Transcript Pertussis Control Through Immunization

IMMUNIZATION
Daniel R Hinthorn, MD, FACP
Professor of Internal Medicine,
Pediatrics, and Family Medicine
Director, Infectious Diseases
KUMED
Early Vaccine Uses
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Earliest use was smallpox vaccinations.
1950s and 60s, vaccines were thought to hold
great promise for better lives.
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Polio vaccines
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Salk, killed polio vaccine, 1955.
Sabin, live OPV, 1961.
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The Cutter vaccine caused paralytic polio.
Measles vaccine licensed, 1963.
Rubella vaccine use was widespread, 1968.
Mumps vaccine was cautiously started, 1969.
Swine flu disease 1918, & vaccine 1976.
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Guillain Barre syndrome occurred.
Recommended Childhood Immunizations
Vaccine
Hepatitis B
Birth
1M
2M
4M
HB 1
HB 1
HB 2
HB 1
HB 2
HB 1
HB 2
DTaP
1
DTaP
Hib
6M
HB 2
HB 3
12 15M
18M
24M
HB 3
HB 3
HB 3
DTaP DTaP
2
3
Hib
Hib
eIPV
eIPB
eIPV
Pneumococcal
PCV
PCV
Hib
DTaP
4
11-12Y
HB
DTaP
Td
MMR
MMR
VZV
Hib
eIPV
PCV
PCV
MMR
MMR
VZV
VZV
Hepatitis A
4-6Yr
HAV
Oval = catch up
* MMWR May 19, 2000 & aafp.org/policy
New vaccines recently released
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Menamune
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Conjugate vaccine for meningococcal disease
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Bound to protein of diphtheria toxin
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Activates T lymphocytes
Longer lasting antibody responses
Adacel
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Conjugate vaccine for pertussis
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Now approved for use in children, adolescents, and for
adults up to age 64 years.
CDC Study –Infant Pertussis:
Who Was the Source?
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774 infant cases from 4 states
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264 cases had source identified
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Sources:
Other 25%
Mother 32%
Grandparent 8%
Father 15%
Sibling 20%
Bisgard, K. PIDJ. 2004;23:985-9.
Age of Pertussis Source* for
Infants
% of Infant Cases
60
50
40
30
20
10
0
0-4
5-9
10-19
Age of Source (Years)
*219 source-persons with known age
Bisgard, K. PIDJ. 2004;23:985-9.
20+
Healthcare Professionals Involved
in Transmission of Pertussis
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Physicians
1912 Schwenkenbecher
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Nurses
1972 Kurt et al
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Physicians
1992 Etkind et al
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Nurses
1995 Christie et al
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Nurses
1997 Matlow et al
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Nurses and Physicians
2005 CDC
Schwenkenbecher, 1912;
Kurt et al. JAMA. 1972;221(3):264-7;
Etkind et al. Am J Dis Child. 1992;146:173-6;
Christie et al. Infect Control Hosp Epidemiol. 1995;16:556-63;
Matlow et al. Infect Control Hosp Epidemiol. 1997;18:715-16;
CDC. MMWR. 2004;54(03):67-71.
Rates of Invasive Pneumococcal Disease among Persons at
Least Five Years Old, According to Age Group and Year
Conjugate pneumococcal vaccine
introduced
69% reduction in 02 year olds
18% reduction
32% reduction
Whitney, C. G. et al. N Engl J Med 2003;348:1737-1746
FluMist: live virus vaccine recently
approved for influenza
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Temperature adapted influenza vaccine
made.
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This is the first live virus influenza vaccine and
should be available this fall, for age 5-50.
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First dose in peds 5-8 years, give two doses 6 wks
apart. Prevention of spread is the idea.
Healthy adults age 8-49 should get one dose.
Each dose has 3 influenza strains rec by the USPHS
for the 2003-4 season.
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Efficacy was 87% in children in 30,000 pts during the trials.
For older adults, the inactivacted vaccine looked better.
Currently suggested adult
re-immunizations
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Hepatitis A: If at risk, travel out of US, highly
endemic areas, job exposures.
Hepatits B: If IVDA, not monogamous.
Tetanus: Td every 5-10 y or after tetanus
prone wound.
Varicella: if never had chickenpox.
Pneumovax
Influenza
Atkinson et al, 6th ed, CDC, 2000
Vaccines possibly considered before
international travel
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Yellow fever
Polio
Varicella
Tetanus-diphtheria
Measles
Typhoid
*Rabies
Meningococcus
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Japenese B
encephalitis
*Plague
Hepatits A
Hepatitis B
*Typhus
*Calmette-Guerin BCG
*Tick-borne
encephalitis
Do your patients know they should
see a physician before travel?
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Worries about diseases during or after travel?
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1 million people travel between developed and
developing countries each week.
60-70% chance each will develop a health
complaint related to travel.
Surveys at 14 major airport, 8000 travelers.
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Leisure 70%, visiting 20%, work 10%.
>50% planned > 4 wks in advance, others less.
40% had not sought medical advice.
