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FREQUENTLY ASKED QUESTIONS AND RECENT ADVANCEMENTS ON CHILDHOOD IMMUNIZATION

Dr Manish Chandra Prabhakar MGIMS Sewagram

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INTRODUCTION

Immunization Play An Important Role In Control Of Infectious Diseases .

It Is One Of The Most Cost Effective Health Intervention Known To Mankind.

One- Quarter Of The World’s Children Still Un -Immunized .

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• Nearly 2 Million children Die Every Year .

•It Is Essential To Update The Information, Knowledge And Practices In The Field Of Immunization. (state of the world’vaccine and immunization,2003)

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What Are The Current Guidelines For treatment of B.C.G Lymphadenitis ?

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• For Non Suppurative - No Medical T/t Is Warranted.

•For Suppurative - Needle Aspiration Or Surgical Aspiration Is Recommended.

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Can DPT Be Given To A Child With HIE at Birth With No History Of Seizures ?

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•In Mild & Mod. HIE, Neurological Status Is Either Non Progressive Or Actually Improving So -No C/i For Giving DPT In Such Children.

•In Severe HIE - Severe Sequelae, If The General Condition Permits DPT Can Be Given Without Detriment.

•If Suspicion Of Neurological Illness/ Deficit, Age Of 1st Dose May Be Delayed.

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A Child of Convulsive Disorder Is on Regular Doses of Anticonvulsant .Can This Child Be Given

DPT,or Should DT Be Given in Such a Case ?

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YES ,DPT Can Be Given to This Child If Convulsions Are Well Controlled .The Child Should Receive Antipyretics at

the Time of Injection .DT is to Be Given If Seizures Are Not controlled .

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Can Children Of Cerebral Palsy Be Given DPT Injection ?

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Yes,DPT Can be given as Cerebral Palsy Is a

non Progressive Disorder of Motor Function.

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Why IAP Recommends Measles At 9 Mo Of Age? While In Our Day To Day Practice We See So Many Cases Of Measles B/w The Age Group Of 6-9 Mo ,How Can We Protect Them From Measles ?

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•Measles Vaccination At 6 Mo. Of Age Holds Good Only In Epidemics .

•If Routine Immu.Started At 6 Mo ,Will Yield Only 65 % -80% Seroconversion And At 9 Mo Plus, Seroconversion Is 95%-98%. •To Establish Effective Control Of Infection & Eradication ,100% Measles Vaccination At 9 Mo. Plus Is Mandatory.

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What Are The Methods To Be Adopted In Measles Epidemic As Measles Vaccine Alone Will Produce Immunity 11-12 Days After Vaccination ?

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•Strict Isolation Is Mandatory to Protect the Contacts of an Index Case.

•For Additional Security Specific Measles Immunoglobulin Can be Administered.

•Current Evidence-- Administration Of Measles/ MMR Vaccine Within 48 to 72 Hours Provide Good Protection.

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Is The 2nd Dose Of MMR Vaccine Mandatory At Puberty ?

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•No, •effi. of single dose of mumps vaccine-95%&chances of vaccine failure is low but out breaks can occurred in immunized children. 2nd dose desirable only for individual protection.

Even 1 dose of its quite negligible in our country,hens 2nd dose can not be reco.for mass use.

•RA27/3 strain of rubella-efficacy90%,2nd doesn't require.

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What Are The Measures To Be Taken To Prevent The Risk Of Close Contact Of A Vaccine Developing Paralytic Polio-myelitis ?

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•Adults who Are At An Increased Risk Of Wild Type Of Polio Virus & who Previously Completed Primary Immunization With OPV or IPV Vaccine Should Receive Single Dose Of IPV Vaccine.

•Household Contacts Of Persons With Immunodefi. ,Altered Immune States, Immunosupp. d/t Drugs or Known HIV Infection Also Receive IPV.

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Should The Efficacy of OPV Be Evaluated To Ascertain How

Effective It Is ?

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•The Proven Efficacy Of 3 Doses Of OPV Is 70%, Of 5 Doses 90% & Of 10 Doses 99% In India , So New Study To Measure Efficacy Is Not Necessary.

•It Would Be A Wastage Of Time,money And Efforts.

NO,

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How Many VAPP Cases Is too Many to Merit Concern Or

Intervention ?

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•Even One Case Of VAPP Must Merit Our Concern And Preventive Measure.

•WHO Recommended That Any Country Using OPV Must Establish Surveillance For VAPP.

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Should The Parents Be told the truth If A Child Happens To Develop VAPP ?

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Its the Ethical Duty of Pediatrician to Inform the Parents If a Child Develops VAPP , However Without Firm Evidence We Should Not Speak About It.

YES

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Can Rat Bite Transmit Rabies ?

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• CDC, Atlanta Have Not Reported Any Case Of Rabies After Rat Bite In USA Therefore CDC,dose Not Recommend Routine Immunization Against Rabies After A Rat Bite.

•WHO And APCRI Do Not Recommend Post Exposure Prophylaxis For Rat Bite.

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Do Cats Transmits Rabies ?

