Immunizations JFK pediatric core curriculum MGH Center for Global Health Pediatric Global Health Leadership Fellowship Credits: Brett Nelson, MD, MPH

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

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

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

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

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, ….

34 million children are not fully immunized

2.3 million still die each year

Diseases reappear when coverage drops

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

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

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

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 Administer these vaccines via intramuscular (IM) route: Diphtheria-tetanus (DT, Td) with pertussis (DTaP, Tdap); Hib; hepatitis A; hepatitis B; human papillomavirus (HPV); inactivated influenza; meningococcal conjugate (MCV4); and pneumococcal conjugate (PCV). Administer inactivated polio (IPV) and pneumococcal polysaccharide (PPV) either IM or SC.

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

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 Measles vaccine is a live-attenuated vaccine but IS recommended in HIV-positive children. Another source: http://www.health.gov.mt/immunisation/Generalconsiderations.html#HIV IMMUNISATION OF HIV POSITIVE INDIVIDUALS HIV positive individuals with or without symptoms can receive the following as appropriate:- Live vaccines: measles, mumps, rubella, polio (inactivated polio vaccine (IPV) may be used instead of OPV, under the supervision of the clinician). Inactivated vaccines: whooping cough, diphtheria, tetanus, polio, typhoid, cholera, hepatitis B, HIB. BCG vaccination is contraindicated as there have been reports of dissemination of BCG in HIV positive individuals. Yellow fever vaccine should not be given to either symptomatic or asymptomatic HIV-positive individuals since there is as yet insufficient evidence as to its safety. Travellers should be told of this uncertainty and advised not to be immunised unless there are compelling reasons. If such travellers still intend to visit countries where a yellow fever certificate is required for entry, then they should obtain a letter of exemption. Vaccine efficacy may be reduced in HIV-positive individuals. Consideration should be given to the use of normal immunoglobulin for HIV-positive individuals after exposure to measles. Asymptomatic HIV-positive individuals do not require Varicella-Zoster Immunoglobulin (VZIG) after contact with chicken pox since there is no evidence of increased risk of serious illness in these individuals. However HIV-positive individuals with symptoms should be given VZIG after contact with chickenpox unless they are known to have V-Z antibodies.

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

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

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

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

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“)

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)

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

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:

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