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IDN July 2003
What diseases of travel should
you consider in such patients?
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Flying problems with
motion sickness
Acclimatization
Water
Food & beverages
Sunstroke
Insects
Schistosomiasis
Sleeping sickness
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Malaria prophylaxis
Traveler’s diarrhea
Problems with meds
and prophylaxis
Insurance overseas
Return of bodies to the
US
Worry about eating when you are
traveling: (not protected by vaccines)
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At home.
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Chicken, turkey, and
other meats.
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Contamination with
Campylobacter,
occasionally with
Salmonella.
Wash the cutting boards.
Hands after touching it.
Food left at room
temperature esp overnight
to serve later.
Eating out.
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Same as at home plus…
*Hepatitis A
Ameba
Neurocyticercosis
Internationally
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Eat only foods that are
served hot.
No ice, no leafy, no fruit
unless you peel it
yourself. (*typhoid)
Hepatitis A vaccination has
reduced rates of hepatitis A
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Hepatitis - 85% of kids infected have no sx.
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Kids traveling account for most of 10% Hep A
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Case fatality is 3/1000 overall, more in older.
10% of people with HAV relapse to Sx & infective
U.S. born children returning to Mexico with
parents to the villages of birth is a big risk factor.
States with mandated HepA vaccine
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83% decline in hepatitis A, especially in kids.
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IDN July 2003
Hepatitis A & B & C
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Hepatitis A
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*Fresh food fussed over
with fecaled fingers.
Food, water, *feces,
*urine transmission.
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Zoo transmission.
Military example.
No therapy.
Prevention: vaccine, 2
doses. Gammaglobulin.
Hepatitis B
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Blood, needles, sexual
transmission.
Vaccine 3 doses for full
protection. Therapy.
Hepatitis C
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Blood transmission.
Cocaine straws are
biggest risk.
No vaccine. Therapy depression for a year.
A salade for military doctors
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A recruit reported to sick-call for fatigue.
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Dx was non-medical and he was assigned to
kitchen police duty.
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Making salad for a banquet.
Felt bad, felt not listened to, so he spiked the salade
with body secretions.
30 days later a high percent of those
attending became ill with hepatitis A.
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All ate the salade.
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He confessed.
Hepatitis B infection
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2 billion people affected & 350
Africans/Asians are carriers
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Maternal transmission HBeAg positive is
85%, but 10-30% if HBeAg negative
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USA 1.25 million & .35% population are chronic
carriers.
85% of these newborns bec chr carriers.
Blood & sexual transmission are most
important mechanisms otherwise.
Who needs HBV vaccine?
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Infants not vaccinated.
Persons who have increased risks of hep B
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Individuals who have multiple sex partners
Partner of HBV positive persons
Household contact has hepatitis B
MSM, IVDA
Travelers to endemic areas of the world
Job exposure to body fluids
Work with intellectually disabeled persons
CRF pts, clotting factor recipients
Persons who have chronic hepatitis C
Special notes: hepatitis B
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Hepatitis B vaccine
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Mother is HB neg
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1st dose by 2 mo, 2nd at least 1 mo later.
3rd dose at least 4 mo after 1st, 2 mo after 2nd.
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Mother is HB pos
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Never before 6 months.
1st dose by 12 hrs, & HBIG at separate site.
2nd dose 1-2 mo, 3rd dose at 6 mo.
Mother HB unkown status
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1st dose by 12 hrs. Test mother.
If pos, give neonate HBIG by 7 days.
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MMWR May 19, 2000.
Impact of HCV Infection
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Prevalence
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170 million affected worldwide
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Risk factors
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USA, 4 million or 1.8% population have HCV RNA
(indicating active disease).
1% of US deaths due to ESLD (40% HCV)
65% are ages 30-49 years.
Drug abuse, risky sexual behavior.
Course
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May be clinically silent, but end in ESLD.
Newly approved vaccine for
influenza: FluMist

