6. Child Immunization lecture about child immunization
- 1. Vaccination Immunization Madeeha Kamal Sr. Consultant Pediatrics Hamad Medical Corporation Sidra Associate Professor at Weill-Cornell Qatar Associate Professor at Qatar University Clerkship Director Qatar University
- 3. Professionalism We expect students to demonstrate: -positive attitude towards learning -Intellectual curiosity Honesty, reliabiltiy and responsibility Flexibility when differences of opinion arise
- 4. Introduction • Immunization is one of the most effective preventive health measures • Vaccination programs directly benefit the immunized child. – indirectly benefit unimmunized persons through community ("herd") immunity
- 13. SLIDE 13 Types of vaccines •Live virus vaccines must be given on the same day or atleast 28 days apart from each other. •If immunoglobulins or blood products have been administered , live vaccines should be delayed 6-10 months to avoid interference with immune response. •Live virus vaccines should never be given to immunocompromised persons or pregnant women.
- 14. SLIDE 14 Live attenuated vaccines • Virulent pathogenic organisms are treated to become attenuated and avirulent but antigenic. • They have lost their capacity to induce full-blown disease but retain their immunogenicity.
- 15. SLIDE 15 Inactivated (killed) vaccines • Organisms are killed or inactivated by heat or chemicals but remain antigenic. • They are usually safe but less effective than live attenuated vaccines.
- 16. SLIDE 16 The only absolute contraindication to their administration is a severe local or general reaction to a previous dose. It is safe to administer many combinations of vaccines simultaneously. Inactivated vaccines can be given together or at any time after different vaccines.
- 17. SLIDE 17 Toxoids • They are prepared by detoxifying the exotoxins of some bacteria rendering them antigenic but not pathogenic. Adjuvants are used to increase the potency of vaccine. • In general toxoids are highly efficacious and safe immunizing agents.
- 20. SLIDE 20 Scheme of immunization • Primary vaccination – One dose vaccines (BCG, measles, mumps, rubella,varicella ) – Multiple dose vaccines (Polio, DTaP, Hepatitis B,PCV 13) • Booster vaccination To maintain immunity level after it declines after some time has elapsed (DTaP, OPV ,PCV 13).
- 21. SLIDE 21 Periods of maintained immunity due to vaccines • Short period (months): cholera vaccine • Two years: Typhoid vaccine • Three to five years:Meningitis • Five or more years: BCG vaccine, DTaP • Ten years: Yellow fever vaccine, Hepatitis A ,Hepatitis B • Solid immunity: MMR, varicella vaccines.
- 22. How many doses of Hepatitis B ? Interval between Hepatitis B doses ? Do we need to check Hepatitis B antibody titres ? Why do some people have no antibodies despite receiving complete series of Hepatitis B vaccination ? Hepatitis B
- 23. • 3-dose series can be started at any age. • Routine checking of antibodies after vaccinations is not recommended • Do not restart series, no matter how long since previous dose. • Minimum intervals between doses: – 4wks between #1 and #2, – 8wks between #2 and #3, – at least 16wks between #1 and #3.
- 24. • Vaccinate all newborns with prior to hospital discharge. (Birth dose or Zero dose) • At birth dose of hepatitis B is given within 24 hrs of birth • If mother is HBsAg-positive or HBsAg status is unknown: Give the newborn HBIG and dose #1 within 12hrs of birth; complete series by age 6m.
- 25. DTaP/D T Tdap/Td Tetan us Toxoid Wound management? Pregnancy ? Adults ? Defaulters ? Animal bites ? Booster doses ? Travellers ?
- 26. • DTaP given at ages 2m, 4m, 6m, 15–18m, 4–6yrs. • Do not give DTaP/DT to children age 7yrs and older –use Tdap or Td.
- 29. • Contraindications • For DTaP/Tdap only: encephalopathy not attributable to an identifiable cause, within 7d after DTP/DTaP/Tdap. • Precautions • Guillain-Barré syndrome (GBS) within 6wks after previous dose of tetanus-toxoid-containing vaccine.
- 30. Temperature of 105°F (40.5°C) or higher within 48hrs Continuous crying for 3hrs or more within 48hrs Collapse or shock-like state within 48hrs Seizure within 3d • For DTaP/Tdap only: • Progressive or unstable neurologic disorder • Uncontrolled seizures, or progressive encephalopathy until the condition has stabilized.
