Transcript New Childhood Vaccines

Childhood Vaccines
Robin Ball
[email protected]
Vaccination
• One of the greatest public health achievements
• With the exception of clean drinking water, no other human
health intervention has had the impact of vaccines in
reducing disease
• Childhood immunizations prevent 33,000 deaths per year
in the US.
• Every dollar spent on immunization saves $6.30 in direct
medical costs in the US, with an aggregate savings of
$10.5 billion (direct medical costs) or a total of $42billion
(total costs)
• Vaccination provides 5-7% of a GP practice income
Diphtheria infection
Corynebacterium
diphtherae
Acute
URTI, sore throat, grey
membrane, fever, skin ulcers
– 100 000 case/year up to
8000 deaths
WHO
47000
cases, 2500 deaths v 1 death
in last 10 years
USSR
–resurgence
Toxoid
Vaccine
Tetanus infection
Clostridium
Tetani - spore forming
Traumatised
Exotoxin
<5
tissue – spores contaminate
> muscle spasm >lockjaw
cases/year, previously >500
Neonatal
Toxoid
tetanus 270,000/year
Vaccine
Pertussis infection
Starts
as coryza
Progresses
to severe paroxysms of cough
followed by vomiting
Characteristic
whoop, Cough lasts 1-3 m
Complications
in infants:
1 in 8 pneumonia
1:125 seizures,
,
1:500 die
1:1000 encephalopathy/ brain damage
Acellular
vaccine
HiB disease
Haemophilus Influenza type b
Bacterial
infection- most common under 5
Complications
–1 in 10 contract Hib meningitis
–15 in 100 get epiglottis
–1 in 10 develop septicaemia
–1 in 20 die (invasive disease)
Conjugated polysaccharide Vaccine
Meningococcal disease
Neisseria
meningitides Group C (B, A, Y..)
5-6/1000
incidence in UK
Onset
is abrupt or insidious
Symptoms:
headache, malaise, nausea vomiting, fever,
joint aches, photophobia, stiff neck, Rash – petechial/purpura
80%, macular 13%, no rash 7%
Meningitis
Death
or septicaemia
1 : 10
Conjugated
polysaccharide Vaccine
Pneumococcal Vaccines
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7 Valent PCV – Now 13V
23 Valent PPV
530 cases 50 deaths/yr UK
PCV in schedule @ 2, 4 &13 m
PPV for at risk groups (including >2yrs)
Measles
1:200
convulsions 1:1000 encephalitis
1:2000
Fever
Mortality
, Rash, conjunctivitis, Koplik spots,
Mumps
Pancreatitis,
Meningitis, Cerebellitis, orchitis, risk of
miscarriage in pregnancy
1:20,000
have hearing impairment
Rubella
Congenital
rubella syndrome 9:10 infections in early
pregnancy cause fetal damage
Three
live attenuated viruses
Polio
80-90%
in under 3 year olds
Asymptomatic
in 90-95%
Headaches
vomiting, photophobia,
neck stiffness, paralysis
1-5/100
1:100
Live
poliomyeloencephalitis
suffer paralysis
attenuated or Killed Vaccine
Selective Vaccines
• Hepatitis B
• Infants and children at risk if infection by
vertical transmission or Household (hidden
parenteral) infection
Non schedule childhood
vaccines
• Influenza - for all children over 6 months who fit into at risk
categories
• Pneumococcal Polysaccharide - for all children who fit into at risk
categories after 2 yrs of age
• e.g.
• Hypo- / asplenia (includes homozygous sickle cell disease and
coeliac syndrome)
• Chronic renal, heart, lung and liver disease
• Diabetes mellitus
• Immunodeficiency / -suppression (due to disease or treatment)
• Children under 5 years - previous invasive pneumococcal disease!
• Chronic respiratory disease inc Cystic Fibrosis, asthma, cerebral
palsy
BCG Vaccine - New Policy
• From 1 September 2005, the new policy is to provide an improved
targeted BCG vaccination programme for • All infants (aged 0 to 12 months) living in areas where the incidence
of TB is 40/100,000 or greater
• All infants (aged 0 to 12 months) with a parent or grandparent who
was born in a country where the incidence of TB is 40/100,000 or
greater
• Previously unvaccinated older children with specific risk factors for
TB who would formerly have been offered BCG through the schools’
programme, should now be identified at suitable opportunities, and
tested and vaccinated if appropriate.
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The contact, occupational and travel-related recommendations
remain unchanged
September 2004
Improvements to vaccination
schedule
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aP replaces wP
IPV replaces OPV
Offer HiB protection up to 10 years
No Thiomersal
Changes to contraindications
September 2006 changes
• Addition of pneumococcal conjugate
vaccine with catch up
• Addition of HiB booster (as HiB/MenC) at
12 months
• Retiming of MenC
The childhood immunisation schedule 2006
When to immunise
Disease protected against
Vaccine given
Two months old
Diphtheria, tetanus, pertussis polio
and H. influenzae type b (Hib)
Pneumococcal infection
DTaP/IPV/Hib Pediacel
PCV Prevenar
Three months old
DTaP/IPV/Hib Pediacel
Diphtheria, tetanus, pertussis, polio
and H. influenzae type b (Hib)
MenC
Meningitis C (meningococcal group
C)
Four months old
Diphtheria, tetanus, pertussis, polio
and H. influenzae type b (Hib)
Meningitis C
Pneumococcus
DTaP/IPV/Hib Pediacel
MenC
PCV Prevenar
12 months old
Haemophilus influenza type b (Hib)
and meningitis C
Hib/MenC
Menitorix
13 months old
Measles, mumps and rubella
Pneumococcal infection
MMR
PCV Prevenar
The childhood immunisation schedule 2010
When to immunise
Disease protected against
Vaccine given
Two months old
Diphtheria, tetanus, pertussis polio and H.
