5Vaccines are safeImmunization is among safest of modern medical interventionsVaccines are easier and safer to administer than ever beforeBeing immunized is much safer than risking infection and disease
6Immunization can save money Immunization is one of the most cost-effective health interventionsInvesting in vaccines SAVES more money than it costs
7Immunization can protect the unprotected When immunization coverage is high, it can prevent viruses and bacteria from circulatingThe more children in a community that are fully immunized, the safer everyone isUnfortunately, ….
13WHO EPI schedule by ageWHO Pocket Book of Hospital Care for Children. Page 297.
14Administering vaccines Most doses for children are 0.5ml IM or SCSites of IM/SC administration:<18months: anterolateral thighToddlers: anterolateral thigh or deltoidOlder children: deltoidGive IM:DTP, Hib, Hep BGive SC:Measles, yellow feverAdminister these vaccines via intramuscular (IM) route: Diphtheria-tetanus (DT, Td) with pertussis (DTaP, Tdap); Hib; hepatitis A; hepatitis B; human papillomavirus (HPV);inactivated influenza; meningococcal conjugate (MCV4); and pneumococcal conjugate (PCV). Administer inactivated polio (IPV) and pneumococcal polysaccharide(PPV) either IM or SC.
15Contraindications to immunizations Important to immunize all children, including those sick and malnourished, unless there are contraindicationsCommon side effects to vaccines:Pain, local swelling, fever, fussiness, drowsiness, vomiting, anorexiaGeneral contraindications to any vaccine:History of anaphylaxis to that vaccine or vaccine componentCurrent moderate or severe illness regardless of fever
16Specific contraindications BCG and yellow feverDo not give BCG or yellow fever vaccines to child with symptomatic HIV/AIDSBut do give BCG and yellow fever vaccines to a child with asymptomatic HIV infectionDPTDo not give DPT-2 or -3 to child who had seizures or shock within 3 days of previous DPT dose (possible encephalopathy to pertussis component)*Do not give DPT to child with poorly controlled seizures or active CNS disease**(If available, can give DT vaccine with no pertussis component)OPVA child with diarrhea who is due for OPV should be given OPVHowever, this dose should not be counted in scheduleMake note on child’s immunization record that it coincided with diarrhea, so that health worker will know this and give an extra doseMeasles vaccine is a live-attenuated vaccine but IS recommended in HIV-positive children.Another source:IMMUNISATION OF HIV POSITIVE INDIVIDUALSHIV positive individuals with or without symptoms can receive the following as appropriate:-Live vaccines: measles, mumps, rubella, polio (inactivated polio vaccine (IPV) may be used instead of OPV, under the supervision of the clinician).Inactivated vaccines: whooping cough, diphtheria, tetanus, polio, typhoid, cholera, hepatitis B, HIB. BCG vaccination is contraindicated as there have been reports of dissemination of BCG in HIV positive individuals.Yellow fever vaccine should not be given to either symptomatic or asymptomatic HIV-positive individuals since there is as yet insufficient evidence as to its safety. Travellers should be told of this uncertainty and advised not to be immunised unless there are compelling reasons. If such travellers still intend to visit countries where a yellow fever certificate is required for entry, then they should obtain a letter of exemption.Vaccine efficacy may be reduced in HIV-positive individuals. Consideration should be given to the use of normal immunoglobulin for HIV-positive individuals after exposure to measles.Asymptomatic HIV-positive individuals do not require Varicella-Zoster Immunoglobulin (VZIG) after contact with chicken pox since there is no evidence of increased risk of serious illness in these individuals. However HIV-positive individuals with symptoms should be given VZIG after contact with chickenpox unless they are known to have V-Z antibodies.
