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Introduction

Introduction. Pediatric services - Preventive -Promotive - Curatative - Rehabilitative Most cost effective health intervention Reduces morbidity and mortality. Historical Aspects. 1796,Edward jenner :1 st small pox vaccine 1885,Louis pasteur: rabies vaccine

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Introduction

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  1. Introduction • Pediatric services • - Preventive • -Promotive • - Curatative • - Rehabilitative • Most cost effective health intervention • Reduces morbidity and mortality

  2. Historical Aspects • 1796,Edward jenner :1st small pox vaccine • 1885,Louis pasteur: rabies vaccine • 1974 WHO: EPI(<5yr and preg; BCG,DPT,OPV, measles and TT) • 1978 GOI : EPI- BCG,DPT and typhoid • 1979 OPV added the measles

  3. Basics of Immunization • Immune (Greek): To be protected • Immunization: Process of inducing immune response which may be humoral or cellular. (active-ag, passive- ab) • Vaccine : Antigen of the pathogen which induces a protective immune response without suffering from disease. • Vaccination: Process of inoculating the vaccine / antigen

  4. Cold Chain The system of transporting, storing and distributing vaccines in a potent state at the recommended temperature from the point of manufacture to the point of use is the Cold Chain Essential components include 1. Manpower – motivated and trained 2. Equipment to store and transport 3. Transport facilities 4. Maintenance of equipment 5. Monitoring

  5. Storage of vaccines in refrigerator

  6. Timings of vaccination • Depends upon the age at which the disease is anticipated as well as on the feasibility of administering the vaccine at that time. • BCG,OPV and HBV can be given soon after birth as the maternally derived immunity apparently does not interfere with the vaccine “take”. • Measles vaccine given after 9months as detectable maternal antibody may inhibit it before 9 months

  7. Interval of vaccination • Interval between two doses of same vaccine ,say for instance DPT, should be at least 4weeks; preferably 8weeks • Interval of 4weeks why? • Early completion of primary schedule • Easier to remember by parents • Decrease drop out rates • BCG and OPV can be given from birth until 2weeks of age , so that there would be 4week gap until next contact at 6week

  8. Route of administration • Oral : OPV & typhoid Ty 21 • Sub cutaneous: measles & MMR • Intradermal: BCG volar surface of forearm • Intramuscular: typhoid, DPT, HB,HA, Hib (antlat thigh in infants & deltoid later)

  9. Safe Injection Practices • Separate syringe and needle for each injection • Separate anatomical site and separate limb for multiple injections • Observation of child for at least 15 minutes after administration of an injection

  10. Minimum Resuscitative Equipment • Airway, ambu bag, mask, IV access (scalp vein, venflon), oxygen cylinder • Injection adrenaline (1: 1000 solution) • IV hydrocortisone • Normal saline

  11. Types of Vaccines Type of antigen Examples Live bacteria, attenuated BCG, Ty21a Live virus, attenuated OPV ,MMR, Varicella Inactivated bacteria Pertussis, whole cell killed typhoid Inactivated virus IPV, Rabies, HAV Toxoid DT,TT,Td Capsular polysacharide Typhoid Vi, Hib, Meningococcal, pneumococcal Viral subunit HBsAg Bacterial subunit Acellular pertussis

  12. National Immunization Schedule Age NIS Birth BCG, OPV0 6week DPT, OPV, HepB, Hib 1 10week DPT, OPV, HepB, Hib 2 14week DPT, OPV, HepB, Hib 3 9-12months Measles 16-24months DPTB1,OPV4 ,MMR 5-6yrs DPT 10yr and 16Year TT Pregnant women TT1 &2 Vitamin A 9, 18, 24, 30 & 36months

  13. BCG BCG Bacillus of Calmette And Guerin Type LAV, Dannish 1331 strain Content/ dose 0.1-0.4million viable bovine mycobacteria, Nature /diluent Lyophilized , normal saline Storage Freezer / 2-8degree C, protect from light Dose/route/site 0.1ml ID , lt deltoid, use within 4hrs of dilution Schedule Single dose at birth or first contact below 5years Protective efficacy 0-80% Major adverse effects Axillary lymphadenitis Contraindications Cellular immunodeficieny Should not be given with measles Other use Some protection for leprosy and leukemia . Bladder cancer

