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

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slide1

Immunisation Update

By Sindy Lee & Eva Wong

27th March 2003

case 1
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
Question 1
  • What immunisation does the child now require?
question 2
Question 2
  • How and in what sites are these immunisation given?
question 3
Question 3
  • How should these vaccines be stored?
question 4
Question 4
  • Where and how should the vaccination be recorded?
question 5
Question 5
  • The parents ask about possible reactions to the vaccines. What advice would you give about possible adverse reaction?
question 6
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
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
Case 2
  • Siu-ming, an 18 month old infant is brought for his fourth triple antigen immunisation. You have not seen him before.
question 111
Question 1
  • What information would you requires before giving the injection?
question 212
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 313
Question 3
  • What examination would you perform?
question 414
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 515
Question 5
  • What is your management of the ear problem?
case 116
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 117
Question 1
  • What immunisation does the child now require?
question 218
Question 2
  • How and in what sites are these immunisation given?
question 325
Question 3
  • How should these vaccines be stored?
case 1 answer 3
Case 1- answer 3
  • Stored 2-8C
  • Upper 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 427
Question 4
  • Where and how should the vaccination be recorded?
case 1 answer 4
Case 1- answer 4
  • In practice record
  • In child health record
  • Immunization record
  • Information:
    • Date
    • Vaccine
    • Adverse reaction
    • Expiratory date and serial number
question 529
Question 5
  • The parents ask about possible reactions to the vaccines. What advice would you give about possible adverse reaction?
case 1 answer 5
Case 1- answer 5
  • BCG: local reaction
  • Polio: poliomyelitis (1/6.2million)
  • DPT: fever, seizures
  • HBV: rare
  • MMR: fever, rash, joints pain
question 631
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
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 733
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
Case 1- answer 7
  • Rhinitis not a contraindication
  • Principles:
    • Careful education
    • Management of fever
    • Immunisation should not be inappropriately deferred due to infection
case 235
Case 2
  • Siu-ming, an 18 month old infant is brought for his fourth triple antigen immunisation. You have not seen him before.
question 136
Question 1
  • What information would you requires before giving the injection?
case 2 answer 1
Case 2 – answer 1
  • Check previous immunisation record
  • Any adverse reaction
  • Allergies
  • Past medical history
  • Neurological diseases
triple vaccine
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 vaccine39
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 vaccine40
Triple vaccine
  • NOT contraindications:
    • Family history of adverse reaction
    • Family history of convulsion
    • Permaturity
    • Asthma, eczema, allergies
    • Stable neurological condition
question 241
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
Case 2 – answer 2
  • Check previous health record
  • Discuss developmental milestone
question 343
Question 3
  • What examination would you perform?
case 2 answer 3
Case 2- answer 3
  • Height and weight
  • Strabismus
  • Gait
  • Abdomen and testis
  • CVS
question 445
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
Case 2- question 4
  • There is no contraindication
question 547
Question 5
  • What is your management of the ear problem?
case 2 question 5
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
Categorization of vaccines

Live or inactivated ?

BCG

Live attenuated

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
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

Are they contraindication for vaccination?

No

No

No

Yes

Yes

No

No

No

No

Yes

No

No

No

routine immunization programme bcg
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
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 bcg53
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
Routine immunisation – Poliovirus vaccine
  • Immunogenicity and vaccine efficacy:
routine immunisation poliovirus vaccine55
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
Routine immmunisation – Poliovirus vaccine
  • 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
Routine immunisation - DPT
  • Adverse event:
  • Local and febrile reaction
  • Bacterial or sterile abscesses 6-10/million
  • Allergic reaction – anaphylaxis 2/100,000
  • Seizures – febrile seizures
  • Hypotonic-hyporesponsive episode 4-291/100,000
  • Fever of 40.5 0.3%
routine immunisation dpt58
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 dpt59
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 mmr61
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
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
Vaccine Storage and Handling
  • Protect MMR from light at all times
polio vaccine

Polio vaccine

Oral polio vaccine VS inactivated polio vaccine

polio vaccine67
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
Inactivated polio vaccine
  • Global eradication targeted at 2005
  • Change to IPV?
inactivated polio vaccine 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 ipv70
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
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
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 vaccine74
Influenza vaccine
  • Epidemiology:
    • 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 vaccine75
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
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, 0.25-0.5ml
influenza vaccine who should receive it
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
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 epidemiology
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
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 a82
Hepatitis A
  • 88-100% seroconverted after 1st dose, 100% after 2nd dose
  • Protective efficacy for clinical hepatitis A of 94-100%
  • Need for booster dose not known yet, kinetic models suggest that protective levels will persist for > 20years
hepatitis a83
Hepatitis A
  • Routine immunization for areas with rates >=20/100000 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 vaccine85
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 vaccine86
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
Varicella vaccine- post-exposure use
  • Prevention of disease about 95-100%
  • Milder clinical presentation
  • Susceptible children with 72 hours and possibly up to 120hrs after exposure
varicella vaccine88
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 vaccine89
Varicella vaccine
  • HK:
    • Epidemiology and burden largely unknown
    • ? Cost-effectiveness of universal immunization
    • Selective immunization
      • Healthcare workers
varicella vaccine specific contraindications
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

Meningitis- children killer?

Meningococcal, pneunococcal and hemophilus influenza type B

meningococcal vaccine
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
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 vaccines94
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
Meningococcal vaccine for HK?
  • 1995-97: 17 cases of infection (meningitis and septicemia) reported to DH
    • Incidence of 0.03-0.08/100000
    • 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
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
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 vaccine98
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
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
Haemophilus influenza type B
  • Meningitis associated with high mortality and morbidity in Europe and North America
  • Annual incidence: 22-109/100000 of age <5 yr
  • Annual incidence in HK: 2.67/100000
  • ? Cost effectiveness
  • ? Combined vaccine
combination 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
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?