17BCG vaccineTB currently accounts for more deaths than any other infectious diseaseAlmost 3 million people a year, including nearly childrenOver 50 million people infected with drug-resistant strainsBCG (Bacille Calmette-Guérin) is a live vaccineAdministered intradermally (produces small raised "bleb“) at birthMost widely used of all EPI vaccinesIn 1997, almost 90% of the world’s children were immunized with BCG50-80% effective against most serious forms of childhood TB: miliary TB and TB meningitisOffers some protection against leprosyUncertain protection against adult forms of TBWHO recommendations:In countries with high incidence of TB, immunize infants and children <5 years with single dose of BCGWhere definable high-risk population, countries may limit BCG to infants (such is schedule in Liberia)Booster doses not recommended
18Oral polio vaccine 2 kinds of polio vaccine Inactivated injectable polio vaccine (IPV) originally developed in 1955 by Dr Jonas SalkLive attenuated oral polio vaccine (OPV) developed by Dr Albert Sabin in 1961Both highly effective against all 3 types of poliovirusOPV is vaccine of choice for eradication of poliomyelitis5x less expensiveEasier to administer (PO vs IM)Most importantly, induces immunity in gut, where poliovirus multipliesIPV provides individual protection against polio paralysis but not capable of preventing spread of wild poliovirus since induces very low immunity in gutWHO recommendations:4 doses of OPV before first birthday (birth, 6, 10, 14 weeks)However, supplementary doses are given during National Immunization Days to achieve eradication
19DTP vaccineCombination vaccine against diphtheria, tetanus, and pertussis (whooping cough)Given IM in 3 doses, at least 4 weeks apart (6, 10, 14 weeks)Variations:DT (full diphtheria and tetanus toxoid, but no pertussis)Td (tetanus toxoid and reduced diphtheria; for adults)TT (tetanus toxoid alone; for women of childbearing age)Some countries have substituted acellular pertussis vaccine (aP) for whole-cell pertussis component (wP)Some manufacturers have added Hepatitis B and/or Hib vaccine to simplify administration and reduce costs
20Hepatitis B vaccine>2 billion people alive today have been infected with hepatitis B virusOf these, ~350 million remain chronically infected, can transmit the infection, and can develop liver cirrhosis or cancerEvery year, ~4 million acute clinical cases of hepatitis B and ~1 million deathsPrimary liver cancer caused by hepatitis B is now one of principal causes of cancer death in many parts of Africa, Asia, and Pacific BasinGlobally, child-to-child and mother-to-child transmission accounts for majority of infections and carriersAlso transmitted through sexual contact, unsterile needles or other medical equipment, infected blood products, skin piercingVaccine given IM in 3 doses, at least 4 weeks apart (6, 10, 14 weeks)Same schedule as DTPAlthough vaccine price has fallen, still more expensive than traditional EPI vaccines -- many developing countries cannot afford
21Hib vaccineHaemophilus influenzae type b (Hib) causes serious bacterial infectionsMeningitis, pneumonia, and infections of blood, bones, and joints (does not cause influenza)~3 million serious illnesses and 386,000 deaths each yearMost common between 4-18 months, but can occur in older childrenLeaves 15-35% of survivors with permanent disabilities such as mental retardation or deafnessVaccine available alone or combined with DTP or hepatitis B (e.g. DTwPHibHep)WHO recommendations:3 doses given IM at 6, 10, and 14 weeks ("where resources permit its use and burden of disease is established“)
22Yellow fever vaccineYellow fever is untreatable, viral, hemorrhagic disease, transmitted by mosquitoes, with high fatality rate (30,000 deaths/year)Yellow fever and measles vaccines are similar in nature and both administered SC at 9 monthsWHO recommendations:1 dose SC at 9 months for all infants in ~45 countries comprising yellow fever belt of Africa and South AmericaRe-immunization not indicated as vaccine thought to produce virtually life-long immunity(However, travelers to these countries require vaccine every 10 years)
23Measles vaccineAmong vaccine-preventable diseases, measles remains the leading cause of child deathsNearly 1 million deaths every year, mainly in developing countriesHowever, even eradication efforts in developed countries like the U.S. have not been successfulLive attenuated vaccineWHO recommendations:Like yellow fever, 1 dose given SC at 9 monthsWhere >15% of measles cases and deaths occur before 9 months of age, give extra dose of measles vaccine at 6 months, then routine dose at 9 monthsAlso give extra measles dose for infants at high risk: infants in refugee camps, admitted to hospitals, HIV-positive, and affected by disasters or measles outbreaksOral Vitamin A drops often given at same time as measles vaccine to prevent blindness and reduce measles mortality
24Conclusions and implications Vaccines are among safest and most effective medical interventionsEnsure up-to-date immunization statusCheck records with each patient encounterGive missing vaccines to hospitalized patients prior to dischargeOne last review:
25ReferencesChildren’s Vaccine Program, Global Alliance of Vaccines and Immunizations.Immunization Action Coalition.WHO. By-country vaccine schedule.WHO. Expanded programme on immunization – overview.WHO. Liberia reported immunization coverage.WHO. Pocket Book of Hospital Care for Children.