Immunizations JFK pediatric core curriculum

1. ImmunizationsJFK pediatric core curriculum MGH Center for Global Health Pediatric Global Health Leadership Fellowship Credits: Brett Nelson, MD, MPH

2. Discussion outline • Success of immunizations • Still significant room for improvement • Immunization schedules • Administration of vaccines • Contraindications • Specific vaccines

3. Immunizations save lives Globally, immunizations save the lives of approximately 3 million people each year

5. Vaccines are safe • Immunization is among safest of modern medical interventions • Vaccines are easier and safer to administer than ever before • Being immunized is much safer than risking infection and disease

6. Immunization can save money • Immunization is one of the most cost-effective health interventions • Investing in vaccines SAVES more money than it costs

7. Immunization can protect the unprotected • When immunization coverage is high, it can prevent viruses and bacteria from circulating • The more children in a community that are fully immunized, the safer everyone is • Unfortunately, ….

8. 34 million children arenot fully immunized

9. 2.3 million still die each year

10. Diseases reappear when coverage drops

11. Immunization coverage in Liberia Significant success over the last decade http://www.who.int/vaccines/globalsummary/immunization/countryprofileresult.cfm

12. Liberia immunization schedule (coming soon?) http://www.who.int/vaccines/globalsummary/immunization/ScheduleSelect.cfm

13. WHO EPI schedule by age WHO Pocket Book of Hospital Care for Children. Page 297.

14. Administering vaccines • Most doses for children are 0.5ml IM or SC • Sites of IM/SC administration: • <18months: anterolateral thigh • Toddlers: anterolateral thigh or deltoid • Older children: deltoid • Give IM: • DTP, Hib, Hep B • Give SC: • Measles, yellow fever

15. Contraindications to immunizations • Important to immunize all children, including those sick and malnourished, unless there are contraindications • Common side effects to vaccines: • Pain, local swelling, fever, fussiness, drowsiness, vomiting, anorexia • General contraindications to any vaccine: • History of anaphylaxis to that vaccine or vaccine component • Current moderate or severe illness regardless of fever

16. Specific contraindications • BCG and yellow fever • Do not give BCG or yellow fever vaccines to child with symptomatic HIV/AIDS • But do give BCG and yellow fever vaccines to a child with asymptomatic HIV infection • DPT • Do not give DPT-2 or -3 to child who had seizures or shock within 3 days of previous DPT dose (possible encephalopathy to pertussis component)* • Do not give DPT to child with poorly controlled seizures or active CNS disease* *(If available, can give DT vaccine with no pertussis component) • OPV • A child with diarrhea who is due for OPV should be given OPV • However, this dose should not be counted in schedule • Make note on child’s immunization record that it coincided with diarrhea, so that health worker will know this and give an extra dose

17. BCG vaccine • TB currently accounts for more deaths than any other infectious disease • Almost 3 million people a year, including nearly 300 000 children • Over 50 million people infected with drug-resistant strains • BCG (Bacille Calmette-Guérin) is a live vaccine • Administered intradermally (produces small raised "bleb“) at birth • Most widely used of all EPI vaccines • In 1997, almost 90% of the world’s children were immunized with BCG • 50-80% effective against most serious forms of childhood TB: miliary TB and TB meningitis • Offers some protection against leprosy • Uncertain protection against adult forms of TB • WHO recommendations: • In countries with high incidence of TB, immunize infants and children <5 years with single dose of BCG • Where definable high-risk population, countries may limit BCG to infants (such is schedule in Liberia) • Booster doses not recommended

18. Oral polio vaccine • 2 kinds of polio vaccine • Inactivated injectable polio vaccine (IPV) originally developed in 1955 by Dr Jonas Salk • Live attenuated oral polio vaccine (OPV) developed by Dr Albert Sabin in 1961 • Both highly effective against all 3 types of poliovirus • OPV is vaccine of choice for eradication of poliomyelitis • 5x less expensive • Easier to administer (PO vs IM) • Most importantly, induces immunity in gut, where poliovirus multiplies • IPV provides individual protection against polio paralysis but not capable of preventing spread of wild poliovirus since induces very low immunity in gut • WHO recommendations: • 4 doses of OPV before first birthday (birth, 6, 10, 14 weeks) • However, supplementary doses are given during National Immunization Days to achieve eradication

