Childhood vaccines ד " ר משכית בר - מאיר, מחלקת ילדים והיחידה למחלות זיהומיות

Childhood vaccines

, - מאיר" בר משכית ר ד

למחלות והיחידה ילדים מחלקתזיהומיות

E.Jenner, smallpox vaccination,1796

1800’s- variolation1978- smallpox eliminated

Polio cases per 100000 population, USA

Active Immunization

Exposure to ANTIGEN leads to IMMUNE MEMORY

Types of Vaccines• Live attenuated (Rotavirus, MMRV, OPV) - must replicate in order to be effective - immunity similar to that of natural disease - less doses (except when oral) - storage issues - could be contraindicated in immunecompromised/pregnancy

• Inactivated/Fractional - more doses needed - mostly humoral response, titers may diminish over time

Adjuvant- enhances immune response ;allows to give the minimum amount of antigen

General contraindications

• Fever• Severe allergic reaction or other severe reaction to previous dose• immunecompromised- live attenuated do not defer immunizations if: Mild disease when fever<380 , antibiotics, pregnancy (except live attenuated), prematurity ( by chronological age)

Hepatitis BWHY?

Hepatitis B in adults- 95% recovery, 5% chronic course (HBsAg+), can proceed after years to cirrhosis and hepatocellular carcinoma Hepatitis B in infants born to HBsAg+ mother-90% can proceed to chronic disease; 25% long-term mortality

Hepatitis B

www.chisunim.co.ilמתוך '

Hepatitis B vaccineHOW?

GENETIC RECOMBINATION- HBsAg

Hepatitis B vaccine

WHEN?

• 0,1,6 months

Minor side effects mainly local

DTaP-P-HIB המחומש :החיסוןWHY?• Corynebacterium diphtheria - upper airway obstruction, - cardiotoxin; neurotoxin - mortality: 1:20

DTaP-P-HIB המחומש :החיסוןWHY?

•Clostridium tetani -toxin that caused painful muscle spasm - damage to autonomic nervous system - neonatal tetanus

mortality 2:10

DTaP-P-HIBWHY? Bordetella pertussis (Whooping cough) - prolonged cough (weeks) - desaturations, apnea complications: Pneumonia (1:8); Encephalitis (1:20) Death (1:1500)

DTaP-P-HIB• WHY? Polio - Viral meningitis - muscle weakness , can proceed to paresis after 3-4 decades: post-polio syndrome with worsening of existing weakness or new paresis

DTaP-P-HIB• WHY? Hemophilus influenza type B - pre vaccine era: the most common cause of bacterial meningitis mortality of 7.5%! morbidity (seizures, deafness etc.)- 30%! - other invasive infections: epiglottis,

pneumonia, arthritis, bacteremia

Hemophilus influenza type B

DTaP-P-HIB המחומש :החיסון

HOW?

DTaP• TOXOIDS (Diphtheria, tetanus) 95% /100% efficacy• Acellular (envelope antigens) Pertussis 80% efficacy Serious problem of waning immunity

DTaP-P-HIB המחומש :החיסון

• WHEN? 2,4,6, 12 MONTHS; , ח כתה ב כתהBooster every 10 years

DTaP contraindicationscontraindication Precaution

Encephalopathy (e.g., coma, decreased level of consciousness, prolonged seizures) not attributable to another identifiable cause within 7 days of administration of previous dose of DTP or DTaP

Progressive neurologic disorder,

Temperature of ≥105° F (≥40.5° C or higher) within 48 hours after vaccination

Collapse or shock-like state (i.e., hypotonic hyporesponsive episode) within 48 hours

Seizure ≤3 days after receiving a previous dose of DTP/DTaP

Persistent, inconsolable crying lasting ≥3 hours within 48 hours

GBS <6 weeks after a previous dose

History of arthus-type hypersensitivity reactions after a previous dose

DTaP side effects

• Local reactions (worse with subsequent doses)• Mild fever• Mild irritability, loss of appetite• Significant side effects: rare - fever>400 , 1:3000 - inconsolable cry>3hrs , 1:900- 1:8000 - seizures , 1:14,000 All the reactions are more rare with the acellular

vaccineOther vaccines: TdaP, Td, DT

HIB Vaccine

• Inactivated (Antigen) 95-100% efficacy very safe mild local reactions or mild fever (2%)

2,4,6, 12 MONTHS

Polio Vaccine

• Inactivated (Salk)- IPV• live attenuated (Sabin) OPV Efficacy 99% Very safe; cases of vaccine associated polio

when OPV was given aloneIsrael is endemic again→ back to combined OPV-

IPV schedule

2,4,6, 12 MONTHS , ב כתה

המחומש החיסון אפקט




PneumococcusWHY?

PneumococcusWHY?

•Very High risk groups: asplenia,immune deficiency, renal insufficiency and nephrotic syndrome,

•high risk: COPD, cirrhosis, CSF leak, cochlear implant, chronic diseases, >65yrs

Pneumococcus

HOW?

