of acyclovir remains in doubt

Varicella vaccine Routine pre-exposure administration
Overall 80-85% protection from infection Milder disease for clinical disease Post-exposure prophylaxis Varicella-zoster immunoglobulin (VZIG) within 96 hours of exposure: efficacy 50%, protection period unknown Oral acyclovir: inadequate studies Post-exposure immunization: encouraging results in Japan and US

Varicella vaccine- post-exposure use
Prevention of disease about % Milder clinical presentation Susceptible children with 72 hours and possibly up to 120hrs after exposure

Varicella vaccine Live attenuated viral vaccine US:
Institutional settings Teachers Non-pregnant women of childbearing age (avoid pregnancy for 3 months afterwards) International travellers Health care workers Family members of immunocompromised patients NOT needed for those with reliable hx of chickenpox

Varicella vaccine HK: Epidemiology and burden largely unknown
? Cost-effectiveness of universal immunization Selective immunization Healthcare workers

Varicella vaccine-specific contraindications
Allergic reaction to neomycin, gelatin or prior dose Pregnancy Immunodeficiency or those on immunosuppressive therapy On aspirin (stopped for 6 weeks) Moderate or severe acute illness Malignant neoplasms affecting bone marrow or lymphatic systems

Meningitis- children killer?
Meningococcal, pneunococcal and hemophilus influenza type B

Meningococcal vaccine
Quadrivalent polysaccharide vaccine (A,C,Y, W-135) and monovalent polysaccharide vaccines, efficacy <100% Men A vaccine in China (large outbreak in 1970s)

Meningococcal vaccines
US: 33% serogroup B, 28% group C, 34% group Y (1995-8) College students 0.6/100000 Freshmen in dorm 4.6/100000 Children 2-5yr 1.7/100000 Not cost-effective

Meningococcal vaccines
UK: Growing burden of serogroup C in late 90s <1 yr: 31.5/100000 1-4 yr: 16/100000 Nov 1999, incorporated MenC conjugate vaccine into routine infant immunization (3 doses for <2m, 2 doses of 5-12mo) National campaign offering vaccine to everyone <18yr (1 dose)

Meningococcal vaccine for HK?
: 17 cases of infection (meningitis and septicemia) reported to DH Incidence of /100000 81% local cases, 38% children <4 yrs 4 serogroup B, 2 group A, 2 nonB Jan 2000 – July 2001 24 cases reported 79% local, same age distribution 8 serogroup W-135

Indication for use Outbreak control caused by strains with a capsular group contained in the vaccine High risk group: Complement deficiency Hyposplenia Travellers to highly endemic areas

Conjugated pneumococcal vaccine
Heptavalent conjugated pneumococcal vaccine trial involving >37000 children followed for 24 months found protective against both invasive disease (meningitis, pneumonia, septicemia) and acute otitis media Serotype-specific efficacy was 94% against invasive disease 85% against bacteremic pnuemonia Licensed in Feb 2000 in US

Conjugated pneumococcal vaccine
Heptavalent vaccine Serotypes (4, 6B, 9V, 14, 18C, 19F, 23F) In various sites of body (nasopharyngeal, mucosal and invasive)

Should we use it in HK? Lack of documentation of disease burden
Very few lab diagnosed bacteremia or meningitis in HA hospital No pneumococcal disease in HK?

Haemophilus influenza type B
Meningitis associated with high mortality and morbidity in Europe and North America Annual incidence: / of age <5 yr Annual incidence in HK: 2.67/100000 ? Cost effectiveness ? Combined vaccine

Combination vaccine Simplify administration and promote compliance
Technical difficulties and decreased immunogenicity Whole cell DTP-Hib, DTaP-Hib, DTaP-Hib-IPV, HepatitisB-Hib

DTaP (acellular pertussis vaccines) VS DTwP (whole-cell pertussis vaccine)
DTwP is effective but well known for post-vaccination fever (48hr) and local reatogenicity (swelling and induration) of injection site DTaP causing less adverse effects and as effective as, if not more effective than DTwP Cost-effective? Combination vaccines in future?

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Immunisation Update By Sindy Lee & Eva Wong 27th March 2003.

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Immunisation Update By Sindy Lee & Eva Wong 27th March 2003.

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