IMMUNIZATIONIMMUNIZATION

Prof. Dr. Muhammad Akbar Prof. Dr. Muhammad Akbar NizamaniNizamani

Liaquat University of Medical Liaquat University of Medical and Health Sciences Jamshoroand Health Sciences Jamshoro

Immunization Global Situation

Each year 130 million children are born, 91 million Each year 130 million children are born, 91 million of them in developing countriesof them in developing countries..

Almost 30 million children have no access to Almost 30 million children have no access to immunizationimmunization..

"Nearly 2 million children worldwide still die"Nearly 2 million children worldwide still dieneedlessly each year of vaccine-preventableneedlessly each year of vaccine-preventable

illnesses. illnesses. Success StorySuccess Story

Eradication of disease EX: smallpox Elimination of disease EX: polio Control of disease EX: diphtheria

Immunization

“The health of the people is the foundation upon which all their happiness and their power as state depends.”

“An ounce of prevention is worth a pound of cure”

diphtheriameaslespoliomyelitistetanusPertusishepatitis Byellow feverHibmeningitis ACrotaviruspneumococcaltotal

Infectious disease deaths 2001

4 000554 000

<100201 000285 000

300015 000

450 00012 000

338 000841 000

2 703 000

1 000191 000

100080 0001 000

518 00015 000

014 000

162 000768 000

1 751 000

5 000745 000

1000281 000286 000521 000

30 000450 000

26 000500 000

1 609 0004 454 000

WHO estimates

Immunization

PAKISTANPAKISTAN Infant Mortality rate: 67 per 1000 live birthsInfant Mortality rate: 67 per 1000 live births Under Five Mortality: 85 per1000 L. BirthsUnder Five Mortality: 85 per1000 L. Births Neonatal Mortality: 38 per 1000 L. BirthsNeonatal Mortality: 38 per 1000 L. Births What Kills:What Kills: approx 600000 per yearapprox 600000 per year

• Pneumonia 200000 per yearPneumonia 200000 per year• Diarrhea 200000 per yearDiarrhea 200000 per year• Vaccine preventable Vaccine preventable

120000 [20%] 120000 [20%] • ?ROUTINE EPI COVERAGE: 30 – 60 % , 80-85%UNICEF?ROUTINE EPI COVERAGE: 30 – 60 % , 80-85%UNICEF• IN 1990 OUR COVERAGE WAS > 90% IN 1990 OUR COVERAGE WAS > 90% One of the 5 countries in EMRO not on target to achieve MDG 4One of the 5 countries in EMRO not on target to achieve MDG 4• WHERE ARE WE GOING? WHERE ARE WE GOING? • WHERE WE SHOULD BE? WHERE WE SHOULD BE? • SHOULD LOOK AFTER OUR CHILDREN?SHOULD LOOK AFTER OUR CHILDREN?

Diseases covered by EPI Diseases covered by EPI immunizationimmunization

PoliomyelitisPoliomyelitis TuberculosisTuberculosis DiphtheriaDiphtheria PertusisPertusis TetanusTetanus Hepatitis BHepatitis B H.Influenzae: Pneumonia , MeningitisH.Influenzae: Pneumonia , Meningitis MeaslesMeasles

ROUTINE IMMUNIZATION: Every ROUTINE IMMUNIZATION: Every journey begins with a single stepjourney begins with a single step

At Birth : OPV , BCG (HEP B)At Birth : OPV , BCG (HEP B) 6 WEEKS : OPV1 ,PENTA 1 6 WEEKS : OPV1 ,PENTA 1 (PENTA: Diphtheria, Pertusis, Tetanus, (PENTA: Diphtheria, Pertusis, Tetanus,

Homophiles Influenza Type B, Hepatitis B)Homophiles Influenza Type B, Hepatitis B) 10 WEEKS : OPV 2 ,PENTA2 , HEP B 210 WEEKS : OPV 2 ,PENTA2 , HEP B 2 14 WEEKS : OPV 3 ,PENTA 3, HEP B 314 WEEKS : OPV 3 ,PENTA 3, HEP B 3 9 MONTHS : MEASLES 19 MONTHS : MEASLES 1 12 MONTHS: MEASLES 212 MONTHS: MEASLES 2 TT IMMUNIZATION for Child bearing age womenTT IMMUNIZATION for Child bearing age women Minimum two vaccines during pregnancy Minimum two vaccines during pregnancy

Active Immunization Types Live attenuated

• Virus OPV,Measles, mumps, rubella• Bacteria BCG 

Killed• Virus IPV• Bacteria

Whole Pertusis Toxoid Tetanus Polysaccharide Meningococcal

Genetically Engineered• Hepatitis B

TT Immunization TT immunization for CBA women, pregnant womenTT immunization for CBA women, pregnant women

Most unfortunate to still see mothers and babies dying of Most unfortunate to still see mothers and babies dying of neonatal tetanus neonatal tetanus

