Transcript Practical II – National Immunization Programme

VACCINE-PREVENTION
VACCINES USED UNDER THE
NATIONAL IMMUNIZATION PROGRAMME
• VACCINE = antigenic product obtained from a
specific pathogenic agent or one very close related
to it, which can induce, in a receptive person, an
immune response that protect against the
pathogenic agent.
• RECEPTIVES = people who interact with a source of
pathogenic agent and did not have an effective
specific or non-specific resistance.
• ANATOXIN (TOXOID) = bacterial exotoxin partially
detoxified, but which keeps it immunogenicity
OBSERVATIONS
• 5 classes of Ig: IgM, IgG, IgA, IgD, IgE
• Normal serum (non-immune serum) – Ig without
Ab activity
• Maternal Ig – cross the placenta (IIIrd trim.) → at
birth, in n.b. circulation – especially maternal IgG –
ensure the n.b. protection in the first 6-9 months,
if the mother has a protective level of Ab and just
against the Ag with which the mother interacts
OBSERVATIONS
• foetus – very low level of IgM (10th week) and IgG
(12th week of intrauterine life)
• after birth – level of IgM grows quickly, IgG
production - start since 4th week of extrauterine
life
• cellular immunity = able from birth → BCG
IMMUNE RESPONSE
• Primary immune response (PIR):
- after the first contact with an Ag
- latency period = 10-15 days
- IgM
• Secondary immune response (SIR):
- after the secondary contact, repeated with the
same Ag
- initiate by the very low doses
- IgG
• PIR/SIR – appear after natural or artificial active
immunization
IMMUNE RESPONSE
• humoral:
- Ab → Ly B
- primary vaccination → immune response → level of Ab
decreases in short time under the protecting limit
- secondary vaccination → repeated administration of Ag at an
appropriate intervals → increases the level of Ab, extends the
synthesis duration = keeping the immunologic memory
• cellular:
- Ly T
- a single administration / at long distances in time → immunologic
memory for the entire life (theoretically)
VACCINE-PREVENTION
= the operation of giving the necessary doses of
Ag to the persons or groups receptive to a
pathogenic agent, in order to give them
protection
VACCINE-PREVENTION
Objective:
specific protection → knowing the factors conditioning
the immune response :
-
age
immune deficiencies
genetic factors
vaccination scheme
vaccination indications
vaccination contraindications
the necessary technical conditions
MINIMAL OPTIMAL AGE FOR VACCINATION
1. Stages of immune
system maturation:
a. Cellular immunity –
efficient from birth → BCG
b. Local intestinal immunity (IgA) – efficient till 6-8 weeks
of life → substituted after that by VPOT
c. Humoral immunity (circulating Ab) – efficient before the
age of 2-3 months → DTP
MINIMAL OPTIMAL AGE FOR VACCINATION
2. Protection - inherited from mother (protective level
of Ab) – efficient till 6-9 months
→ measles vaccine (live attenuated vaccine) = after 9 months
3. Epidemiological context – according to the
incidence and severity of transmissible diseases in
the area, available vaccines, economic resources
• IMMUNE DEFICIENCIES → reduces the IR
• GENETIC FACTORS :
- strong IR, good quality
- IR with unprotected levels
- IR humoral – weak; cellular - strong
• SCHEDULE VACCINE :
- specify the population groups
- methods and routes of administration
- number and size of doses
- the interval between doses and the interval between
different vaccines
INDICATIONS
1. Vaccines administrated under the National
Immunization Program - according to age group:
BCG, IPV, DTPa, MMR, HepB, Hib,
pneumococcal vaccine (PCV)
2. Vaccines administrated in special epidemiological
situations – for risk groups: HepA vaccine,
influenza vaccine, rabies vaccine, leptospirosis,
HPV vaccine, meningococcal vaccine; chickenpox
vaccine (varicella); rotavirus vaccine; yellow fever
vaccine
Polio is an infectious disease caused
by a virus that lives in the throat and
intestinal tract. It is most often
spread through person-to-person
contact with the stool of an infected
person and may also be spread
through oral/nasal secretions. Polio
used to be very common in the
United States and caused severe
illness in thousands of people each
year before polio vaccine was
introduced in 1955. Most people
infected with the polio virus have no
symptoms; however, for the less
than 1% who develop paralysis it
may result in permanent
disability and even death.
