childhood vaccines ד " ר משכית בר - מאיר, מחלקת ילדים והיחידה...
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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
המחומש החיסון אפקט
המחומש החיסון אפקט
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)
measles-mumps-rubella-varicella (MMRV) המרובע החיסון
• 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
measles-mumps-rubella-varicella (MMRV) המרובע החיסון
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
measles-mumps-rubella-varicella (MMRV) המרובע החיסון
• 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
measles-mumps-rubella-varicella (MMRV) המרובע החיסון
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