Transcript Childhood Immunisation, ‘The new schedule and what the

‘Childhood Immunisation,
‘The new schedule and what the
future may bring’.
Workshop for TARGET Event
21st June 2006
Helen Donovan
Practice Educator
Hertsmere PCT
Aims
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To provide an understanding of the
current and proposed vaccination
schedule for children.
To consider current advice and
contraindications
To explore possibilities for the future
Public Health
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The two public health
interventions with the greatest
impact are clean water and
vaccination
Vaccination is the most effective
medical intervention in the world
History of Vaccination
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7th Centaury: recordings of attempts of vaccination
1796: Edward Jenner demonstrated that inoculation with
cowpox virus produced protection from infection with smallpox.
(Hence “Vaccination”: taken from vacca – the latin word for cow)
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1860s-1890s: Louis Pasteur produced vaccines against
chickenpox, cholera, diphtheria, anthrax and rabies
Early 20th Century: toxoid vaccines against diphtheria and
tetanus produced following discovery of effective inactivation
with chemicals
Post World War 2: successful live viral vaccines developed
using cell culture techniques
Present and future: new technologies constantly developing:
recombinant protein vaccines, DNA and conjugate vaccines
Vaccination Has always had it’s critics.
In this cartoon from 1802, the British satirist James
Gillray implied that vaccination caused people to
become part cow.
Development of a vaccination
programme
The aim of a vaccination programme is to control
a disease successfully
 Before designing a vaccine programme, important
to establish:
? Is there a need for the programme?
i.e. does the disease cause a significant public
health problem?
? Is a suitable vaccine available that is safe and
effective?
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Establishing the need for
a vaccination programme
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Disease incidence
Age distribution
Trends
Disease complications
Mortality
These are ascertained by surveillance and also
through published literature and special studies
Current Schedule
Two Three and
Four Months
Polio, Diphtheria, Tetanus,
acellular Pertussis and Hib
(DTaP/IPV/Hib)
One injection
Men C
One injection
Around 13 months
Measles Mumps and Rubella One Injection
(MMR)
3 - 5 Years
Pre School Booster
Polio, Diphtheria, Tetanus
One injection
acellular Pertussis
(dTaP/IPV or DTaP/IPV)
Measles Mumps and Rubella One Injection
(MMR)
13-18 School leavers
Polio, Tetanus and Low dose One injection
diphtheria (Td/IPV)
BCG
MMR
No longer routine Children screened
2nd dose recommended. Advice to go to GP some school
catch up will take place
Contraindications to inactivated
vaccines
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Previous anaphylaxis to vaccine or
antibiotic in vaccine (neomycin,
polymyxin or streptomycin).
Severe allergic reaction
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Get advice
Immunise
No longer contraindicated!
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Neurological conditions
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Immunise if stable
Reason for waiting – to avoid blaming the vaccine.
Avoid undue delay
Severe local or generalised reaction
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More recent evidence indicates that children can
be immunised safely.
Thought to relate to whole cell pertussis, but
even this can be given without recurrent
reaction.
Role of the media
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Parents have been misled by balance of
media reporting (Report from Cardiff
School of Journalism, Media and Cultural
Studies)
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Equal weight given by media to pro and anti
arguments
Leading parents to believe that the
scientific community is genuinely divided
The Mirror
Thursday February 7, 2002
Giving vaccines singly is “safer”
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Andrew Wakefield’s comments at press conference in 1998
advising single vaccines at yearly intervals but was not based on
evidence
More data on safety of MMR than single vaccines given
sequentially
Autism rates in Japan continued to rise despite use of single
vaccines
Single schedules could be damaging to both individual and
population
 Risk of catching disease while waiting for next dose
 Failure to complete 6 dose course
 Girls given rubella vaccine and boys mumps vaccine
No obligation for NHS to provide inferior service to satisfy
patient’s “right to choose ”
Measles, mumps and rubella notifications
Five weekly moving averages 1999-2005
1400
1200
Mumps
Measles
Rubella
1000
800
600
400
200
20044
20043
20041
20035
20033
20031
20025
20023
20021
20015
20013
20011
20010
20003
20001
20000
19993
19992
19990
0
Healthy western children don’t
die of measles
Netherlands outbreak 1999/2000
About 3250 cases reported.
 97% cases in unvaccinated religious community children
(Dutch Reform)
 ~20% serious complications; 5 encephalitis (1/650)
 3 children died
Irish outbreak 2000
Nearly 1500 cases notified.
 mainly from Dublin
MMR coverage is only 74%
 3 children died
BCG
[TB Prevention]
Targeted vaccination to Infants
aged 0-12 months
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Living in areas where TB is ≥ 40/100,000.
Children whose parents/grandparents come
from countries where incidence is
≥ 40/100,000.
Travelling for more than 1 month to at risk
countries.
Mantoux test replacing the Heaf test.
Rate (per 100,000)
TB rates by place of birth (UK
born/abroad),
Eng and Wales, 1999 - 2003
100
90
80
70
60
50
40
30
20
10
0
90.7
79.9
90.9
80.8
73.1
Born in the UK
Born abroad
4.3
4.2
4.5
4.1
3.9
1999
2000
2001
2002
2003
Year
Sources: Enhanced Tuberculosis Surveillance, Labour Force Survey population estimates
Stopping Tuberculosis
England: Factfile
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in
^ by 25% in last decade and rising 6,638 in 2002 ie
13/100,000
Incidence similar to that of HIV
350 deaths pa
Most in inner cities
2/5 in London where rate doubled in last 10 yrs. Most
common in certain ethnic groups. Especially if born
abroad
7/10 in ethnic minorities
2/3 of TB in those born abroad
50% of TB pts. born abroad diagnosed in first 5 yrs of
entering the country
3% TB pts. co-infected with HIV
Recent Changes Implemented
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Acellular Pertussis
Thiomersal free vaccine
Inactivated polio [IPV] added
for babies
DTaP/IPV/Hib
Preschool booster
dTaP/IPV or DTaP/IPV
School leaver booster Td/IPV.
