IMMUNIZATION (1) “ Discuss the population health benefits of immunization programs ” Probability of contracting communicable disease depends on probability that contacts are already immune, are carriers or have the disease If sufficient proportion of population is immune, then disease will not spread (herd immunity) Prevention is usually cheaper and more effective than treatment (if treatment even exists) Possibility of eradicating some diseases Implications for school attendance (Ontario) –Mandatory choice vs. mandatory immunization –Exclusion from school for non-immunized children during outbreak 03/2012

Standard immunizations Age 0-17 Diphtheria Tetanus Pertussis Polio H. influenzae B Mumps Measles Rubella Hepatitis B Chickenpox (varicella) Pneumococcus Meningococcus Influenza HPV Taken from: Canadian Immunization Guide, 2010

03/2012 Need to add HPV: Females age 9-13, 3 doses

03/2012 Pneumococcal vaccines (1) 1,200 cases in Ontario, 2009; pneumonia and meningitis; 4% case fatality rate Prevnar valent pneumococcal conjugate vaccine to protect under age 6 years Replaced Prevnar (7 valent) due to emergence of 3, 7F and 19A as frequently reported serotypes 19A is becoming resistant to first line antibiotics Conjugated with diphtheria toxoid but does not protect against diphtheria –Introduced fall 2010 –Routine doses at 2, 4, 12 months of age 4 doses at 2, 4, 6 and 15 months if chronic disease –At 12 months, child receives Prevnar 13, Meningococcal C conjugate and MMR vaccines

03/2012 Pneumococcal vaccines (2) Pneumococcal polysaccharide 23 valent vaccine –Anyone age 2 or older with chronic conditions moderate-severe respiratory, cardiac, cirrhosis, renal, diabetes, asplenia, sickle-cell, CSF leak, immune deficiency, cochlear implant recipients U.S. adding any asthma and cigarette smoking Booster dose 3-5 years later –Age 65 years or older—everyone –Residents of nursing homes and chronic care facilities—everyone –50-80% effectiveness among the immunocompetent

03/2012 Meningococcal vaccines Meningococcal C Conjugate Vaccine Give one dose at 12 months May be offered in Grade 7 or age for those unimmunized Meningococcal ACYW-134 Quadrivalent Conjugate Vaccine 2-55 years asplenic, complement, properdin or factor D deficiency, or cochlear implant recipient Meningococcal ACYW-135 Quadrivalent Polysaccharide Vaccine Over 55 years for same indications as (2)

03/2012 Human Papilloma Vaccine (HPV) (1) Garadsil –Protects against 4 strains of HPV Types 16 and 18 (linked to 70% of cervical cancer and 80% of anal cancer) Types 6 and 11 (linked to 90% of anogenital warts) –Females age 9-45 Cervical, vulvar and vaginal cancer and precursor lesions Cervical adenocarcinoma in situ Genital warts –Males age 9-26 Anogenital warts and general HPV infection –Males and females age 9-26 Anal cancer and anal intraepithelial neoplasia

03/2012 Human Papilloma Vaccine (HPV) (2) Ceravix –Protects against 2 strains of HPV Types 16 and 18 (linked to 70% of cervical cancer and 80% of anal cancer) –Females age CIN Type 1, 2 and 3 Cervical adenocarcinoma in situ If goal is to protect only against type 16/18, can use either vaccine

03/2012 Human Papilloma Vaccine (HPV) (3) Need three doses –Give at times 0, 2 and 6 months Best to give prior to sexual activity –40% of women become infected with HPV within 16 months after initiation of sexual activity Ontario –Provided free to grade 8 girls in school Can still be given once sexually active, with previous pap abnormalities have had a previous HPV infection Routine vaccination of boys would be useful

03/2012 IMMUNIZATION (2) “ State that a lapse in immunization schedule does not require re-instituting the initial series, merely giving it at the next visit ” You can give a dose too early; you cannot give a dose too late

03/2012 IMMUNIZATION (3) “ Communicate to patients and parents about vaccine benefits and risks ” Obtain an immunization history on all children Late immunization is still very effective Immigrants require special attention –Depends on availability of good records; countries have different immunization coverage –When in doubt, start the series again; –Canadian Immunization Guide gives more detailed information

03/2012 IMMUNIZATION (4) Travel –Update regular immunizations –High risk exposure consider additional immunizations BCG, cholera, hepatitis A, typhoid, rabies –Meningococcal quadrivalent vaccine meningitis belt and Hajj –Influenza if the right season –Follow legal requirements Yellow fever (strict) Cholera –some countries may require; –medical exemption letter can be provided

03/2012 IMMUNIZATION (5) “ List possible complications of immunization ” Seizures –secondary to fever –Introduction of acellular pertussis reduced febrile seizures dramatically and was much more protective Anaphylaxis –Need to differentiate from fainting Neurological damage –Often a major worry of parents –BUT: rarely associated –Casual rather than causal relationship no good evidence for MMR causing autism

03/2012 IMMUNIZATION (6) “ Discuss misconceptions about immunization contraindications ” Following are not contraindications: –Mild/moderate local reactions to previous dose –Mild acute illness with or without fever –Taking antibiotics –Allergy to penicillin, duck, molds, pollens –Positive Mantoux TB skin test –Breast feeding –Asplenia –Prior febrile seizure reaction (consider prophylactic acetaminophen)

03/2012 IMMUNIZATION (7) “ Discuss immunization of immuno-compromised children (e.g., asplenia, chronic diseases or seizures) ” Asplenia (surgical or congenital/functional) –No contraindication to any vaccine –Particularly need protection against encapsulated bacteria to which these individuals are highly susceptible. Streptococcus pneumoniae, Haemophilus influenzae B, Neisseria meningitidis (A,C,Y, W135), Immunosuppression –Avoid live vaccines –Follow regular immunization schedule –High dose steroids can mute immune response Congenital immunodeficiency –Read the Canadian Immunization Guide!