1. 03/2015 Back to Basics, 2015 POPULATION HEALTH : Immunization Dr. Nicholas Birkett School of Epidemiology, Public Health and Preventive Medicine 1

2. 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 03/20152

3. A ‘pep rally’ Shouldn’t need to pep you up about immunization Biggest health advance in the past 100 years Has eliminated smallpox and polio (almost) Public has forgotten what it was like in the 1950’s and before Your job is to convince people to get kids immunized. Something that I very rarely say: 03/20153 There is no debate on this point!

4. Some recent news stories Mumps in the NHL (2014-15) About 15 NHL hockey players have been diagnosed with mumps this year. –Missed time playing –Mumps can lead to sterility Immunization status unclear but some were immunized. Booster doses? 03/20154

5. Some recent news stories Measles cases at Disneyland and in Quebec and elsewhere (2015) and in Ontario and BC (2014) Over 100 cases linked to Disneyland –Fifth ‘Google hit’ was a site reporting on the ‘Fake Disney outbreak’ –Involved small groups of children –Mainly affected unimmunized children –Some evidence of immunization failure Despite the media reports, herd immunity is working –Does not prevent spread to individual people –Prevents growth of local outbreak into a widespread outbreak 03/20155

6. Some recent news stories Measles Measles is communicable 4 days BEFORE a child shows the illness –Easy to spread cases to non-immunized children –Easy to start an epidemic if immunization rates are low Measles is not a trivial disease –1-2 weeks of missed school –moderate discomfort –1 in 20 develop pneumonia –1 in 10 develop ear infections can lead to permanent hearing loss –1/1,000 develop encephalitis –1/1,000 will die –Can lead to miscarriage or premature birth in a pregnant woman. 03/20156

7. Some recent news stories Ottawa, 2014: Measles cases non-immunized children have been suspended from school for two weeks Students suspended over immunizations. Almost 1,000 of Ottawa’s high school students have been suspended for improperly-kept immunization records. –Sent home for 20 days for not having the records, not necessarily for not having their shots. 03/20157

8. Some recent news stories Dropping immunization rates Alberta's immunization rates are continuing to drop, worrying some doctors Anti-immunization message taught in introductory health class at Queen’s university Information based on fraudulent data from England –Designed to promote a new commercial product –‘scientist’ is in jail for fraud 03/20158

9. Some recent news stories Public skeptical of immunization Strong anti-immunization campaign on the Internet –Google immunization and a lot of anti-immunization sites come up 20% of the people believe that MMR causes autism. –20% more are ambivalent –Jenny McCarthy (TV ‘personality’) is pushing this view Ottawa daycare promises a ‘vaccine-free’ environment –implies that vaccination kids are harmful – huh? 40% agree that –the science on vaccinations isn’t quite clear. –Indicts our educational system as well as public health A bigger problem with people under age 30 03/20159

10. Some recent news stories Vaccine-related adverse event rates found to be low in Ontario... A recent Ontario report on vaccine safety shows the rate of adverse events reported after vaccinations in the province is low. 56 serious vaccine-related adverse events reported in 2012, in a year when 7.8 million vaccinations took place –Convulsions, seizures and anaphylaxis –No fatalities 03/201510

11. Side Effects of Vaccine (DTaP/IPV/Hib) DTaP/IPV/HIB vaccine –Serious adverse effects are rare –Most common adverse reactions redness, swelling, pain at injection site Fever and irritability are less common –Redness and swelling greater than 3.5 cm with minimal pain More common in children receiving fifth consecutive dose at 4 to 6 years of age Reported in 16% of children –Injection site reactions in 10% of older people receiving Td booster 03/201511

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13. 03/2015 Pertussis: Incidence trends 1924-2010 13

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15. Impact of drop in Vaccination rates In Japan, pertussis vaccine coverage dropped from 90% to less than 40% because of public concern over two infant deaths that followed DPT immunization. Prior to the drop in coverage there were 200 to 400 cases of pertussis each year in Japan. From 1976 to 1979, following the marked drop in vaccine coverage, there were 13,000 cases of pertussis, of which over 100 were fatal. 03/201515

16. Source of information Details about immunization is presented in the Canadian Immunization Guide Available on-line: http://www.phac-aspc.gc.ca/publicat/cig-gci/index-eng.php Minor updates since 2012 Provinces also publish immunization schedules 03/201516

17. 03/2015 Standard immunizations Age 0-17 Diphtheria Tetanus Pertussis Polio H. influenzae B Mumps Measles Rubella Hepatitis B Chickenpox (varicella) Pneumococcus Meningococcus Influenza HPV Rotavirus Taken from: Canadian Immunization Guide, 2014 17

18. 03/201518 C-13 * * Rotovirus at 2/4 months

19. AbbreviationTarget(s)Type DTaP-IPV (pediatric) Diphtheria Tetanus Acellular Pertussis Inactivated Polio Toxoid acellular Inactive, viral HibHaemophilus influenzae type bConjugate MMRMeasles Mumps Rubella live, attenuated VarVaricellalive, attenuated HBHepatitis Brecombinant Pneu-C-7 Pneu-C-13 PneumococcalConjugate Men-CMeningococcalConjugate Tdap (adult) -lower dose of diphtheria Tetanus Diphtheria Acellular Pertussis Toxoid acellular HPVHuman Papilloma virusrecombinant InfInfluenzainactivate OR live, attenuated 03/201519

