Administrative Principles of Vaccination Prof. Dr. AHMET ARVAS I.U. Cerrahpasa Medical Faculty, Department of Pediatrics

Vaccine preventable diseases

infant mortality in world-2010 Lancet 2012;380:2095-125

child mortality-2010 (1-4 y) Lancet 2012;380:2095-125

Vaccine preventable deaths in world-2008 Measles 118.000 Hib inf. 199.000 Pertussis 195.000 Tetanus 2.000 N. Tetanus 59.000 Yellow fever 30.000 Diphteria 4.000 Rotavirus inf. 453.000 Pneumococcal dis. 476.000 Hepatitis B inf. 10.000 1.5 million of deaths among children under 5 years are due to diseases that could have been prevented by routine vaccination

Measles: 2011:111; 2012:101 cases

Active vaccination Protection produced by vaccine Usually permanent Immunity and immunologic memory similar to natural infection but without risk of disease

Classification of vaccines Live attenuated bacterial viral Inactivated whole: viruses, bacteria fractional: protein based (toxoid, subunit) polysaccharide-based (pure, conjugate)

Live Attenuated Vaccines Attenuated (weakened) form of the "wild" virus or bacterium Must replicate to be effective Immune response similar to natural infection Usually produce immunity with one dose (except those administrated orally) *except those administered orally

Inactivated Vaccines Cannot replicate Generally not as effective as live vaccines Less interference from circulating antibody than live vaccines Generally require 3-5 doses Immune response mostly humoral Antibody titer may diminish with time

General Rules Inactivated vaccines are generally not affected by circulating antibody to the antigen Live attenuated vaccines may be affected by circulating antibody to the antigen

Polysaccharide Vaccines Pure polysaccharide pneumococcal meningococcal Salmonella Typhi (Vi) Haemophilus influenzae type b Pneumococcal (PCV-7, PCV-10, PCV13) Meningococcal (MenC, MCV4) Conjugate polysaccharide

Immunization Schedule-Turkey 2012 birth 1 month 2 months 4 months 6 months First school grade (6 yrs) Eighth school grade (13-14 yrs) m m P v B PCV B MMR B OPV DaPT/IPV + HepA II Varicella ı

Source: Turhish Health Ministry Public Health Institute Immunization coverage rate in Turkey (%) Source: Turhish Health Ministry Public Health Institute

Immunization schedule (unvaccinated children: > 1 year) 12-59 mos(1-5 yrs) 6-13 yrs >14 yrs at first time DaPT/IPV/Hib,HepB, ppd DaPT/IPV, HepB, KKK Td, OPV, HepB, KKK >2 days KKK, ppd: BCG - 2 months DaPT/IPV/Hib or DaPT/IPV,HepB,OPV DaPT/IPV, HepB, KKK, OPV Td, OPA, HepB, KKK 8 months DaPT/IPV, HepB, OPV Td, HepB

All vaccines can be administered at the same visit as all other vaccines

Spacing of Vaccine Combinations Not Given Simultaneously two live injected or intranasal influenza vaccine all other Minimum Interval 4 weeks None

Increasing the interval between doses of a multidose vaccine does not diminish the effectiveness of the vaccine. It is not necessary to restart the series or add doses because of an extended interval between doses Decreasing the interval between doses of a multidose vaccine may interfere with antibody response and protection Vaccine doses should not be administered at intervals less than the minimum intervals or earlier than the minimum age *after the series has been completed

Time limits for using vaccines after reconstitution MMR≤ 8 hrs BCG ≤ 4-8 hrs protect from ligth Varicella ≤ 30 min

Types of administration errors wrong vaccine or wrong diluent wronge dosage expired vaccine wrong route/site/needle size wrong time wrong patient

Correct route, site, needle size

Vaccine Adverse Reactions Local pain, swelling, redness at site of injection common with inactivated vaccines usually mild and self-limited

Vaccine Adverse Reactions Systemic fever, malaise, headache nonspecific may be unrelated to vaccine

Vaccine Adverse Reactions Allergic due to vaccine or vaccine component rare risk minimized by screening

Contraindication A condition in a recipient that greatly increases the chance of a serious adverse reaction

Precaution A condition in a recipient that might increase the chance or severity of an adverse reaction, or Might compromise the ability of the vaccine to produce immunity

Contraindications Permanent contraindications to vaccination: severe allergic reaction to a vaccine component or following a prior dose (anaphylactic reaction: all vaccines) Encephalopathy/encephalitis not due to another identifiable cause occurring within 7 days of pertussis vaccination Severe combined immunodeficiency (live vaccines)

Immunosuppression Disease congenital immunodeficiency leukemia or lymphoma generalized malignancy Chemotherapy alkylating agents antimetabolites radiation

Immunosuppression Corticosteroids 20 mg or more per day of prednisone* 2 mg/kg or more per day of prednisone* NOT aerosols, alternate day, short courses, topical *for 14 days or longer

Vaccination of household contacts of immunosuppressed persons Healthy household contacts of immunosuppressed persons should receive MMR and varicella vaccines and annual influenza vaccination

Invalid contraindications to vaccination Mild illness Antimicrobial therapy Disease exposure or convalescence Pregnant or immunosuppressed person in the household Breastfeeding Preterm birth Allergy to products not present in vaccine or allergy that is not anaphylactic Family history of adverse events Tuberculin skin testing Multiple vaccines

Vaccination during acute illness No evidence that acute illness reduces vaccine efficacy or increases vaccine adverse reactions Vaccines should be delayed until the illness has improved Mild illness, such as otitis media or an upper respiratory infection, is NOT a contraindication to vaccination

Missed opportunity A healthcare encounter in which a person is eligible to receive vaccination but is not vaccinated completely

Reasons for missed opportunities Lack of simultaneous administration Unaware child needs additional vaccines Invalid contraindications Inappropriate clinic policies

Vaccine Adverse Event Reporting System (VAERS) National reporting system

Vaccine Adverse Event Reporting System (VAERS) Detects new or rare events increases in rates of known side effects patient risk factors Additional studies required to confirm VAERS signals Not all reports of adverse events are causally related to vaccine

Adverse Event Classification Vaccine-induced: Due to the intrinsic characteristic of the vaccine preparation and the individual response of the vaccinee. These events would not have occurred without vaccination (e.g., vaccine-associated paralytic poliomyelitis after oral polio vaccine). Vaccine-potentiated: The event would have occurred anyway, but was precipitated by the vaccination (e.g., first febrile seizure in a predisposed child). Programmatic error: Due to technical errors in vaccine storage, preparation, handling, or administration. Coincidental: The reported event was not caused by vaccination but happened by chance occurrence or due to underlying illness.

Vaccine-associated paralytic polio (VAPP): overall incidence of once case of VAPP: per 2.4 million doses of OPV Rotavirus vaccine/ increased risk of intussusception: no evidence for a causal link (coins.) MMR-V: additional 4.3 febrile seizures per 10.000 MMR-V doses compared to MMR and V administered separately MCV4/ Guillain-Barre Syndrome: no evidence for a causal link (coincidental) Hep B V/ Guillain-Barre Syndrome, transverse myelitis: no evidence for a causal link MMR/ autism, inflammatory bowel diseases: no evidence for a causal link (coinc.) Thimerosal (mercury containing preservative)-containing vaccines/ autism, inflammatory bowel diseases, ADHD : no evidence for a causal link (coincidental) Vaccines/ ITP: vaccine potentiated