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IMMUNIZATION, NOT JUST FOR CHILDREN

IMMUNIZATION, NOT JUST FOR CHILDREN. Najwa Khuri-Bulos, MD,CIC,FIDSA Jordan Universrity Hospital. The impact of immunization Comparison of Annual and Current Reported Morbidity, Vaccine-Preventable Diseases,USA.

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IMMUNIZATION, NOT JUST FOR CHILDREN

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  1. IMMUNIZATION, NOT JUST FOR CHILDREN Najwa Khuri-Bulos, MD,CIC,FIDSA Jordan Universrity Hospital

  2. The impact of immunizationComparison of Annual and Current Reported Morbidity, Vaccine-Preventable Diseases,USA Disease 20th Century Annual Morbidity* 2000** % change Diphtheria 175,885 4 -99.99 Measles 503,282 81 -99.98 Mumps 152,209 323 -99.79 Pertussis 147,271 6,755 -95.41 Polio (wild) 16,316 0 -100 Rubella 47,745 152 -99.68 Cong. Rubella Synd. 823 7 -99.15 Tetanus 1,314 26 -98.02 Invasive Hib Disease 20,000 167 -99.16 * Maximum cases reported in pre-vaccine era and year + Estimated because no national reporting existed in the prevaccine era ^ Adverse events after vaccines against diseases shown on Table = 5,296 ** Provisional

  3. Impact of the EPI Case Study, Jordan, a great success story Diphtheria Measles poliomyelitis

  4. HIV/AIDS Future TB Malaria Dengue Mening (conj) HPV Rotavirus Pneumo (conj) Cholera Underutilized Typhoid Vaccines Hib (conj) HepB Influenza Rubella YF JE Measles Traditional EPI Tetanus Polio Pertussis Diphtheria // // 1960 1980 2000 The vaccines pipeline

  5. The Decade of Vaccines and The GVAP Mission "TO EXTEND, BY 2020 AND BEYOND, THE FULL BENEFIT OF IMMUNIZATION TO ALL PEOPLE, REGARDLESS OF WHERE THEY ARE BORN, WHO THEY ARE OR WHERE THEY LIVE"

  6. Why should adults be vaccinated • Risk of some diseases persists if not infected or immunized even if one is adult, e.g, measles, VZV, influenza • Immunity wanes e.g D,T,P, ? Measles (only vaccine induced immunity) • Vaccine may not be a 100% effective e.g, measles, mumps, rubella • Protection of ones own children, e.g pertussis,tetanus, influenza • Protection of fetus, e.g, rubella • Risk of disease in elderly, Herpes Zoster, Pneumococcus,influenza

  7. The Case of the twin infants with rash and the case for the MMR in adults, or back to the future • Is there any of these in your future??

  8. Two month old twins with fever and rash • SS and HS presented to the ER with fever and rash of one day duration on March 1 2012 • They are the product of a 36 week pregnancy, delivered by CS to a 30 year old woman • On examination they appeared well, febrile with maculopapular rash mainly on face and trunk • ?Koplik spots seen in the buccal mucosa of SS

  9. Twin infants with rash • History of fever and maculopapular rash in mother two weeks earlier • Infants presumed to have measles • Infants admitted to hospital, strict isolation • Treated for possible sepsis with antibiotics plus vitamin A • Viral cultures and serology obtained on infants • Measles IgG, IgM antibodies obtained on mother

  10. Laboratory results • Measles IgM antibodies positive on mother • Nasal and pharyngeal swab positive for measles virus in the infants • Unknown history of immunization in mother Questions raised?? How can this adult have escaped measles disease or vaccine?? Is this possibly an increasing phenomenon? What can be done to make sure all adults are immune??

  11. Measles • Highly contagious disease • Almost always clinically apparent • If not vaccinated or developed disease almost certainly non immune • As late as 1997, more than thirty years after introduction of an effective vaccine, 36 million cases occurred worldwide and one million deaths • Currently in 2012, 167,000 deaths annually Poland GA, Jacobson RM. Vaccine. 2012;30:103-104.

  12. Measles

  13. Measles Koplic spots

  14. Measles re emergence • Measles elimination declared in USA 2000 • 2011 198 cases , 15 outbreaks • Mainly in unimmunized • In Europe outbreaks in 36 countries, 30,000 cases. • Measles declared endemic in UK even though it was eliminated in 1995 • Africa 36,000 in 2009, up to 172,000 in 2010

  15. Why the re emergence of measles • High transmissibility • Increased rates of vaccine refusal • Globalization and easy transmission between countries • Must maintain vaccine status above 90% to control transmission • To be immune must have two measles vaccines after the age of 12 months • ??waning immunity or immunity less effective

  16. Increasing Susceptibility to Measles among Infants in the United States Infants of vaccinated mothers are more likely to be susceptible at a younger age • 30% of infants of vaccinated mothers had measles antibody titers <300 mIU/mL at birth; 97% by age 6 months (Belgium 2006-2009) • 48% (14/29) of 6-month-old infants had undetectable transplacentally derived measles neutralizing antibodies (US 2004)

