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Vaccine 2Vaccine 2

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PoliomyelitisFirst described by Michael Underwood in 1789First outbreak described in U.S. in 184321,000 paralytic cases reported in the U. S. in 1952Global eradication in near future

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PoliovirusEnterovirus (RNA)Three serotypes: 1, 2, 3Minimal heterotypic immunity between serotypesRapidly inactivated by heat, formaldehyde, chlorine, ultraviolet light

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Poliomyelitis PathogenesisEntry into mouth

Replication in pharynx, GI tract, local lymphaticsHematologic spread to lymphatics and central nervous systemViral spread along nerve fibersDestruction of motor neurons

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0 20 40 60 80 100

Percent

Asymptomatic Minor non-CNS illness

Aseptic menigitis Paralytic

Outcomes of poliovirus infection

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Poliovirus EpidemiologyReservoir Human

Transmission Fecal-oral Oral-oral possible

Communicability 7-10 days before onset Virus present in

stool 3-6 weeks

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Poliovirus Vaccine1955 Inactivated vaccine

1961 Types 1 and 2 monovalent OPV

1962 Type 3 monovalent OPV

1963 Trivalent OPV

1987 Enhanced-potency IPV (IPV)

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Inactivated Polio VaccineContains 3 serotypes of vaccine virusGrown on monkey kidney (Vero) cellsInactivated with formaldehydeContains 2-phenoxyethanol, neomycin, streptomycin, polymyxin B

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Oral Polio VaccineContains 3 serotypes of vaccine virusGrown on monkey kidney (Vero) cellsContains neomycin and streptomycinShed in stool for up to 6 weeks following vaccination

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Inactivated Polio Vaccine

Highly effective in producing immunity to poliovirus>90% immune after 2 doses>99% immune after 3 dosesDuration of immunity not known with certainty

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Oral Polio VaccineHighly effective in producing immunity to poliovirus50% immune after 1 dose>95% immune after 3 dosesImmunity probably lifelong

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Polio Vaccination Recommendations, 1996-

1999

Increased use of IPV (sequential IPV- OPV schedule) recommended in 1996Intended to reduce the risk of vaccine- associated paralytic polio (VAPP)Continued risk of VAPP for contacts of OPV recipients

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Polio Vaccination Recommendations

Exclusive use of IPV recommended in 2000OPV no longer routinely available in the United StatesVAPP eliminated

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Polio Vaccination Schedule

VaccineOPVOPVOPVOPVOPV

Age2 months3 months4 months16months

6 years

MinimumInterval

---4 wks4 wks

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Polio Vaccination Schedule

VaccineIPVIPVIPVIPV

Age2 months4 months

6-18 months4-6 years

MinimumInterval

---4 wks4 wks4 wks

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Schedules that Include Both IPV and OPV

Only IPV is available in the United StatesSchedule begun with OPV should be completed with IPVAny combination of 4 doses of IPV and OPV by 5 years constitutes a complete series

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Polio Vaccination of Adults

Routine vaccination of U.S. residents >18 years of age not necessary or recommendedMay consider vaccination of travelers to polio-endemic countries and selected laboratory workers

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Polio Vaccination of Unvaccinated Adults

IPVUse standard IPV schedule if possible (0, 1-2 months, 6-12 months)May separate doses by 4 weeks if accelerated schedule needed

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Polio Vaccination of Previously Vaccinated Adults

Previously complete seriesadminister one dose of IPV

Incomplete seriesadminister remaining doses in series

no need to restart series

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Polio Vaccine Adverse Reactions

Rare local reactions (IPV)No serious reactions to IPV have been documentedParalytic poliomyelitis (OPV)

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Vaccine-Associated Paralytic Polio

Increased risk in persons >18 yearsIncreased risk in persons with immunodeficiencyNo procedure available for identifying persons at risk of paralytic disease5-10 cases per year with exclusive use of OPVMost cases in healthy children and their household contacts

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Vaccine-Associated Paralytic Polio (VAPP)

1980-1998Healthy recipients of OPV 41%Healthy contacts of OPV recipients 31%Community acquired 5%Immunodeficient 24%

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Polio VaccineContraindications and Precautions

Severe allergic reaction to a vaccine component or following a prior dose of vaccineModerate or severe acute illness

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Polio Eradication

Western Hemisphere certified polio free in 1994Last isolate of type 2 poliovirus in India in October 1999Global eradication goal by 2010

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At the start of 2010, 9 countries in west and central Africa are considered to have active outbreaks of polio (i.e. cases within the last six months): Burkina Faso, Chad, Guinea, Liberia, Mali, Mauritania, Nigeria, Senegal and Sierra Leone.

October 04, 2011Cases of polio have been reported in China, the country’s first

cases in more than 10 years. All cases were reported in Xinjiang Uygur autonomous region. Genetic sequencing has shown that the poliovirus isolated from these cases most closely resembles wild poliovirus type 1 found in Pakistan during the second half of 2010.