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•Yes, Cats Are Second Commonest Species That Transmit Rabies In Our Country.

•In All Cases Of Cat Bites The Circumstances Should Be Examined In Depth .

•Washing Of The Wound And The Dosage Of Rabies Vaccine Are To Be Followed Just As In Case Of Dog Bite .

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What Interventions Need To Be Taken if a Child Is Bitten By An Un Immunized Dog Who Is Not Likely To Be Available For Observation ?

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•Local Wound Care .

•Avoidance Of Suturing.

•Admin. of TT IM ,If Indicated.

•Initiation Of Proper Antirabies vaccination.

•Prophylaxis Regime .

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Intradermal Immunization Against Rabies Requires Only A Fraction Of I.M. Dose ,Can This Method Be Adopted For Post- Exp. Prophylaxis In Order To Reduce The Cost ?

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•This Method Cannot Be Recommended For General Use As Exact I D Placement Of Vaccine Is Not Guaranteed When

Persons Inject.

•The Volume Of Vaccine Is Either 0.1 Or 0.2ml ,Some Leakage Or Loss In Dead Space Of Needle And Syringe May Reduce Actual Volume Injected .

•If Treatment Failure Occurs The Physician Could Be Accused Of Non Practice .

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Are The Consideration For Mass Use Of Hepatitis A Vaccine Justified ?

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•NO,Considering the Mild Symptomatic Nature of the Ds. Where Majority of Population Have Become Immune, Undertaking Large Scale Immunization Efforts Are Not Justified.

• Mass Hepatitis Vaccination Is Not at All Warranted in India •Better Approach to Control the Disease - Improve Sanitation & Living Condition .

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To Whom Should We Recommend Varicella Vaccine ?

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•Its Not Routinely Recommended for Universal Immunization for Children but May Be Offer to Susceptible Children on an Individual Basis.

•the Susceptible Group Includes Immunocop. Children With Chronic Cardiac & Pulmonary Ds and With Asymp or Mildly Symp. HIV Infection.

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DoesVaricella Occur InVaccinated Children ?

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•Its A Very Effective Vaccine ,95% Effective Against Typical Varicella & Is Upto 90 % Effective In Preventing All Ds.

•In Children & Adolescents It Reduces Severity & No. Of Skin Lesions .

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What Precautions Need To Be Observed And Considered For Immunization In Children Who Are Receiving Steroid Therapy ?

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•A Dose > 2mg/kg of Prednisolone or Its Equivalent or a total of 20 mg/d of prednisolone for

•More Than 15 Days - Should Not Receive Live Virus Vaccine .

•Until Its Has Been Discontinued for At least 1 Month

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How To Immunize Thalassemic Child Who Is Given Regular Blood Transfusion ?

Can Blood Transfusion Affect His Seroconversion ?

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•Routine Immunization Schedule Can Be Followed After Blood Transfusion.

•Blood Transfusion Doesnot Affect Seroconversion .

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As Per WHO ,Diluents Are Vaccine Specific , Can We Use Distilled Water In Case Of Accidental Breakage Of Diluent Ampoule ?

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•Diluents Are Not Only Vaccine Specific but of Exact Quantity Also Vig 0.5 Ml.

•Distilled Water Is an Irritant to Skin , Should Be Avoided.

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Should Typhoid Vaccine Be Given To Children Who Have Already Suffered From Typhoid Fever?

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•Immunity Following Natural Infection Develops But Not In All Cases.

•Use Of Antibiotics May Also Inhibit The Development Of Immune Response.

•So typhoid Vaccine Should Be Given But Only After 2-3 Months .

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Currently 3 Types Of Vaccines Are Available -

•W C Inactivated Ty Vaccine -Efficacy 50-70%.

•Vi-cap. Polysaccharide Vaccine-efficacy50-60%.

•Oral Live Attenuated Ty 21a Vaccine-50-60%.

•Currently The Vi-cap Pol.Vaccine Is Available In India .IAP COI Strongly Recommend Its Use for All Children.

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Is There Any Need To Offer JE Vaccination To All Children ?

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No , Only Those Children Residing In Rural Areas Where Disease Occurs In Epidemic Or Endemic Forms. Other Indication In Agricultural &Animal Husbandry Workers.

•Currently Sa-14-14-2live JE Vaccine,imported From China is Used In A Mass Compaign Mode to Children Age 1-15yr.

•Efficacy Reaching 99% even With Single dose.

.

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What is the Current Status of Cholera Vaccine ?

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•Whole cell killed vaccine -not indicated any more by WHO b/o its poor efficacy &high reactogenicity.

•WC/Rbs vaccine,a heat or formalin killed vaccine,given in 2 doses,1-2 week apart.efficacy 85% for 6mo.50% for 3 yr..WHO recommend it for refugees in camps.

•CDV103-Hgr-LA oral cholera vaccine.Efficacy is low .but confer protection with in 7days.

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What Is The Current Status Of Rota Virus Vaccine ?