TT 1: First contact with a girl reaching CBA or As early as

possible in pregnancy TT2: 4 weeks after TT1 TT3: At least 6 months after TT2 or in next pregnancy TT 4:At least one year after TT3 or in next pregnancy TT5: At least one year after TT 4

For Trauma/ wound in Immunized person single dose TT

Protection Protection

against against 55 diseasesdiseases

just just oneone injection:injection:

First do no harm: First do no harm: Hippocrates oathHippocrates oath

Hib

Hep B

Diptheria

Pertussis

Tetanus 55 inin

Plus… Plus… the Pentavalent the Pentavalent

AdvantageAdvantage

H. Influenza type b vaccineH. Influenza type b vaccine

H. Influenza type b is a common cause H. Influenza type b is a common cause of bacterial meningitis, pneumonia, of bacterial meningitis, pneumonia, epiglottis and sepsis in infants and epiglottis and sepsis in infants and childrenchildren

H. Influenza type b (Hib) vaccine is H. Influenza type b (Hib) vaccine is polysaccharide vaccine polysaccharide vaccine

Administered together with PENTA Administered together with PENTA vaccine vaccine

Dose is 0.5ml intramuscularlyDose is 0.5ml intramuscularly

Hib (Haemophilus influenzae type b)

A serious infectious disease causing meningitis and pneumonia in infants and

children• At least 3 million infected worldwide 1

• Children aged between 4 and 12 months most at risk 1,2

• 400,000 – 700,000 deaths worldwide each year 1

• Prevalence of Hib disease is 15-50% or more in developing countries 3

• 500,000 children die from Hib pneumonia every year 4

• 50,000 children die from Hib meningitis every year 4

3 McIntyre P. JAMA (SEA Suppl) 1993; 9: 5-10. 4 Shapiro ED, Ward, JI. The epidemiology and prevention of disease caused by Haemophilus influenzae type b. Epidemiologic Reviews 1991; 13:112-143.

1WHO position paper Wkly Epidemiol Rec 1998; 73: 64-68 2Cambell H. et al Drugs 1993; 46: 378-383

PneumoniaPneumonia

Hepatitis B key factsHepatitis B key facts

Over 2 billion people infected worldwide1

350 million chronic carriers worldwide1,2

4 million new acute hepatitis B cases per year3

1-2 million deaths annually directly related to HBV infection2,4

HBV is 100 times more infectious than HIV5

Around 62% of liver cancer cases in Pakistan are due to hepatitis B

HBsAg the seventh EPI antigenHBsAg the seventh EPI antigen

WHO, 1992

‘‘Only by mass vaccination of infants Only by mass vaccination of infants with HB vaccine as part of EPI with HB vaccine as part of EPI will the burden of HB infection will the burden of HB infection

be significantly reduced globally’be significantly reduced globally’

Measles RashMeasles Rash

Measles PharyngitisMeasles Pharyngitis

Koplik SpotsKoplik Spots

AVAILABLE VACCINES NOT AVAILABLE VACCINES NOT YET PART OF EPIYET PART OF EPI

Conjugated Pneumococcal Vaccine for IPD at 2 Conjugated Pneumococcal Vaccine for IPD at 2 ,4 and 6 months or with routine immunizatioin.,4 and 6 months or with routine immunizatioin.

MMR : 15- 18 MMMR : 15- 18 M Hepatitis A Vaccine 1 y , 2Hepatitis A Vaccine 1 y , 2ndnd Dose 3 – 6 M Dose 3 – 6 M Chicken Pox VaccineChicken Pox Vaccine Typhoid Vaccine 2 yearsTyphoid Vaccine 2 years Influenza Virus vaccine 1 y , Every YearInfluenza Virus vaccine 1 y , Every Year Yellow Fever VaccineYellow Fever Vaccine Rota Virus VaccineRota Virus Vaccine Meningococcal VaccinesMeningococcal Vaccines Rabies VaccineRabies Vaccine

Forghani et al, 1994

(Chickenpox Vaccine) (Chickenpox Vaccine) Primary infection: varicella Primary infection: varicella

Can develop in an estimated 95% of adults Can develop in an estimated 95% of adults in temperate climates by the age of 25 in temperate climates by the age of 25 yearsyears

is associated with complications in healthy is associated with complications in healthy children as well as high-risk groups, e.g. children as well as high-risk groups, e.g. immunocompromised patientsimmunocompromised patients

is the leading cause of vaccine-is the leading cause of vaccine-preventable deaths in children in the USApreventable deaths in children in the USA

Chicken Pox EncephalitisChicken Pox Encephalitis

Congenital varicella syndromeCongenital varicella syndromePrimary infection: varicella

Clinical presentation of herpes Clinical presentation of herpes zosterzoster

Reactivation: herpes zoster

Measles-Mumps-Rubella:Measles-Mumps-Rubella: what is the best choice for three in one?what is the best choice for three in one?