INDICATIONS
3. Vaccines administered in relation with certain
diseases
- anatomic / functional asplenia: pneumococcal
vaccine, influenza vaccine, Hib vaccine,
meningococcal vaccine
- hemodialysis, recipients of transplants: Hib
vaccine, influenza vaccine, pneumococcal vaccine
- chronic alcoholism
GENERAL CONTRAINDICATIONS
• TEMPORARY– must be recovered
-
fever due to mild infection
incubation period of some infectious diseases
infectious disease in progress and in convalescence
recent administration of standard Ig → after 4-6 weeks
immunosuppressive therapy with corticosteroids → high
doses, extended scheme
- pregnancy
- diabetes mellitus
- active TB
- prematurity
- IIIrd degree dystrophy
GENERAL CONTRAINDICATIONS
• DEFINITIVE:
- progressive neurological disorders
- organic diseases - decompensated
- immunodeficiency status (including HIV
positive persons)
- major allergy to egg proteins
- skin diseases
SIDE EFFECTS /
ADVERSE EVENTS
• Side Effects After Vaccination (SEAV)
= medical incidents occurring after vaccination,
which are considered to be due to its
- SEAV produced by vaccines with live attenuated
agents → of infectious nature and with late onset
- SEAV produced by vaccines with killed / inactivated
agents → immediate / early onset and are based on
hypersensitivity mechanisms
SIDE EFFECTS /
ADVERSE EVENTS
1. Local side effects after vaccination :
• Early (the first 3 days) ~ localised pain, redness, swelling
at injection site (vaccines with killed / inactivated agents).
• Late (3-12 weeks) ~ suppurated lesions (TB vaccine)
2. Febrile episodes :
• Early (the first 1-3 days) → anatoxin, pertussis vaccine,
influenza vaccine, Hep B vaccine.
• Late (5-15 days) → vaccines with live attenuated virus
(measles vaccine, yellow fever vaccine).
SIDE EFFECTS /
ADVERSE EVENTS
3. Seizures (hyperthermic to young children) →
pertussis vaccine, measles vaccine.
4. Exanthema
• Allergic (early) - vaccines with inactivated agents
• Infectious (late) – measles vaccine
5. Arthralgia (adults) - rubella vaccine, Hep B vaccine
.
SIDE EFFECTS /
ADVERSE EVENTS
Severe side effects:
• shock, persistent seizures, encephalopathy ~ after
pertussis vaccine ;
• ~ paralysis after poliomyelitis vaccine – live
attenuated virus (returning to initial neuro
virulence);
• generalized tuberculosis ~ after TB vaccine
administered to a person with congenital
immunodeficiency, undetectable at birth.
VACCINES USED UNDER THE NATIONAL
IMMUNIZATION PROGRAM
- Morbidity structure
- Morbidity trend
for transmissible diseases
ROMANIAN NATIONAL IMMUNIZATION PROGRAM
- Vaccination against- tuberculosis (BCG)
- Vaccination against- poliomyelitis (IPV)
- Vaccination against- viral hepatitis B (HepB)
- Vaccination against- diphtheria-tetanuspertussis
(DTPa, dT)
- Vaccination against- measles-mumps-rubella
(MMR)
- Vaccination against- Hemophilus influenzae b
infection (Hib)
- Pneumococcal conjugate vaccine (PCV)
Schedule in use (2014-2015)
The
recommended age
First 24 hours
2-7 days
2 months
Vaccines
Hep B
BCG
DTPa-IPV-Hib-Hep B, PCV
DTPa-IPV-Hib, PCV
4 months
DTPa-IPV-Hib-Hep B
6 months
DTPa-IPV-Hib, MMR
12 months
PCV, Hep B
14 months
DTPa (until the end of the
4 years
existing doses)
DTPa-IPV (since 2015)
6 years
MMR
7 years (in Ist grade) IPV (until 2014)
6 and 8 years
dT
14 years
dT
Observations
In Maternity
In Maternity
Family doctor
Family doctor
Family doctor
Family doctor
Family doctor
Family doctor
Family doctor
School campaigns
School campaigns
School campaigns
Tuberculosis Vaccination
(BCG)
INDICATIONS
- 4-7 days from birth (Wbirth > 2500 g)
- until 3 months (babies not vaccinated in the
maternity hospital)
- at 6 months – reading of postvaccinal scar
(those without a scar or with a scar Ø < 3 mm –
are receiving a vaccine dose without a previous
tuberculin test)
ADMINISTRATION TECHNIQUE
- lyophilized product
- powder non-adhering to the walls of the ampoule – 1 vial = 20 mg
bacterial mass
- open the ampoule after protection with a sheet of cellophane that
comes with the vaccine
- for reconstitution : Sauton medium (2ml sol/ampoule)
- Injection site: deltoid muscle of the left arm
- dose: 0,1 ml vaccine
- route of administration: strictly intradermal
- correct vaccination: papule with Ø = 5-6 mm which disappears in 30