- 31. High risk factors for influenza related complications People factors • Children less than 5 years (especially under 2 years of age). • People less than 19 years on long term aspirin therapy. • Adults more than 65 years of age. • Lower socio economic status • Certain ethnic groups • Residents of nursing homes or chronic care facilities • Health care personnel • Travelers- Hajj and Umra
- 32. High risk factors for influenza related complications Medical condition factors • Asthma • Neurological conditions like cerebral palsy , epilepsy, stroke. • Chronic lung diseases like CF, COPD • Heart disease • Blood disease like sickle cell anemia • Endocrine and metabolic disorders ( Diabetes, obesity) • Kidney disease • Liver disease • Compromised immune system (Cancer , HIV, chronic steroid therapy, organ transplant) • Splenectomy
- 33. FIGURE 1. Influenza vaccine dosing algorithm for children aged 6 months through 8 years — Advisory Committee on Immunization Practices, United States, 2013–14 influenza season •Doses should be administered at least 4 weeks apart.
- 34. •Pregnant women especially in the 2nd and 3rd trimesters , their unborn babies or their new infants are at greater risk from complications associated with the flu. •There are a range of changes that occur during pregnancy that put expectant mothers at greater risk, including changes to lung capacity, the immune system and heart rate response. •Pregnant women with existing medical conditions are at even greater risk of severe influenza-related illness. •Because of the higher risk of influenza infection to both mother and baby, the World Health Organization (WHO) recommends that pregnant women should be the highest priority in seasonal influenza vaccination programmes. •The influenza vaccine does not actually cross the placenta to the baby. The vaccine simply stimulates immune system to make antibodies that can fight off the virus.
- 35. Act-Hib • Give at ages 2m, 4m, 6m, 12–15m (booster dose). • Hib is not routinely given to healthy children age 5yrs and older.
- 36. Rotavirus • Rotarix (RV1): give at ages 2m, 4m. • RotaTeq (RV5): give at ages 2m, 4m, 6m. • May give dose #1 as early as age 6wks. • Give final dose no later than age 6 months. • Do not begin series in infants older than age 14wks 6 days. • Minimum interval may be as short as 4wks
- 37. • Contraindications • Allergy to latex, use RV5. • History of intussusception. • Diagnosis of severe combined immunodeficiency (SCID). • Precautions • Moderate or severe acute illness. • Immunosuppressed • Chronic gastrointestinal disease. • Spina bifida or bladder exstrophy.
- 38. How many doses of MMR ? What if MMR was taken before 12 months of age ? MMR and PPD test What if a pregnant woman is not immune to Measles , Mumps and Rubella ?
- 39. MMR • 2 doses at age 12m and 18 m. • Adult should receive MMR if no record of vaccine
- 40. MMR • For women of childbearing age who lack rubella immunity , give 1 dose of MMR . • If pregnant, MMR should be given postpartum • Within 72hrs of measles exposure, give 1 dose of MMR as postexposure prophylaxis to susceptible healthy children age 12m and older
- 41. • Contraindications • Pregnancy or possibility of pregnancy within 4wks. • Severe immunodeficiency • Precautions • If blood, plasma, or immune globulin given in past 11m • History of thrombocytopenia or thrombocytopenic purpura.
- 42. Varicella • 2 doses at age 12m and 4–6yrs. • All adults ,older children and adolescents who lack evidence of vaccination or immunity to varicella should receive two doses of varicella vaccine . • If younger than age 13yrs, space dose #1 and #2 at least 3m apart. If age 13yrs and older, space at least 4wks apart. • May use as postexposure prophylaxis if given within 5d.
- 43. • Contraindications • Pregnancy or possibility of pregnancy within 4wks. • Immunosuppression
- 44. PCV 13 or PCV 23 ? Which age group? Defaulters High risk groups Which one should be taken first ? Total number of doses Time intervals
- 45. PCV 13 • Give at ages 2m, 4m, 6m, 12–15m (booster dose). • Dose #1 may be given as early as age 6wks. • Healthy persons above 5 years are not routinely given PCV 13. – If there is no or incomplete or unclear history of vaccination with PCV 13, a single dose of PCV 13 may be given
- 46. • Contraindication • Previous anaphylaxis to a PCV vaccine or diptheria , tetanus and pertussis vaccines
- 47. PPSV23 • High-risk children age 2yrs and older. • All adults aged 65 years and older • Adults younger than age 65 years with high risk conditions
- 48. Dual Pneumococcal vaccination recommendations for adults • All adults aged 65 years should receive PCV 13 followed by PPV 23. PCV 13 may also be given at 50 years of age . • Travelers to Hajj and Umra with high risk conditions • Age 2- 64 years with immunocomprimising and high risk conditions
- 49. Chest x ray of miliary TB Decorticate posture in TB meningitis BCG vaccination