I. POLYSACHRIDE antigen-T cell independent-no memory cells- infants<2 yrs respond poorly PCV 23 (pneumovax) recommended for

children>2yrs and adults at high risk

Pneumococcus

• HOW?

II. CONJUGATED Pneumococcal vaccine (Prevenar13 )

• Effective in children > 2 months of age• Elicits memory and booster effect

Pneumococcal polysaccharides

conjugate vaccine(T-dependent response)

protein carrier

+

Diphtheria toxoid

II. CONJUGATED Pneumococcal vaccine (Prevenar13)

PCV13

• WHEN?

• Since 2010• 2,4,12 MONTHS (2,4,6,12M FOR HIGH RISK) • PCV7 was ≈ 80% effective against meningitis

and bacteremia In the USA; less effective against pneumonia

• 10-20% LOCAL REACTIONS; FEVER LESS COMMON

ROTAVIRUS

• WHY?

• Acute gastroenetritis, possible dehydration• 100% of children will have at least one

episode before 2 yrs; reccurent episodes frequent

• 4000 admissions/year• Mortality in western countries 1:14000

ROTAVIRUS

HOW?

•Live attenuated•Given orally•95% effective against severe disease/admissions

ROTAVIRUS

WHEN?

• Rotateq – 2,4,6M• Rotarix – 2,4M• SINCE 2011• SIDE EFFECTS: mild diarrhea, ?intussusception• Contraindications: Latex allergy (Rotarix);

Intussusception in the past; previous gut surgery; immunedeficiency; acute gastroenteritis

measles-mumps-rubella-varicella (MMRV) המרובע החיסון

• WHY?

• A. Measles- Rubeolla virus; VERY contagious (100% in non-immunized)complications: Pneumonia (6%) Encephalitis (1/1000) Death (2/100) SSPE(Subacute Sclerosing PanEncephalitis,1:1000)


• WHY?

B.Mumps- Parotitis, aseptic meningitis orchitis (10-20%)Complications: encephalitis (5/1000);Hearing loss; Sterility;

measles-mumps-rubella-varicella (MMRV) המרובע החיסוןWHY? C. Rubella

WHY?

D. Varicella50%! COMPLICATIONS:Secondary bacterial infectionPneumoniaEncephalitisAtaxia

500 admissions and 1-2 deaths in Israel annually


HOW?

• Live attenuated viruses• 12-15 m and on first grade• 99% efficacy against measles; 95% for rubella 80% for varicella (any disease), but 100% for

severe disease; 95% (?)for mumps


• Side effects: Rash±fever (20%) 1-2 weeks after vaccination; lymphadenopathy, arthralgia; RARE: febrile convulsion;

• <1:106 encephalitis(?)• No association with autism!• C/I: severe allergy to gelatin or neomycin;

immunodeficiency; wait after immunoglobulin; pregnancy

• No problem with egg allergy


Hepatitis A

WHY?

• Acute liver disease; fecal-oral transmission• Complications: fulminant liver failureHOW?

Killed virus; IM at 18 m, 24m 94-100% efficacy; ALSO FOR PREVENTIEN WITHIN

2 WEEKS FROM EXPOSURE

Influenza

• Inactivated- IM; 3 killed strains (based on WHO forecast); has to be given annually

• Attenuated (Flumist)- 4 strains; intranasal spray; heat inactivated

• Efficacy depends on matching with circulating strains

• Side effects: local; myalgia, malaise X 48hrs

Influenza

• C/I for inactivated: General; Guiilian-Barre within 6 weeks

• C/I for intranasal: <2yrs,>50; comorbidities; pregnancy; Immunodeficiency or contact with immunodeficiency; asthma; therapy with aspirin

• Indications: EVERYONE FROM 6 MONTHS OF AGE

Human Papilloma Virus (HPV)

WHY?

• 100% OF CERVICAL CANCER is caused by persistent HPV infection

• Acquired by sexual contact (STD)• Most infections resolve, but some persist → cervical intraepithelial neoplasia (CIN)• 100 strains; ≈30 carcinogenic, other associated

with warts

HPV

Normal CIN 1 CIN 2 CIN 3

Basal cell layer

Cytology findings confirmed by histology

Pap smear: ICC (Invasive squamous cell cervical cancer)

• HOW?

GARDASIL (MSD)- 16;18;6;11; 3 doses; 9-45yrsCERVARIX (GSK) – 16,18; 3 doses; >9 yrsFor girls 13-14 yrs, since 2013-4

Viral-like Particles:

Human Papiloma Virus (HPV)

Other Vaccines

• Meningococcal (MENCEVAX)

• RSV- passive (PALIVIZUMAB)

Vaccine information

•Israel www.chisunim.co.il www.health.gov.il•General www.cdc.gov/vaccines www.immunize.org www.immunizationinfo.org

http://www.chisunim.co.il/

http://www.health.gov.il/

http://www.cdc.gov/nip

Documents

Childhood vaccines ד " ר משכית בר - מאיר, מחלקת ילדים והיחידה למחלות זיהומיות