minutes
CONTRAINDICATIONS
- persons with positive tuberculin skin test
- HIV infection
- underweight newborns (Wbirth< 2500 g)
- malignancies
- treatment with corticosteroids
- acute dermatological diseases
- pregnancy
- convalescents after infectious diseases
ADVERSE EVENTS
- persistent ulcerations (over 3 months)
- abscess at the inoculation site
- locoregional lymph nodes
- inflammatory nodules
- osteitis, osteomyelitis
- disseminated BCG infection – Mycobacterium
bovis strain
Poliomyelitis vaccination
INDICATIONS
- first-vaccination (primary immunisation): at the
age of 2, 4, 6 months (IPV)
- Ist revaccination: at 12 months (6 months from
first-vaccination) (IPV)
- IInd revaccination: at 6 years (IPV)
- IIIrd revaccination: at 9 years (IPV)
ADMINISTRATION TECHNIQUE
- IPV (injectable poliomyelitis vaccine)
prepared from inactivated agent
- i.m. administration
- dose: 0,5 ml
ADMINISTRATION
TECHNIQUE
For small babies
Infants < 12
months of age
ADMINISTRATION
TECHNIQUE
Children > 3 years:
deltoid muscle
CONTRAINDICATIONS
- infectious diseases during the acute period and in convalescence
- contact with sick persons (rubella, measles, chicken pox, mumps)
- immunosuppressive treatments
- Ig administration less than six weeks before
- administration of other vaccines with less than 30 days before
- convalescents after infectious diseases
- allergic reaction to neomycin, streptomycin or polymyxin B
ADVERSE EVENTS
•
local: pain, redness, swelling
•
medium fever
Hepatitis B vaccination
INDICATIONS
- Ist Dose : in the first 24h from birth (maximum 7
days)
- IInd Dose: at 2 months
- IIIrd Dose: at 6 months
INDICATIONS
•
•
•
•
active medical staff
familial / sexual contacts
intravenous drug users
hemodialysis, haemophilia, recipients of blood and
derivatives, candidates for organ transplants
• population in areas where VHB is hyperendemic
• institutionalized persons
PARTICULAR CASES
1.
Newborns from mothers with positive HBsAg:
- specific Ig against-HBV (HBIg)
+
- concurrent vaccination (in other anatomic site) in the first 12h after
birth - with one of the schemes : 0, 1, 2 months or 0, 1, 6 months
2. Accidental exposure:
- before exposure: vaccination (scheme 0,1,6 months) ± IVth dose
after 1 year and Vth dose after 5 years (for high risk sectors)
- post exposure - dermal exposure or percutaneous :
- person with complete vaccination scheme → check the level
of Ab → protective level (> 10mUI/ml) → not require
additional doses
- unvaccinated person or with an incomplete vaccination
scheme → HBIg + vaccination (Ist dose) → level of Ab –
the vaccination is stopped or we continue with the quick
scheme
ADMINISTRATION TECHNIQUE
• Slightly opaque white suspension
• Administration: deep i.m.
- before 3 years age (infant and toddler): at the thigh level,
at the union of upper 1/3 with the inferior 2/3
- in older children and adults : deltoid muscle
• Dose:
- infant and toddler = 0,5 ml suspension /10 µg HBsAg
- older children and adults = 1 ml suspension /20 µg
HBsAg
- immunosuppressed adults = 2 ml suspension /40 µg
HBsAg
CONTRAINDICATIONS
- Subjects with high sensibility to one of the vaccine
components (yeast or others)
- Subjects with sensibility at previous administration
ADVERSE REACTIONS
1. Most frequently – local:
- pain
- rash
- induration
2. Rarely – transitory:
- subfebrility, fatigue, headache, vertigo, malaise
- abdominal pain, nausea, vomiting
- pruritus, urticaria
- arthralgia
Vaccination against –
diphtheria-tetanus-pertussis
(DTPa, dT)
Infanrix hexa = DTPa-hepB-IPV-Hib - GlaxoSmithKline
Infanrix -IPV= DTPa-IPV – GlaxoSmithKline
Infanrix Penta = DTPa-hepB-IPV – GlaxoSmithKline
Adacel – Sanofi Pasteur = dTpa
Adacel Polio – Sanofi Pasteur = dTpa-IPV
INDICATIONS
- The first vaccination: 3 doses at age 2, 4, 6 months –
with DTPa product (tetra-vaccine DTPa-IPV or pentavaccine DTPa-IPV-Hib)
- Ist Revaccination : 12 months (at 6 months from the first
vaccination) with DTPa-IPV or DTPa-IPV-Hib
- IInd Revaccination : 4 years with DTPa
- IIIrd Revaccination : 6 years with DTPa-IPV
- IVrd Revaccination : 14 years with dT
- Vth Revaccination : 24 years with dT
- After 24 years age: revaccination at every 10 years with
dT
ADMINISTRATION TECHNIQUE
• Milky white liquid