influenzae type b (Hib)
Pneumococcal infection
DTaP/IPV/Hib Pediacel
PCV Prevenar
Three months old
Diphtheria, tetanus, pertussis, polio and
H. influenzae type b (Hib)
Meningitis C (meningococcal group C)
DTaP/IPV/Hib Pediacel
MenC
Four months old
Diphtheria, tetanus, pertussis, polio and
H. influenzae type b (Hib) Meningitis C
Pneumococcus
DTaP/IPV/Hib Pediacel
MenC
PCV Prevenar
Haemophilus influenza type b (Hib) and
meningitis C
Measles, mumps and rubella
Pneumococcal infection
Hib/MenC
Menitorix
MMR
PCV Prevenar
12 to 13 months old
Simultaneous administration
PCV
DTaP/IPV/Hib
Prevenar
Pediacel
MenC
World Health Organisation (2004)
New Vaccines
Pre - School Booster
dT5aP / IPV + MMR
or
DT3aP / IPV
+ MMR
dT5aP / IPV - Repevax ® made by Sanofi Pasteur
DT3aP / IPV - Infanrix-IPV ® made by GSK
New Vaccines
Teenage
Td / IPV Booster
Revaxis® made by Sanofi Pasteur
HPV Cervarix®
Year 8 Girls and catch up
• Contraindications (1)
True anaphylaxis is the only
contraindication to immunisation with
inactivated vaccines
– a previous dose of a vaccine
– antibiotics such as neomycin, polymyxin B
and streptomycin
– rarely seen (less than 1 per million doses)
• Definition of anaphylaxis
 Typically rapid and unpredictable with variable
severity and clinical features including cardiovascular
collapse, bronchospasm, angioedema, pulmonary
oedema, loss of consciousness and urticaria
Contraindications (2)
Severe allergic reactions (not
anaphylaxis)
– not a contraindication
– specialist advice should be sought
before continuing
A NEUROLOGICAL CONDITION IS NOT A
CONTRAINDICATION TO IMMUNISATION
History (family or personal) of pre-existing
seizures with fever
– Not a contraindication
– increased risk as fever following immunisation
may lead to a seizure
– no evidence of neurological deterioration 
immunise as normal & advice on how to prevent a
fever
– evidence of neurological deterioration 
immunise once stabilised & advice on how to
prevent a fever
History (family or personal) of seizures without
fever
– not a contraindication
– no evidence of neurological deterioration 
immunise as normal.
– evidence that children who experience a seizure
develop normally (Ramsay et al, Health Trends,
1997)
• Stable pre-existing neurological abnormality
(e.g. spina bifida, cerebral palsy, or perinatal
hypoxic ischaemic encephalopathy).
– not a contraindication
– immunise as normal
Evidence of current neurological deterioration
Neurological
conditions
(3)
– investigate cause
– immunise once condition has stabilised
– not based on evidence of harm but to ensure
progression of the condition is not wrongly
associated with immunisation
• Encephalopathy or encephalitis within 7 days of
immunisation
– investigate cause
– if no underlying cause found and did not fully
recovered within 7 days  defer immunisation
until stable
– if no underlying cause found and fully recovered
within 7 days  immunise as normal
Deferral
of any immunisation
should
Neurological
conditions
(4) be
minimal as the child remains unprotected
Febrile seizure within 72 hrs of
immunisation
– investigate cause
– if no underlying cause found and did not fully
recovered within 24 hours  defer immunisation
until stable
– if no underlying cause found and fully recovered
within 24 hours  immunise as normal
Severe local or general reactions
• New advice (GB 2006)
– evidence shows children who have had a
previous reaction to DTP can be re-immunised
safely (Gold et al, 2000;Vermeer-de Bondt et al,
1998)
– immunisation should proceed in children who
have had a severe local or general reaction to a
previous dose
MMR: The Controversy
• 1997 Wakefield et al. Claimed protein found
in gut wall in IBD similar to measles
1998 Ditto “Characteristic” inflammatory lesion
in bowel self selected subjects with
behavioural change in 2nd year of life
attributed to MMR
2000 Wakefield in a press conference suggests
separating antigens
2009 Wakefield and Walker Smith Struck off the
medical register (research ethics and undeclared
financial interests)
2011 Extent of scientific and financial fraud
published.
MMR :The Facts
Neither pathological finding has been replicated
At
least 20 epidemiological studies have shown no
evidence of causal link between MMR and Autism or
IBD
Research was scientifically and financially fradulant
Separating
the antigens is illogical, untested and
guarantees a greater susceptible population
Some
separate antigen vaccines are either
ineffective or have high rates of adverse effects
MMR and egg
• There is no egg protein in MMR
• Egg allergic children should be vaccinated at the same time
, in the same way as non allergic children
• (children with a history of cardio-pulmonary anaphylaxis to
egg
• - refer)
• Recommendations for using MMR vaccine in children
• allergic to eggs
• G A Khakoo, G Lack BMJ 2000;320:929–32
• Green Book Google or
• http://www.dh.gov.uk/en/Publicationsandst
atistics/Publications/PublicationsPolicyAnd
Guidance/DH_079917
And finally…
• Don’t forget –
immunisation is the most
important contribution to
public health you can
make!
• Robin Ball 01904 725314
• [email protected]
Potential Future Vaccines
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Conjugated Pneumococcal
HiB booster
Hep B
Varicella
Rotavirus
Human Papilloma Virus
Meningococcal B