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Aim Of Rota Virus Vaccine Is To Prevent The Severity Of Disease.Following Vaccines Are In Pipeline &Hope Fully Hit The Market Soon -

•LLR Vaccine From China -In Phase 2& 3of Trial.•WL-3 Vaccine From Merk -In Phase 2&3 Trial.•RV -5 .&89-12vaccine From GSK.

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•In USA It’s the Pentavalent Live Vaccine Having Efficacy Of 63-88%.It can be administered along with other vaccines. • Recommended orally At 2,4&6mo Of Age .

•It Can Be Administered To Infants With Transient Mild Illness,w/wo Low Grade Fever.

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Do We Need Routine Influenza Vaccine In India ?

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•The Exact Epidemiology Of Disease In Our Country Is Not Known .

•d/t The Less Specified Seasonality, The Proper timing Of Administering`flu Shots`not Precisely Known.•Before Making Official Recommen.,encourage the Virological & Serological Surveillance In Different Parts Of Country To Identify Virus Strains For Inclusion Of Vaccine.

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Would Hepta- Valent Conjugate Pneumococcal Vaccine Effective in India ?

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7 Serotypes(-4,6b,9v,14,18c,19f,,23f) Included in Hepta- Valent Conjugate Pneumococcal Vaccine Are Responsible for Only 51% of Invasive Serotypes Prevalent in India .

In India Type 1&5account for 29%&type 6 for 11.5% of Invasive Disease. PCV-7 Dose Not Cover Type 1&2.

Hens ,There Is Of limited Utility in India .

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What Are The Newer Technologies For Vaccine Delivery ?

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•Transcutaneous Immunization - Antigen & Adjuvents Are Applied Topically to Induce Potent Ab & CMI Responses Specific to Both Antigen & Adjuvants.

•Some of Promises of Combining TI With Experimental Vaccines for Malaria&dengue Fever.

•Advantage - Needle Free Delivery With Targeting of Immunologically Rich Milieu of Skin.

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Bacterial Ghosts -• Its A Novel Vaccine Delivery System.

•These Are Non Living Bacterial Cells Devoid Of Cytoplasmic Contents While Maintaining Their Cellular Morphology And Native Surface Antigenic Structure & Bioadhesive Properties.

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•Edible Vaccines -• Prepared By Introducing Selective Genes Into Plants & Inducing The Transgenic Plant To Express The Encoded Protein By A Process Called Molecular Farming .E.g. Bananas, Potatoes, Tomatoes e.t.c. •Edible Vaccines Are In Pipeline Against Norwalk Virus, E.Coli e.t.c.

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What are the newer modalities for vaccine administration?

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•Auto Disable Syringes-Presents the lowest Risk of Person to Person Transmission of Blood Borne Pathogens as it can not be reused.

•Monodose Prefilled Injection Devices- A new plastic Pouch &needle device(Uniject).Mono Dose Preparation Eliminate Risk of Cross Contamination &Reduce Wastage of Vaccine.

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•Needle Free Injections-jet a Mean of Administering Vaccine in to or through the skin With Out Use of Needle.

•Vaccine Particles Penetrate the Skin &Be Deposited Subcut.Or in to Epidermis by a Compressor System.

•Two Types -1.Multidose Jet Injector for mass Immunization. 2.Monojet Injector for Routine Immunization. .

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What is the status of vaccines against diseases such as

malaria, HIV and other pediatric infectious diseases?

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•Mosquerix-a New Vaccine Against Malaria, Developed by GSK.It Is in Phase 3rd Trials.Useful in 70% Red. In Mortality D/t P.falciparum.•Vaccine Against HIV-

recomb.Surface Glyco-protein Antigen Induces Strong Ab. Immune Response ,It Can Be Used As Therapeutic Vaccines Rather Than the Primary Preventive Vaccine.

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Dengue vaccines-• Live Attenuated Vaccines ,Cell Cultured, Site Directed Mutagenesis, or Genetically Engineered Chimeras of the Non- Structural Genome Region of Yellow Fever or Dengue and the Dengue Envelope Vaccine. •A Recombinant Envelope Proteins Subunit Vaccine . Dengue Vaccines Are Now Entering Into Expanded Phase 2 Clinical Trials and Efficacy and Safety Data From Large-scale Clinical Trials Will Become Available Over Next 3-5 Years.

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1.IAP Guide Book on immunization2005-2006.2.Prevention of influenza: recommendations for influenza immunization of children,2006-2007.Pediatrics APR 2007;119, 846-851.3.Childhood immunization,issues & options, by Naveen Thacker 2005.

References:

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5.Indian pediatrics

Jun2005;42,572.

6.Indian pediatrics Dec

1995;32 ,1331.

7indian pediatrics

May2007;44,391-392.

8.Indian pediatrics

feb1996;33,163.

4.Prevention of Rota virus disease:guidelines for use of rotavirus vaccine.pediatrics JAN 2007 ;119 ,171-181.

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9.Immunization in practice. by. S. K. Mittal &S.Kukreja2004 .

10.Infectious disease in children and newer vaccine(vol.. 2)2007

JAYPEE318-319.

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THANK YOU