• Administration - deep intramuscular injection:
- infants and young children: at the union of superior 1/3 with
the inferior 2/3, 2-3 cm lateral to the midline
- children after 3 years of age and adults: the deltoid muscle
• Dose: 0.5 ml
CONTRAINDICATIONS
- Temporary:
- recent Ig administration
- incubation period of infectious diseases
- immunosuppressive treatments
- Definitive:
- kidney diseases, decompensated cardiovascular diseases
- autoimmune diseases, hematological diseases
- cancers
- Related to pertussis:
- fever (> 40,5˚C), persistent crying (> 3 hours), seizure
syndrome (within 3 days after vaccination) occurred after a
previous vaccination
- onset of encephalopathy within 7 days after a previous dose of
DTP
SIDE EFFECTS /
ADVERSE EVENTS
1. Local:
- pain
- swelling
- induration at the injection site
2. General: febrile reaction for 1-2 days
3. Neurological:
- Guillain-Barré syndrome, brachial neuritis (correlated
with – ATPA)
- encephalopathy, episodes of hypotonia-areflexia ,
persistent crying (correlated with pertussis component)
Measles – mumps - rubella
(MMR) vaccination
INDICATIONS
- First dose: at 12 months
- Revaccination: 7 years
ADMINISTRATION TECHNIQUE
• Trivaccine MMR
• White lyophilised powder/red pill with a vial of
solvent
• Use as soon as possible after opening – it is
extremely sensitive
• i.m. / s.c. administration - deltoid region
• Dose: 0.5 ml
CONTRAINDICATIONS
-
Acute febrile illness
Allergic reactions to egg proteins
Recent administration of standard Ig
Immunosuppression
Allergies to kanamycin / neomycin
Pregnancy
Individuals with HIV infection - are
contraindicated (before monthly dose of Ig)
not
SIDE EFFECTS/
ADVERSE EVENTS
Minor:
- low-grade fever
- coryza
- nasopharyngitis
Causes of measles among vaccinated
people
• thermal lability of the vaccine
• immunological inertia (5%)
• the reduction of post-vaccination level of Ab
• population or medical negligence
• blocking of the immunogenicity (Ab from mother/ Ig /
IFN production in viral infections
• groups which are not included in the vaccination
programme
• religious motivations
• population migration
Haemophilus influenzae b vaccine
(Hib)
INDICATIONS
(Infanrinx hexa)
- Primary immunisation: 3 doses
at 2, 4 and 6 months
- Revaccination: 12 months of age
• Children >2 years of age who have received all doses of
Hib vaccine do not require a booster dose after
splenectomy
• A single dose of Hib vaccine is recommended for other
splenectomised individuals who were not vaccinated in
infancy or are incompletely vaccinated.
ADMINISTRATION TECHNIQUE
• the vaccine consists of both a pre-filled syringe
containing diphtheria toxoid, tetanus toxoid;
pertussis toxoid (PT); AgHBs; polioviruses type 1, 2
and 3; traces of formaldehyde, polymyxin and
neomycin AND a vial containing a lyophilised pellet
of Hib
• i.m.
• Dose: 0.5 ml
CONTRAINDICATIONS
• anaphylaxis following a previous dose of any of the
vaccines, or
• •anaphylaxis following any component of the
vaccine.
SIDE EFFECTS/
ADVERSE EVENTS
•
Swelling and redness at the injection site after the
first dose
•
Fever
•
These adverse events usually appear within 3 to 4
hours and resolve completely within 24 hours
•
The incidence of these adverse events declines
with subsequent doses
Pneumococcal conjugate vaccine
INDICATIONS
• people over 60 years with or without chronic lung disease, chronic
renal disease, chronic heart disease, low physical activity and poor
nutritional status
•
institutionalized persons → health care facilities, hospitals, prisons
• people suffering from chronic diseases regardless of age
(alcoholism, cirrhosis, etc.)
• anatomical / functional asplenia - pneumococcal infection has a
rapid development and a high mortality (75%)
• immunosuppression of various causes (including HIV-positive)
CONTRAINDICATIONS
• children under the age of 2 years
• strong postvaccination reaction to a previous
administration
• previous vaccination less than 5 years
• pregnancy
SIDE EFFECTS
(ADVERSE EVENTS)
• hypersensitivity
• pain, tiredness, induration, mild fever
• rare: asthenia
VACCINE-PREVENTION
- is mandatory
- is free of charge
- reporting is necessary for the evaluation of
transmissible diseases at national and
international level – reporting to the WHO