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Distribution of laboratory-confirmed wild poliovirus type 1 cases (N = 476) European Region, 2010 (458 in Tajikistan, 14 in Russia, three in Turkmenistan, and one in Kazakhstan)

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RubellaFrom Latin meaning "little red"

Discovered in 18th century - thought to be variant of measles

First described as distinct clinical entity in German literature

Congenital rubella syndrome described by Gregg in 1941

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Rubella VirusTogavirus

RNA virus

One antigenic type

Rapidly inactivated by chemical agents, low pH, heat and ultraviolet light

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Rubella PathogenesisRespiratory transmission of virus

Replication in nasopharynx and regional lymph nodes

Viremia 5-7 days after exposure with spread to tissues

Placenta and fetus infected during viremia

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Rubella Clinical FeaturesIncubation period 14 days (range 12-23 days)

Prodrome of low grade fever

Lymphadenopathy in second week

Maculopapular rash 14-17 days after exposure

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Rubella Complications

Arthralgia or arthritischildrenadult female

Thrombocytopenic purpuraEncephalitisNeuritisOrchitis

rareup to 70%

1/3000 cases

1/6,000 casesrarerare

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Congenital Rubella SyndromeInfection may affect all organs

May lead to fetal death or premature delivery

Severity of damage to fetus depends on gestational age

Up to 85% of infants affected if infected during first trimester

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Congenital Rubella Syndrome

DeafnessCataractsHeart defectsMicrocephalyMental retardationBone alterationsLiver and spleen damage

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Rubella Laboratory DiagnosisIsolation of rubella virus from clinical specimen (e.g., nasopharynx, urine)

Significant rise in rubella IgG by any standard serologic assay (e.g., enzyme immunoassay)

Positive serologic test for rubella IgM antibody

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Rubella EpidemiologyReservoir Human

Transmission RespiratorySubclinical cases may transmit

Temporal pattern Peak in late winter and spring

Communicability 7 days before to 5-7 daysafter rash onsetInfants with CRS may shedvirus for a year or more

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Measles

Highly contagious viral illnessFirst described in 7th centuryNear universal infection of childhood in prevaccination eraFrequent and often fatal in developing areas

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Measles Virus

Paramyxovirus (RNA)Hemagglutinin important surface antigenOne antigenic typeRapidly inactivated by heat and light

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Measles Pathogenesis

Respiratory transmission of virusReplication in nasopharynx and regional lymph nodesPrimary viremia 2-3 days after exposureSecondary viremia 5-7 days after exposure with spread to tissues

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Measles Clinical Features

Incubation period 10-12 days

Stepwise increase in fever to 103°F or higherCough, coryza, conjunctivitisKoplik spots

Prodrome

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Measles Clinical Features

2-4 days after prodrome, 14 days after exposureMaculopapular, becomes confluentBegins on face and headPersists 5-6 daysFades in order of appearance

Rash

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ConditionDiarrheaOtitis mediaPneumoniaEncephalitisHospitalizationDeath

Percent reported876

0.1180.2

Measles Complications

Based on 1985-1992 surveillance data

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Measles Laboratory Diagnosis

Isolation of measles virus from a clinical specimen (e.g., nasopharynx, urine)Significant rise in measles IgG by any standard serologic assay (e.g., EIA, HA)Positive serologic test for measles IgM antibody

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Measles EpidemiologyReservoir Human

Transmission Respiratory Airborne

Temporal pattern Peak in late winter–spring

Communicability 4 days before to 4 days after rash onset

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MumpsAcute viral illnessParotitis and orchitis described by Hippocrates in 5th century BCEViral etiology described by Johnson and Goodpasture in 1934Frequent cause of outbreaks among military personnel in prevaccine era

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Mumps Virus

ParamyxovirusRNA virusOne antigenic typeRapidly inactivated by chemical agents, heat and ultraviolet light

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Mumps Pathogenesis

Respiratory transmission of virusReplication in nasopharynx and regional lymph nodesViremia 12-25 days after exposure with spread to tissuesMultiple tissues infected during viremia

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Mumps Clinical FeaturesIncubation period 14-18 daysNonspecific prodrome of low-grade fever, headache, malaise, myalgiaParotitis in 30%-40%Up to 20% of infections asymptomaticMay present as lower respiratory illness, particularly in preschool-aged children

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CNS involvement

Orchitis

Pancreatitis

Deafness

Death

15% of clinical cases

20%-50% in post- pubertal males

2%-5%

1/20,000

1-3/10,000

Mumps Complications

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Mumps Laboratory Diagnosis

Isolation of mumps virusSerologic testing

positive IgM antibodysignificant increase in IgG antibody between acute and convalescent specimens

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Mumps EpidemiologyReservoir Human

Transmission Respiratory drop nuclei Subclinical infections may transmit

Temporal pattern Peak in late winter–spring

Communicability Three days before to four days after onset of active

disease

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Measles Mumps Rubella Vaccine

12 months is the recommended and minimum ageMMR given before 12 months should not be counted as a valid doseRevaccinate at >12 months of age

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MMR IndicationsAll infants >12 months of age

Susceptible adolescents and adults without documented evidence of rubella immunity

Emphasis on non-pregnant women of childbearing age, particularly those born outside the U.S.

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Second Dose Recommendation

First dose of MMR at 12-15 monthsSecond dose of MMR at 4-6 yearsSecond dose may be given any time >4 weeks after the first dose

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MMR Adverse Reactions

Fever 5%-15%

Rash 5%

Joint symptoms 25%

Thrombocytopenia <1/30,000 doses

Parotitis rare

Deafness rare

Encephalopathy <1/1,000,000 doses

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Severe allergic reaction to vaccine component or following prior dose

Pregnancy

Immunosuppression

Moderate or severe acute illness

Recent blood product

MMR VaccineContraindications and

Precautions

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MMR Vaccine and Autism “The evidence favors a rejection of a

causal relationship at the population level between MMR vaccine and autism spectrum disorders (ASD).”

- Institute of Medicine, April 2001

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Measles and Mumps Vaccines and Egg Allergy

Measles and mumps viruses grown in chick embryo fibroblast cultureStudies have demonstrated safety of MMR in egg allergic childrenVaccinate without testing

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Measles Vaccine and HIV Infection

MMR recommended for persons with asymptomatic and mildly symptomatic HIV infectionNOT recommended for those with evidence of severe immuno- suppressionPrevaccination HIV testing not recommended

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PPD and Measles Vaccine

Apply PPD at same visit as MMRDelay PPD >4 weeks if MMR given firstApply PPD first—give MMR when skin test read