- 50. Contraindications for BCG vaccine • Immunosuppression • Pregnancy. • A past history of TB. • A positive pre-immunization tuberculin test. • A previous anaphylactic reaction to vaccine component. • Generalized septic skin conditions. • Acute illnesses with fever or systemic upset • Previous BCG vaccination
- 51. Adverse events with BCG vaccination 1. Pain and scarring at the site of injection 2. Keloids—large, raised scars 3. If given subcutaneously, it may induce local infection and spread to the regional lymph nodes, causing either suppurative and nonsuppurative lymphadenitis 4. Abscesses can occur due to haematogenous and lymphangiomatous spread. 5. Regional bone infection (BCG osteomyelitis or osteitis) and disseminated BCG infection are rare complications of BCG vaccination, but potentially life threatening. 6. If BCG is accidentally given to an immunocompromised patient (e.g., an infant with SCID or HIV), it can cause disseminated or life-threatening infection
- 52. Meningitis • Microbiologists routinely exposed to isolates of Neisseria meningitidis • Military recruits • Travellers to countries in which meningococcal disease is hyperendemic or epidemic. ( Subsaharan Africa . Saudi Arabia for Hajj or Umra , India ) • College students if they have not received a dose on or after their 16th birthday • Close contacts of persons with meningcoccal meningitis • Persons with functional asplenia or persistent complement component deficiencies. • HIV-infected persons
- 53. Meningococcal • MCV4 Menactra, Menveo Give IM • Provides immunity against serotypes A C Y and W 135
- 55. Infant and child immunization defaulters • Defination: Infants or children from 3 months- 18 years of age who : 1. Start vaccination late or have delayed vaccination for more than 1 month according to National Immunization Schedule
- 56. Infant and child immunization defaulters 1. Have not completed vaccination series of recommended vaccines in National Immunization Schedule 2. Lack reliable evidence of immunity or immunizations
- 57. Defaulters Schedule summary All children must complete • MMR-2 doses • Varicella-2doses • Hepatitis B-3 doses • DTaP 3months – 1years: 5 doses 1year -5 years : 4-5 doses 5years-7 years: 3 doses • Tdap 1 dose above 7years followed by 2 doses of Td if no doses or incomplete doses of DTaP were given before 7 years of age. Booster dose at 13-16 years • IPV/OPV 1-2 doses of IPV and 3-4 doses of OPV Rotavirus- 2 doses before 6 months Hepatitis A-2 doses between 12-24 months and above 24 months for travelers to endemic areas
- 58. Vaccinating high risk groups • Live vaccines are contraindicated in immunocompromised and pregnant patients • Persons with HIV infection should receive pneumococcal vaccine as soon as possible after their diagnosis.
- 60. Why do we need adult vaccinations? • Some adults incorrectly assume that the vaccines they received as children will protect them for the rest of their lives. Generally this is true, except that: • Some adults were never vaccinated or partially vaccinated as children • Newer vaccines were not available when some adults were children Immunity wanes over time. • As we age, we become more susceptible to serious diseases caused by common infections, such as shingles, flu & pneumonia. This results in otherwise preventable morbidity & mortality. • Considerable vaccine-preventable morbidity – Excess hospitalization – Diminished quality of life (post-herpetic neuralgia) – Missed work – Medical complications
- 61. Vaccine General Recommendation for Use in Pregnant Women (CDC) Hepatitis A Can be given if otherwise indicated Hepatitis B Can be given if otherwise indicated ( Can be used for high risk situations or accidental exposure ) HPV Not recommended Influenza inactivated Recommended ( Infants born to women who receive influenza vaccine in the 2nd and 3rd trimesters may have protective antibodies lasting up to 6 months) Influenza live intranasal Contraindicated MMR, Varicella, Zoster, Yellow fever Contraindicated MCV4,MPSV4 Can be given if otherwise indicated PCV 13 , PPSV 23 No specific recommendation , inadequate data Polio May be used if needed Td May be used if needed Tdap Recommended in the last trimester of pregnancy . ( Most effective way of preventing pertussis and tetanus in newborns and children ) Rabies May be used if needed ( In case of bite with a rabid animal rabies vaccination is life saving procedure )
- 62. HPV • Human papillomavirus (HPV) is a sexually transmitted pathogen that causes • Anogenital and oropharyngeal disease in males and females. • High-risk HPV genotypes causes cancers of the cervix.
- 63. The high-risk HPV genotypes • 16 and 18 cause – 70 % of all cervical cancers – 90 %of anal cancers , oropharyngeal cancer, vulvar, vaginal cancer, and penile cancer. • Additional 20 % of cervical cancer caused by types 31, 33, 45, 52,58 • 6 and 11 cause 90 percent of anogenital warts.
- 64. • Three different vaccines: – Quadrivalent HPV vaccine (Gardasil) targets HPV types 6, 11, 16, and 18. – 9-valent vaccine (Gardasil 9) targets the same HPV types as the quadrivalent vaccine 6, 11, 16,18, 31, 33, 45, 52, and 58. – Bivalent vaccine (Cervarix) targets HPV types 16 and 18.