Temperature adapted influenza vaccine
made.

This is the first live virus influenza vaccine and
should be available this fall, for age 5-50.



First dose in peds 5-8 years, give two doses 6 wks
apart. Prevention of spread is the idea.
Healthy adults age 8-49 should get one dose.
Each dose has 3 influenza strains rec by the USPHS
for the 2003-4 season.

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Efficacy was 87% in children in 30,000 pts during the trials.
For older adults, the inactivacted vaccine looked better.
More on FluMist
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The vaccine made by crossing
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a master donor strain with wild virulent strains
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to give the desired hemagglutinins and
neuraminadase.
Grown in chickens.
Temp sensitive allows growth in nose but not the
lower respiratory tract.
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Avoid giving to immune suppressed, or those with
chronic medical problems who might get disease.
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Probably protects against some strains not in the vaccine too
unlike the inactivated vaccines.
Immunizations and the illnesses
they prevent: staying healthy
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Influenza A or B.
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Who should take the influenza (inactivated)
vaccine?
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Those with other illnesses: heart, lung, diabetes.
Who should use the live virus FluMist?
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Fever, runny nose, muscle aching, sore throat, cough.
Ages 5-49. Temperature sensitive strain.
Are there rapid diagnostic tests and therapies if
someone doesn’t take it in time?
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Relenza & Tamiflu, amantadine & rimantadine.
Pneumovax (the pneumonia shot)
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Of the dozens of causes of pneumonia, this is
the most lethal. The first 7 days are critical.
Symptoms are cough, pleurisy, sputum, high
fever, aching.
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Deaths more often in under age 5 and over 60.
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Vaccine for kids has 7 types. For adults 23 types.
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Both are inactive, not live organisms.
Diabetes, other illnesses as for influenza.
Repeat it every 5 years.
Vaccination combinations
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The mega-combo vaccine with multiple
components rejected by FDA panel in a close
5-4 vote
 Reasons: InfanrixDTaP-HepB-IPV
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Fever in a few children
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200,000 calculated among 4 million kids
Tested on mostly white children in Germany
with small USA studies.
How will it work with Prevnar added?
Twinrix (hepatitis A&B) approved.
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IDC 14:1, 2001
Vaccine use questioned
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The concern as each disease is decreased
in frequency:
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Should we keep immunizing for a rare disease?
Number of adverse problems equals diseased.
Common concerns today (some valid, some not):
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Influenza vaccine: Guillain Barre Syndrome.
DPT: seizures & brain damage.
DPT: linked to autism (IOM found no evidence)
OPV believed to be too risky to use routinely.
MMR: Wakefield & regressive autism + lymphoid nodular
hyperplasia.
Thimerosal and CNS development.
Special concerns: eIPV &
MMR
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Enhanced inactivated polio vaccine
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Anaphylaxis to neomycin, streptomycin, or
polymyxin B has been reported.
Precaution in pregnancy.
No data to support reducing eIPV to 3 doses.
MMR (live viral components)
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Neomycin or gelatin anaphylaxis
Pregnancy: avoid
Immunodeficiency: avoid
Precautions: Recent IG, decreased platelet
counts, history of purpura from low platelets.
Meningococcal vaccine now suggested for college
College students get meningitis
23 year-old woman, K-State student
Found comatose in her apartment.
In February the student had URI
5 days later, she had myalgia, arthralgia
The next day, nausea, vomiting, headache.
Spoke to her mother on the phone.
She didn’t answer phone, so parents went to
Manhattan and found her.
She was stuporous on arrival in the emergency
department.
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Meningococcal vaccines
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Epidemiology changing
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1998-99, 88 cases and 8 deaths in
college students among 2,300 US cases
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Increase in vaccine-preventable cases
Now inform students & parents re:
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disease & quadrivalent ACYW135 for dormitory
entering freshman.
No group B vaccine available (1/3 cases)
Repeat dose in 3-5 yrs if freshman/dorms.
To prevent most cases, immunize starting at
17 y/o.
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CID 2000;30:648, MMWR 2000:49(RR07):1-10, JAMA 1999;281,
1906.
Contraindication to immunization
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Hypersensitivity to components: read labeling!
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Most common are egg proteins (MMR, Influenza,
yellow fever)
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Antibiotics: neomycin (MMR), streptomycin,
thiomerosol
Congenital immunodeficiency
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If patient can eat egg containing foods, it’s OK.
Avoid oral polio vaccine (patient or family)
MMR not shed (only patient avoid)
Systemic prednisone may alter response
Febrile illness and vaccination
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All vaccines can be administered to persons with
minor illness such as diarrhea,URI with or without
low-grade fever, or other low-grade febrile illness
Minor illness will not affect the seroconversion
rate of vaccines
Persons with moderate or severe febrile illness
should be vaccinated as soon as they have
recovered from the acute phase of the illness
Real problems with
Immunizations
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Contents of vaccines
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Presence of thiomerisol
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RotaShield rotavirus vaccine
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Large amounts of mercury exposure
Intussusception
Vaccine causing problems
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Oral polio vaccine
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Paralysis
Measles & MMR
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Argued, not well studied pre-release
Preservatives in vaccines
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1997, FDA assessed the health risk of mercury in
foods and drugs.
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Drug companies asked to give data on thimerosal in
products.
Use began in 1930s.
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Prevents bacterial growth in mulit use vials.
Was used in over 30 vaccines: DPT, hepB, flu.
Metabolized to thiosalicylate and ethyl Hg.
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Latter has T 1/2 of 9 days. Urinary excretion.
Accumulation occurs if intake exceeds excretion.
Minimata Bay neuromotor disability of infants.
 Spasticity, muscle wasting, joint pains.
 Due to industrial dumping.
Large study of 2% of US peds
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HMO study of children <age 7 years
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No association between MMR and IBD or autism.
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But children who had MMR after 18 months had a
reduced incidence of IBD, called a protective effect.
(Beware the association here too)
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Recall the child who drove up with his parents to his burning
house.
 The child wanted to know why the firemen had set his
house on fire.
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Arch Ped Adol Med 2001;155:355.
Rubella vaccine
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Was licensed in 1969,
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live attenuated RA27/3 strain,
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Induces protective antibody in about 95% of
susceptible persons
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grown in human diploid cell culture
Immunity appears to be long lasting
Route: subcutaneous injection, dose-0.5ml
Storage: 20 to 80C and protect from light
Side effects: fever, rash, arthralgia and
arthritis
IMMUNIZATION