  17. Increase in measles cases among infant • Measles among US infants<12 months of age • Period 2001-2008 versus 2011 • 0-5 months • 0.2/million for 0-5 m vs 1.4/million in 2011 • 6-11 months • 3.5/million versus 5.6/milliom 2011 • Is this related to decreased maternal immunity to measles

  18. Measles cases 2011 171 456 126 2675 1498 561 143 5616 101 847 563 >17,000

  19. Measles Clinical Features • 2-4 days after prodrome, 14 days after exposure • Maculopapular rash, becomes confluent • Begins on face and head • Persists 5-6 days • Fades in order of appearance

  20. Condition Diarrhea Otitis media Pneumonia Encephalitis Hospitalization Death Measles Complications Percent reported 8 7 6 0.1 18 0.2 All complications are more common in <2 yrs, Malnourished, Immune compromised And ADULTS Based on 1985-1992 surveillance data

  21. Measles Complications by Age Group

  22. Measles Vaccine • Composition Live virus • Efficacy 95% (range, 90%-98%) • Duration ofImmunity Lifelong • Schedule 2 doses • Should be administered with mumps and rubella as MMR to All infants >12 months of age • Susceptible adolescents and adults without documented evidence of immunity should also receive the vaccine

  23. Why give two doses of measles vaccine

  24. Rubella • From Latin meaning "little red TogavirusRNA virus/one antigenic typeRapidly inactivated by chemical agents, ultraviolet light, low pH, and heatRespiratory transmission of virus • Human infection only /transmitted by droplet, respiratory Replication in nasopharynx and regional lymph nodes • Viremia 5-7 days after exposure with spread to tissues • Placenta and fetus infected during viremia Only primary infection leads to viremia and congenital infection

  25. Rubella Clinical Features/complications • Incubation period 14 days (range 12-23 days) • Prodrome of low-grade fever • Maculopapular rash 14-17 days after exposure • Lymphadenopathy in second week • Complications include arthralgia and arthritis in older females • Thrombocytopenia • Major complication is that of infection of the fetus • This occurs only with primary infection • This occurs in early pregnancy less than 16 weeks

  26. Rubella • Mild febrile maculopapular rash illness • 20 - 50% of infections are without rash or asymptomatic • Complications of encephalitis and arthritis are rare for children

  27. Occurs only with primary maternal infection and mainly in the first trimester 85% of fetuses Rubella infection in early pregnancy can result in Miscarriages, fetal death, or infants born with congenital defects Congenital rubella syndrome Hearing Impairment Cataracts Heart defects Microcephaly, mental retardation / developmental delay Congenital Rubella Syndrome A Child with CRS, autism, mental retardation, and deafness

  28. Rubella Vaccine • Composition Live virus (RA 27/3 strain) • Efficacy 95% (Range, 90%-97%) • Duration ofImmunity Lifelong • Schedule >1 Dose • Acute arthralgia in about 25% of susceptable adult women, Acute arthritis-like signs and symptoms occurs in about 10% • Rare reports of chronic or persistent symptoms • Population-based studies have not confirmed association

  29. Mumps Virus • Paramyxovirus • RNA virus • One antigenic type • Rapidly inactivated by chemical agents, heat, and ultraviolet light

  30. Mumps Epidemiology • Reservoir Human Asymptomatic infections may transmit • Transmission Respiratory drop nuclei • Temporal pattern Peak in late winter and spring • Communicability Three days before to four days after onset of active disease

  31. 15% of clinical cases 20%-50% in post- pubertal males 2%-5% 1/20,000 Average 1 per year (1980 – 1999) CNS involvement Orchitis Pancreatitis Deafness Death Mumps Complications

  32. Mumps Vaccine • Composition Live virus (Jeryl Lynn) • Efficacy 95% (Range, 90%-97%) • Duration ofImmunity Lifelong • Schedule 2 doses after 12 months • Should be administered with measles and rubella All infants >12 months of age including susceptible adolescents and adults • Contraindicated in pregnancy and immunocompromise

  33. Mumps (MMR) vaccine in outbreaks • Summary of Third Dose Intervention Studies • Impact in targeted group Orange County: 96% decline among those aged 11-17 years • Guam: Lower attack rates among 3 dose versus 2 dose recipients • Limitations include timing of intervention • Very few mild and no serious adverse events reported • Do not provide conclusive evidence on impact of a third dose for outbreak control but consistent with potential impact

  34. Conclusions • Adults are a target group for immunization for their own benefit and that of their contacts • Adults should have received two dose MMR after age one year and if not to be vaccinated • Rubella screening premarital for all women • Rubella screening of all female health care workers • ? Measles antibody titer also for pregnant women and if not immune vaccinate postpartum??

  35. A plan to take immunization to the next level • Polio eradication • Elimination of measles & neonatal tetanus • Elimination of rubella • Under 5 mortality rate declines • Hundreds of millions of cases & deaths averted Country, regional & global R&D efforts maximize the benefits of immunization Sustainable access to long-term funding & quality supply Strong immunization systems that are an integral part of a well functioning health system Benefits equitably extended to all people Individuals & communities understand & demand immunization All countries commit to immunization as a priority

  36. No genotype data from 4 countries: PAL, LEB, S.SUD, UAE

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