MMRMMRPRIORIXPRIORIX

Measles –complicationsMeasles –complications

Otitis media: 1/10 childrenOtitis media: 1/10 children

Pneumonia: 1/20 childrenPneumonia: 1/20 children

Encephalitis: 1/1000 childrenEncephalitis: 1/1000 children

Sub-acute sclerosingSub-acute sclerosingpanencephalitis (SSPE):panencephalitis (SSPE):1/100,000 children1/100,000 children

Other complications: Other complications: blindness, miscarriages, blindness, miscarriages, premature births and premature births and congenital malformationscongenital malformations

Encephalitis

Pneumonia

Mumps – complicationsMumps – complications

Meningo-encephalitis:Meningo-encephalitis:5–15%5–15%

Deafness: 0.5–5/100,000Deafness: 0.5–5/100,000

Orchitis: 30–40% of adult Orchitis: 30–40% of adult menmen

Mastitis: approx. 30% of Mastitis: approx. 30% of women after pubertywomen after puberty

Oophoritis, miscarriage, Oophoritis, miscarriage, pancreatitispancreatitis

Encephalitis

Congenital rubella syndrome (CRS) – Congenital rubella syndrome (CRS) – clinical features and complicationsclinical features and complications

• Rubella during pregnancy: Rubella during pregnancy: up to 80% chance of baby up to 80% chance of baby born with CRSborn with CRS

• Growth retardation, eye Growth retardation, eye problems, deafness, heart problems, deafness, heart defects, mental retardationdefects, mental retardation

• Many other organs and body Many other organs and body systems can be affectedsystems can be affected

• Onset of signs, symptoms Onset of signs, symptoms and abnormalities may be and abnormalities may be delayeddelayed

Thrombocytopenia in a baby born with CRS

Meningococcal Vaccines:Meningococcal Vaccines:

• Meningococcal polysaccharide Meningococcal polysaccharide vaccine A/C/Y/W-135vaccine A/C/Y/W-135

• Recommended to children older than Recommended to children older than 2 years AND at risk (terminal 2 years AND at risk (terminal complement component deficiency, complement component deficiency, asplenia, military recruits ,traveling asplenia, military recruits ,traveling

• Meningococcal conjugate vaccine A/C Meningococcal conjugate vaccine A/C used in Europe for infantsused in Europe for infants

• Minor side effectsMinor side effects

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34 million children arenot fully immunized

2.3 million still die each year

Diseases reappear when coverage drops

Opportunities: Best way of escaping from a problem is to solve

it Vaccines are safe Immunization is among

the 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.

Immunization can save money

Immunization is one of the most cost-effective health interventions.

Investing in vaccines SAVES more money than it costs.

Immunization saves lives

Immunization saves the lives of approximately 3 million people each year, all over the world.

Immunization

Challenges ???

EPI : Current Status in Pakistan Started in 1978 Promising start Coverage Rates in 80s reached >80% Fully immunized rates now only 47% Wide spread provincial differences in coverage:

Punjab 53%, KPK 47%, Sindh37%,Balochistan 35%.

Campaign districts in 2009 reported coverage of BCG 93%, Polio 86%, Penta 86%, Measles 85% and TT 55% and over all coverage of 86%.

UNICEF state of the world children reports 80-85%

Challenges to EPI Poor routine coverage Poliomyelitis eradication still serious issue Outreach capacity of vaccinators Service structure of EPI staff Attitude of doctors in health facilities Private sector involvement Political interference in management of EPI staff;

absenteeism Maintenance of vaccine stock and quality “ he

who should do good to another must do it in the Minute Particulars. William Black”

Challenges to EPI Maintenance of cold chain ( A desk is dangerous place from where to view the world)

Lack of accountability

Monitoring , evaluation and information management (Not every thing that counts can be counted and not everything that can be counted, counts. A . Einestein).

Poor disease surveillance “ All interest in disease and death is only another expression of interest in life”.

Demand creation, behavior change “ Knowing is not enough we must apply, willing is not enough we must do. Goethe’

Lack of political will ,commitment and proper planning

“We tackle 20 year problems with 5 year plans, staffed by two year personnel working with one year appropriation. It is simply not good enough”

Questions to be answered Why we are not able to eliminate poliomyelitis in spite of so

many rounds? Inject able polio vaccine versus oral vaccine. Alternative to BCG; when will be more effective vaccine

available? Should we start Hepatitis B vaccine at birth now? Why Pertusis resurgence? A cellular Pertusis versus whole cell Pertusis!! Booster of penta !! Which should be ninth vaccine of EPI: Pneumococcal,

Typhoid, Hepatitis A, MMR ,Chicken Pox??? Measles at months ? Why are our newborns still dying in tetanus?

References and more reading UNICEF state of the world’s children 2011 Immunization essentials. A practical field guide US AID

2003 ,2010 Immunization Basics:

www.immunizationbasics.jsi.com.resources.general.htm www.who.int/pmnch/topics www.who.int/vaccine_research www.path.org/vaccineresources www.cdc.gov/vaccines/ www.vaccines.org www.niaid.nih.gov www.immunizationinfo.org/vaccines/hepatitis B

Thank you once again

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