  14. OPV Community vaccine Type LAV Content/ dose Sabin strain Type 1,2 &3 Nature /diluent Liquid Storage Freezer / 2-8degree C Dose/route/site 2 drops (0.1ml), oral (total 6dose) Schedule Birth ,6,10 &14wks, 15-18mo,5yrs, NIDS, & SNIDs Protective efficacy 10-15% per dose Major adverse effects Rarely VAPP Contraindications Immunodeficient patients and house hold contacts Questions: 1. strategy of polio eradication 2. pulse polio, 3. mopping up. 4. Ring immunization

  15. IPV IPV Inactivated Polio Vaccine (IMOVAX POLIO) Strain Salk Trivalent (Lansing, Leon and Brunhide ) Content Type 1-40units, type2 -8units, type3- 32units Dose 0.5ml Route S/C or IM antlat aspect of thigh or deltoid Schedule 6,10.14 weeks and booster at 15months Storage 2-8 degree centigrade Protective efficacy 98% Dr Jonas salk -1976 Nehru award at AIIMS for international understanding

  16. DPwT / DTaP: Triple vaccine Type LAV ( Content/ dose Diphtheria toxoid 20-30 Lf, Tetanus oxoid 5-20Lf, wP 4IU / aP 3-25mcg of 2-5 pertussis antigens Nature /diluent Liquid vaccine Storage 2-8degree C, avoid DTaP from from light Dose/route/site 0.5ml im , thigh / deltoid Schedule 6,10 &14wks, booster at15-18mo,5yrs Not recommended above 7yrs Protective efficacy 95-100% for diptheria /tetanus and 70-90% for pertussis Major adverse effects More with DPwP high fever,excessive cry, seizure, encephalopathy Contraindications Serious hypersensitivity, Encephalopathy with previous dose Tdap: reduced antigen for older children and adolescent

  17. MEASLES Type LAV Content/ dose 1000CCID50 of Edmonston Zagreb strain Nature /diluent Lyophilized , diluent sterile water Storage Freezer / 2-8degree C, protect from light Dose/route/site 0.5ml s/c thigh/ deltoid Schedule Single dose at 9months Protective efficacy 80% Major adverse effects Mild measles like illness in <5%, rarely thrombocytopenic purpura Contraindications Severely immunocompromised, pregnancy Precaution Reconstituted vaccine must be employed in the same day and leftover is discarded

  18. RUBELLA Type LAV Content/ dose 5000CCID50 of RA 27/3 strain of rubella virus Nature /diluent Lyophilized , diluent sterile water Storage Freezer / 2-8degree C Dose/route/site 0.5ml s/c thigh/ deltoid Schedule As for MMR, MMR preferred, adol girl Protective efficacy 95% Major adverse effects Mild rubella like illness in <5%, rarely arthritis and ITP Contraindications Severely immunocompromised, pregnancy

  19. MMR Priorix Type LAV Content/ dose Measles and rubella as above, 5000CCID50 of mumps jeryl lynn/ urabe strain Nature /diluent Lyophilized , diluent sterile water Storage Freezer / 2-8degree C, protect from light Dose/route/site 0.5ml s/c thigh/ deltoid Schedule Two doses at 15-18months and 5years Protective efficacy 80% Major adverse effects Mild measles like illness in <5%, rarely thrombocytopenic purpura Contraindications Severely immunocompromised, pregnancy Jeryl - Linn-named after the child from whom it was derived , dose 317TCID

  20. HEPATITIS B Type Recombinant (Engerix B) Content/ dose 25mcg /ml of HBsAg Nature /diluent Liquid vaccine Storage 2-8 degree C Dose/route/site <18yr 0.5ml (10mcg), >18yr- 1ml IM deltoid / thigh Schedule Birth, 6wk &14wks 6,10,14wks 0, 1& 6months Protective efficacy 90% Major adverse effects None Contraindications Serious hypersensitivity