- 65. HPV vaccines • Prophylactic vaccines, designed to prevent initial HPV infection and subsequent HPV-associated lesions. • Therapeutic vaccines, designed to induce regression of existing HPV-associated lesions, are in development but are not clinically available
- 66. • HPV vaccine provides a direct benefit to female recipients (protecting against cancers) • Cervical cancer is common cancer among females
- 67. Recommended age • <15 years • 2 doses of HPV vaccine at – 0 – 6 to 12 months. – Minimum interval is 5 months between the 2 doses
- 68. • ≥15 years • 3 doses at – 0 – 1 to 2 ( min 4 weeks between 1st & 2nd) – 6 months.( min 12 weeks between 2nd & 3rd) • If a vaccine dose is administered at a shorter interval, it should be re-administered
- 69. Many thanks to Dr Samina ( ministry of health) for sharing her slides with students at Qatar University 2018
- 70. • Thank you • Questions
- 71. Addressing parents concerns • Acknowledging parents’ concerns – Listen respectfully – Provide accurate information about both benefits and risks of vaccines Several factors contribute to parental vaccine concerns, hesitancy, of vaccines, including:
- 72. Addressing parents concerns • Lack of information about the vaccine and about immunizations in general • Lack of understanding of the severity diseases
- 73. Addressing parents concerns • Opposing information and misinformation from other sources (eg, alternative medicine practitioners, anti-vaccination organizations and Web sites, and some religious groups) • Perceived risk of serious vaccine adverse effects
- 74. Addressing parents concerns • Mistrust of the source of information regarding vaccines (eg, vaccine manufacturer, the government) • Concern regarding number of injections to be administered simultaneously
- 75. Addressing parents concerns • Delivery of information in a culturally insensitive manner or that is not tailored to individual concern. • Delivery of information at an inconvenient time or in a hurried manner. • Some people view the risk of immunization as disproportionately greater than the risk of disease
- 76. Managing Injection Pain • Talk to your child ( pinch you not hurt you) • Physical techniques – skin to skin contact between the mother and infant, breastfeeding – older children sit on parents lap – position the limb allow relaxation of the muscle – give multiple injections simultaneously at multiple sites • Psychological (breathing, distraction, blowing bubbles) • Pharmacological techniques
- 77. Syncope • Syncope following immunization has been reported among teens. • Its advised to observe the teen for 15 minutes after immunization.
- 78. Lapsed Immunization • A lapse in the immunization schedule does not require reinitiation of the entire series.
- 79. Vaccine Contraindications and precautions • Contraindication when increased risk of an adverse reaction outweighs the benefit of the vaccine.
- 80. Vaccine Contraindications and precautions • A vaccine should not be administered when a contraindication is present. • The only contraindication applicable to all vaccines is a history of anaphylaxis to a previous dose.
- 81. • Vaccinations may be deferred when a precaution is present until the health condition resulting in the precaution improves or resolves.
- 82. • Vaccination may be recommended in the presence of a precaution if the benefit outweighs the risk. • Most precautions are the result of temporary conditions (eg, moderate or severe illness), and a vaccine can be administered when the illness subsides.
- 83. • Severely immunocompromised people generally should not receive live vaccines.
- 84. • Pregnant women should not receive live-virus vaccines because of a theoretical risk to the fetus. • Personal or family history of seizures is a precaution, rather than a contraindication, for MMRV vaccination in a child.
- 85. Common conditions that should not delay vaccination but often are considered mistakenly to be contraindications i • Diarrhea • Minor upper respiratory tract illnesses (including otitis media) with or without fever
- 86. Common conditions that should not delay vaccination but often are considered mistakenly to be contraindications i • Mild to moderate local reactions to a previous dose of vaccine • Exposure to an infectious disease • Current antimicrobial therapy • Being in the convalescent phase of an acute illness
- 87. Common conditions that should not delay vaccination but often are considered mistakenly to be contraindications • Allergy to an antibiotic (except anaphylactic reaction to neomycin, gentamicin, or streptomycin, if any of these are in the vaccine to be administered) • History of nonanaphylactic allergy to egg
- 88. Common conditions that should not delay vaccination but often are considered mistakenly to be contraindications • Personal or family history of seizures • Family history of sudden unexpected death • Family history of an adverse event following immunization • Breastfeeding or pregnancy in a household contact
- 89. Summary • The childhood and adolescents immunization schedule is complex. • Although serious adverse reactions to immunizations are uncommon – clinicians must be knowledgeable in these reactions as well as the contraindications and precautions to each vaccine.