20. 03/2015 Pneumococcal vaccines (1) 1,200 cases of pneumococcal pneumonia and meningitis in Ontario, 2009 –4% case fatality rate Prevnar 13 13 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 baby has a chronic disease –At 12 months, child receives Prevnar 13, Meningococcal C conjugate and MMR vaccines 20

21. 03/2015 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, asthma 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 21

22. 03/2015 Meningococcal vaccines Meningococcal C Conjugate Vaccine Give one dose at 12 months May be offered in Grade 7 or age 14-16 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) 22

23. 03/2015 Human Papilloma Vaccine (HPV) (1) Gardasil –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 23

24. 03/2015 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 10-25 CIN Type 1, 2 and 3 Cervical adenocarcinoma in situ If goal is to protect only against type 16/18, can use either vaccine 24

25. 03/2015 Human Papilloma Vaccine (HPV) (3) Need three doses –2 nd dose: 2 months after 1 st dose –3 rd dose: 6 months after 1 st dose 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 even if patient has had a previous HPV infection Routine vaccination of boys would be useful 25

26. 03/2015 Passive Immunization (1) Direct administration of Immunoglobins against specific organism –Human or animal origin for Ig’s –Human derived agents are preferred to reduce side effects (serum sickness) Use –Exposure to organism is prior to vaccination –People with compromised immune systems 26

27. 03/2015 Passive Immunization (2) Two ‘types’ available Standard human Ig –Immune Serum globulin/Gamma globulin –No specific target agent –Created from pooled human plasma –Mainly IgG –Has limited role Specific immune globulins 27

28. 03/2015 Passive Immunization (3) Use of ‘standard’ human Ig –Measles (give within 3-6 days post-exposure) –Hepatitis A –Rubella Supress symptoms Doesn’t prevent infection Don’t use in pregnant women Not the primary method to deal with these diseases May not be effective due to low Ig concentrations 28

29. 03/2015 Passive Immunization (4) Specific Immune Globulins –Botulism antitoxin (equine) –Botulism Ig (human) –Cytomegalovirus (human) –Diphtheria antitoxin (equine) –Hepatitis B Ig (human) –Rabies Ig (human) –Palivizumab for RSV (humanized monoclonal) –Tetanus Ig antitoxin (Human) –Vaccina Ig (human) –Varicella zoster Ig (Human) Not routinely available –require special orders –Check with Public Health Department (especially for Rabies) 29

30. Toxoid; active & passive agents (1) Tetanus is caused by a toxin secreted by the infectious organism (Clostridium tetani). –Immunizing agents are directed against the toxin –Active immunization is called a 'toxoid'. –Passive agents can target the toxin rather than the organism For tetanus (and hepatitis B) –Can administer the passive and active agents at the same time –Inactivated antigen in the toxoid does not react with the circulating antibody. 03/201530

31. Toxoid; active & passive agents (2) DO NOT administer a passive agent along with an active, live attenuated virus vaccine (e.g. MMR and measles passive immunization). –The antibody interacts with the attenuated organism and prevents it from dividing. –Blunts or eliminates the immune response. –Wait at least 3 months before giving the active agents in such a case. http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/ genrec.pdfhttp://www.cdc.gov/vaccines/pubs/pinkbook/downloads/ genrec.pdf 03/201531

32. 03/2015 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 32

33. 03/2015 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 33

34. 03/2015 IMMUNIZATION (4) Travel –Update regular immunizations –High risk exposure regions 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 –May be required for some countries –medical exemption letter can be provided 34

35. 03/2015 IMMUNIZATION (5) “ List possible complications of immunization ” Seizures –Secondary to fever –Introduction of acellular pertussis reduced febrile seizures dramatically and was more protective Anaphylaxis –Need to differentiate from fainting Neurological damage –Often a major worry of parents –BUT: there is no evidence that MMR causes autism –Casual rather than causal relationship 35

36. 03/2015 IMMUNIZATION (6) Research claiming a link has been debunked as fraudulent –Dr. Wakefield was convinced he would win a Nobel Prize, even though he falsified medical records and recruited patients unethically (for example, drawing blood from children at a birthday party) in a bid to "prove" the theory. [BMJ, 2011] –The British Medical Journal revealed in Thursday's edition that the disgraced researcher had planned to sell diagnostic tests for the invented condition, and estimated his company would reap $112-million a year. He stood to bring in another $43-million annually for a measles vaccine he invented to replace MMR. 36

37. 03/2015 IMMUNIZATION (7) Rubella vaccination and adult women –Vaccine is ‘live, attenuated’ –Rubella infection during first trimester can cause spontaneous abortion, serious fetal development problems, etc. Congenital Rubella Syndrome (CRS) –Giving vaccine to pregnant women might, in theory, cause similar issues –NO EVIDENCE to support this risk –Inadvertent vaccine administration to pregnant women is NOT reason for pregnancy termination –But as a general guideline: avoid immunizing women who might be pregnant delay pregnancy at least 4 weeks post-immunization 37

38. 03/2015 IMMUNIZATION (8) “ 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) 38

39. 03/2015 IMMUNIZATION (9) “ Discuss immunization of immuno-compromised children (e.g., asplenia, chronic diseases or seizures) ” Asplenia (surgical or congenital/functional) –Not a 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) 39

40. 03/2015 IMMUNIZATION (10) “ Discuss immunization of immuno-compromised children (e.g., asplenia, chronic diseases or seizures) ” Immunosuppression –Avoid live vaccines –Follow regular immunization schedule –High dose steroids can mute immune response Congenital immunodeficiency –Read the Canadian Immunization Guide! 40

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