19. DTP vaccine • Combination vaccine against diphtheria, tetanus, and pertussis (whooping cough) • Given IM in 3 doses, at least 4 weeks apart (6, 10, 14 weeks) • Variations: • DT (full diphtheria and tetanus toxoid, but no pertussis) • Td (tetanus toxoid and reduced diphtheria; for adults) • TT (tetanus toxoid alone; for women of childbearing age) • Some countries have substituted acellular pertussis vaccine (aP) for whole-cell pertussis component (wP) • Some manufacturers have added Hepatitis B and/or Hib vaccine to simplify administration and reduce costs

20. Hepatitis B vaccine • >2 billion people alive today have been infected with hepatitis B virus • Of these, ~350 million remain chronically infected, can transmit the infection, and can develop liver cirrhosis or cancer • Every year, ~4 million acute clinical cases of hepatitis B and ~1 million deaths • Primary liver cancer caused by hepatitis B is now one of principal causes of cancer death in many parts of Africa, Asia, and Pacific Basin • Globally, child-to-child and mother-to-child transmission accounts for majority of infections and carriers • Also transmitted through sexual contact, unsterile needles or other medical equipment, infected blood products, skin piercing • Vaccine given IM in 3 doses, at least 4 weeks apart (6, 10, 14 weeks) • Same schedule as DTP • Although vaccine price has fallen, still more expensive than traditional EPI vaccines -- many developing countries cannot afford

21. Hib vaccine • Haemophilus influenzae type b (Hib) causes serious bacterial infections • Meningitis, pneumonia, and infections of blood, bones, and joints (does not cause influenza) • ~3 million serious illnesses and 386,000 deaths each year • Most common between 4-18 months, but can occur in older children • Leaves 15-35% of survivors with permanent disabilities such as mental retardation or deafness • Vaccine available alone or combined with DTP or hepatitis B (e.g. DTwPHibHep) • WHO recommendations: • 3 doses given IM at 6, 10, and 14 weeks ("where resources permit its use and burden of disease is established“)

22. Yellow fever vaccine • Yellow fever is untreatable, viral, hemorrhagic disease, transmitted by mosquitoes, with high fatality rate (30,000 deaths/year) • Yellow fever and measles vaccines are similar in nature and both administered SC at 9 months • WHO recommendations: • 1 dose SC at 9 months for all infants in ~45 countries comprising yellow fever belt of Africa and South America • Re-immunization not indicated as vaccine thought to produce virtually life-long immunity • (However, travelers to these countries require vaccine every 10 years)

23. Measles vaccine • Among vaccine-preventable diseases, measles remains the leading cause of child deaths • Nearly 1 million deaths every year, mainly in developing countries • However, even eradication efforts in developed countries like the U.S. have not been successful • Live attenuated vaccine • WHO recommendations: • Like yellow fever, 1 dose given SC at 9 months • Where >15% of measles cases and deaths occur before 9 months of age, give extra dose of measles vaccine at 6 months, then routine dose at 9 months • Also give extra measles dose for infants at high risk: infants in refugee camps, admitted to hospitals, HIV-positive, and affected by disasters or measles outbreaks • Oral Vitamin A drops often given at same time as measles vaccine to prevent blindness and reduce measles mortality

24. Conclusions and implications • Vaccines are among safest and most effective medical interventions • Ensure up-to-date immunization status • Check records with each patient encounter • Give missing vaccines to hospitalized patients prior to discharge • One last review:

25. References • Children’s Vaccine Program, Global Alliance of Vaccines and Immunizations. www.childrensvaccine.org • Immunization Action Coalition. http://immunize.org/catg.d/p2020.pdf • WHO. By-country vaccine schedule. www.who.int/vaccines/globalsummary/immunization/ScheduleSelect.cfm • WHO. Expanded programme on immunization – overview. http://wbln0018.worldbank.org/HDNet/HDdocs.nsf/0/6b9066a4c84916ec8525676a004d6c5e?OpenDocument • WHO. Liberia reported immunization coverage. http://www.who.int/vaccines/globalsummary/immunization/countryprofileresult.cfm • WHO. Pocket Book of Hospital Care for Children. http://www.who.int/child_adolescent_health/documents/9241546700/en/index.html