  21. HIB VACCINE Hiberix , ACT- HIB Type Subunit , conjugated polysacharide vaccine Content/ dose 10mcg of PRP-T or HbOC Nature /diluent Lyophilized/ liquid , diluent sterile water Storage 2-8degree C Dose/route/site 0.5ml im thigh/ deltoid Schedule 6,10.&14wks, booster at 15-18months Protective efficacy >90% Major adverse effects None Contraindications Severely immunocompromised, pregnancy

  22. HEPATITIS A VACCINE Type Killed (HAVRIX) Dose 1-18yr-720units, >18yr:1440 units single dose, booster after 6-12 months Storage 2-8 Side effects Pain,fever and malaise

  23. VARICELLA /CHICKEN POX VARILRIX , OKAVAX Type LAV Storage 2-8degree C Dose/route/site 0.5ml S/c thigh/ deltoid Schedule Given after 1yr of age <13yr Single dose, >13yr 2dose 6-10wk apart Protective efficacy 80% Major adverse effects Rare Contraindications HIV with lymphopenia and neomycin hypersensitivity OKAVAX is given only single dose

  24. TYPHOID VACCINE Types 3 types: Vi polysacharide (available in india) - whole cell inactivated and - oral Ty 21a Dose 0.5ml IM inactivated Vi psv Schedule First dose after 2yr and booster every 3year Efficacy 70% Storage +2 to +8%

  25. Pneumococcal Conjugate Vaccine (PCV 7) Type Conjugate capsular polysacharide vaccine Content/ dose Contains 2mcg of serotype 4,9V,14,18c,19F, 23F and 4mcg of serotype 6B (7 valent) Nature /diluent Liquid form Storage +2 to +8degree C Dose/route/site 0.5ml IM antlat aspect thigh/ deltoid Schedule 3 primary doses 6,10,14wks.booster 12-15months Protective efficacy 97.4% Major adverse effects Local reactions and fever, GBS, relapse of ITP Contraindications Known hyper sensitivity

  26. MENINGOCOCCAL VACCINE Type Inactivated capsular polysacharide vaccine Bivalent: (A+C), tetravalent: A, C,Y& W135 Content/ dose 50mcg each A &C serotype Nature /diluent Lyophilized , sterile water Storage +2to +8degree C, protect from light Dose/route/site 0.5ml IM or S/C thigh/ deltoid Schedule 2years and above during epidemics Indication Chemoprophylaxis in close contacts A/Hyposplenia, complement deficiency Haj pilgrimage Protective efficacy 90% against the covered strains Major adverse effects Mild fever & local reaction

  27. RABIES Type Tissue culture inactivated vaccine HDCV- Human diploid cell vaccine PCEV- Purified chick embryo cell vaccine (rabipur) Content/ dose >2.5 IU of inactivated rabies antigen Nature /diluent Lyophilized , diluent sterile water Storage 2-8degree C, protect from light Dose/route/site 1ml IM deltoid Schedule Pre exposure-Three doses: day 0,7 & 28 Post exposure-5doses day-0,3,7,14 & 28 Protective efficacy 90-100% Adverse effects Local pain Seroprophylaxis Rabies human immunoglobulin (RHIG) 20IU/kg single injection in all cases with severe exposure

  28. Combination vaccines currently licensed in Pakistan • DTwP+ Hib, • DTwP+ Hep B, • DTwP+Hib+ HepB • DTaP+ IPV+HepB

  29. Emergency management of anaphylaxis 1. Inj epinephrine (1:1000 solution) 0.01 ml/kg/dose (max 0.5 ml) im in anterolateral thigh 2. Set up IV access 3. Lie patient flat and elevate legs if tolerated. 4. Give high flow oxygen and airway/ ventilation if needed 5. If hypotensive also, set up additional wide bore access and give IV NS 20 ml/kg under pressure over 1-2 minutes 6. IM adrenaline may be repeated after 3-5 minutes if required 7. Oral antihistaminics may be given. 8.Injectable corticosteroids may be given .

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