Hib up to age 10 (Previously up to age 4)
BCG now targeted
2nd dose of MMR to teenagers
Changes to contraindications
New Green Book
Proposed Schedule
2 months
DTaP/IPV/Hib +
pneumococcal (Prenvar)
1 injection
1 injection
3 months
DTaP/IPV/Hib
+ Men C
1 injection
1 injection
4 months
DTaP/IPV/Hib
+ pneumococcal (Prenvar)
+ Men C
1 injection
1 injection
1 injection
12 months
Hib/Men C
1 injection
13 months
MMR
+ Pneumococcal (Prenvar)
Pre School
As before DTaP/IPV or
dTaP/IPV + MMR
1 injection
1 injection
School leavers
As before dT/IPV
1 injection
BCG argeted and MMR 2nd dose advised for those who missed.
Proposed Changes
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1. Introduction of a new vaccination to protect
against pneumococcal infection (Prenvar)
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2. A pneumococcal vaccination catch-up programme
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3. Ammending the MenC vaccination schedule to give
two doses of vaccine in the first year of life and a
booster dose in the second year
4. Addition of a Hib booster vaccine in the second
year of life
5. Proposed new vaccination schedule - there is a new
additional vaccination visit at 12 months in the
routine programme.
Pneumococcal Infection
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When invasive can cause meningitis,
septicaemia and pneumonia
>5,000 cases p.a., England and Wales
530 cases < 2 years
30% of cases are pneumococcal meningitis
Approx 50 deaths p.a. in < 2s
In USA, 94% drop in cases in young and
60% in elderly after this programme
introduced
Non-meningitic pneumococcal infection
Otitis Media
1 in 3 children each year
Sinusitis
(common)
Invasive Pneumococcal
Disease (bacteramia)
Soft Tissue Infection (rare)
Arthritis (rare)
Pneumonia
Peritonitis (rare)
Invasive pneumococcal disease (IPD)
rates by age per 100,000 population per year
Age Group
80+
75-79y
65-74y
45-64y
15-44y
10-14y
5-9y
2-4y
1<2y
6-11m
90
80
70
60
50
40
30
20
10
0
<6m
Rate of IPD per 100,000 population
Source: HPA, CFI
Conjugation
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Some bacteria (e.g. Haemophilus influenzae type b,
Neisseria meningitidis, Streptococcus pneumoniae)
have an outer coating of sugar molecules (called
polysaccharides)
Polysaccharide coatings make it difficult for a baby
or young child’s immature immune system to see and
respond to the bacterium inside
Polysaccharide vaccines are poorly immunogenic in
children under 2 years old and do not stimulate
long term immunological memory
Conjugate vaccines have enabled us to effectively
protect children against Hib, Men C and
pneumococcal diseases
Conjugation
Conjugate vaccine
Bacteria
Carrier
protein
Polysaccharide linked to
carrier protein
Polysaccharide
(sugar) coating
Conjugation is the process of attaching (linking) the
polysaccharide antigen to a protein carrier (e.g.
diphtheria or tetanus) that the infant’s immune system
already recognises in order to provoke an immune
response
The Future
Useful information
 ‘UK Guidance on Best Practice in Vaccine Administration’
Copies available from;
The Vaccine administration task force, Shire Hall
Communications, PO Box 31580 London W11 4YZ
 Vaccine information Service, [V.I.S.]: 01628 587693.
http://www.apmsd.co.uk/
 Department of health publications available from:
[email protected] or Tel: 08701555455.
 http://www.hpa.org.uk/
With thanks to Marian McEvoy and HPA for some of the slides
Web Sites
 MMR the - facts www.mmrthefacts.nhs.uk
 Immunisation the safest way to protect your child
www.immunisation.nhs.uk
 Immunisation against infectious disease 1996 –
Green Book www.dh.gov.uk
For any changes to the vaccine schedule check
the CMO link
 Prodigy useful printable info leaflets
www.prodigy.nhs.uk
 National Electronic Library of Health
www.nelh.nhs.uk
Some useful references!!
•
Honda H, Shimizu Y and Rutter M (2005) No effect of MMR withdrawal on
the incidence of autism: a total population study. Journal of Child Psychology
and Psychiatry. Vol 46 (6) P 572 -
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Mäkëla et al. ( 2002 ) Neurologic disorders after measles-mumps-rubella
vaccination. Pediatrics 110:957-63.
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Madsen KM et al. (2002). A population-based study of measles, mumps and
rubella vaccination and autism. New England Journal of Medicine 347: 1477-
•
Offit PA, Quarles J, Gerber MA et al (2002). Addressing parents’ concerns: do
multiple vaccines overwhelm or weaken the infant’s immune system?
Paediatrics; 109, 1:124-129.
•
Smeeth L, Cook C, Fombonne E, Heavey L, Rodrigues LC, Smith PG, Hall
AJ, (2004). MMR vaccination and pervasive developmental disorders: a casecontrol study Lancet; 364: 963-69.
•
Maitra A, Sherriff A, Griffiths M, and Henderson J, (2004). Pertussis
vaccination in infancy and asthma or allergy in later childhood: birth cohort
study BMJ, Apr; 328: 925 - 926.