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VACCINE UPDATE

DR Neminathan , coimbatore
child trust hospital , 9842811198
The discussions are based on

ACVIP – Advisory Committee on


Vaccines and Immunization Practices

Red Book – American Academy of


Pediatrics
Nelson Text Book of Pediatrics
RECOMMENDATIONS 2016

MMR and MMRV Vaccines

a)Three doses of MMR – 9months, 15 months,

4-6 years.

b)No stand alone Measles dose at 9 months.

c)MMRV is approved for use at 4 – 6 years

of age only.
POLIO IMMUNIZATION

a) The alternative two dose schedule for IPV to be preferred


over 3 dose schedule for primary immunization.

b) Full does of IM – IPV for children who had already received


2 ID-f IPV doses at 6 and 14 weeks or single dose of IM – IPV
at 14 weeks.

c) An interval of at least 8 weeks to be maintained between


the additional dose and last dose of ID or IM IPV.

d) No change in the booster dose schedule of IPV and OPV


TYPHOID IMMUNIZATION
a) Typhoid conjugate vaccine is now approved for
prevention of typhoid fever in children.

b) Typhoid conjugate vaccine to be preferred over


Vi-polysaccharide vaccine for both booster and
catch-up vaccination.

JAPANESE ENCEPHALITIS VACCINATION


The recommended age for JE Vaccination raised to 18 years in
endemic region, as more and more children belonging to older
age group are getting affected.
IAP’s CLASSIFICATION OF VACCINES
VACCINE FOR HIGH RISK
ROUTINE VACCINES CHILDREN
 BCG, OPV • Influenza Vaccine
 DTP • Meningococcal Vaccine
 Polio • Japanese Encephalitis
 Rotavirus Vaccine
 Hepatitis B • Cholera Vaccine
 Hepatitis A • Rabies Vaccine
 MMR • Yellow Fever Vaccine
 Varicella,Typhoid • Pneumococcal
 T dap Polysaccharide Vaccine
 HPV (PPSV23)
HIGH-RISK CATEGORY
 Congenital or acquired immunodeficiency (including HIV)
 Chronic cardiac, pulmonary (asthma on prolonged oral steroids)
hematologic, renal (nephrotic syndrome) liver disease and diabetes
mellitus.
 Children on long term steroids, salicylates, immunosuppressive or radiation
therapy.
 Diabetes mellitus, C S F leak, cochlear implant, malignancies.
 Children with functional / anatomic asplenia / hyposplenia
 During disease outbreaks.
 Lab personnel and healthcare workers
 Travellers
 Children having pets at home and those with higher threat of being bitten by
stray dogs.
IAP SCHEDULE

‘O’ OPV at birth


IPV 1, 2, 3 doses - 6, 10, 14 weeks
OPV – 6 months and 9 months
IPV booster 15 – 18 months
OPV booster 4 – 6 years
What are the changes in Polio Vaccination ?
POLIO VACCINATION
Considering the acute shortage of IPV and the urgent need of
providing immunity against type 2 polio virus
In the Govt. Sector –
Intradermal fractional IPV –IDf IPV
is given as 0.1 ml ID ® upper arm- deltoid ( (L) arm BCG) at 6
weeks and 14 weeks, followed by full dose IPV IM 8 weeks later.

Polio in office practice - IPV as a combination vaccine (HEXAXIM


/ PENTAXIM / EASY 6).
If IPV is unfeasible, OPV in place of IPV, minimum 3 doses.

No child should leave your facility without polio immunization


(IPV or OPV)
Question – 5

What is eIPV ?
DR.SIVAPRAKASAM.V

Polio Virus types


1 2 3
20 8 32
Old IPV contents in antigen units
DU
Current IPV contents in antigen 40 8 32
units DU
So currently used IPV vaccines are enhanced potency
(eIPV) vaccines.
wP- Whole cell pertussis DTwP
ap - a cellular pertussis components - DTaP
D - Diphtheria toxoid > 20 – 30 IU – DT
d - Lower dose > 2 IU - Tdap
Td - Tetanus toxoid - 40 – 60 IU / 5 Lf

Note : The amount of tetanus toxoid in all products is


almost equal. So it always remains as upper case T
DTwP / DTaP VACCINE

DTP vaccines for primary series – 6,10,14 weeks.

DTaP should preferably be avoided in primary series.

DTaP preferred to DTwP in children with history of severe


adverse effects after previous dose of DTwP or children
with neurologic disorders.

I and II boosters also as DTwP, considering a higher


reactogenicity, DTaP may be considered for boosters.

NOTE : ACVIP does not approve the use of Tdap as


second booster of DTP schedule
Catch up below 7 years:

DTwP / DTaP at 0, 1 and 6 months

Catch up above 7 years

Tdap, Td and Td at 0, 1 and 6 months.


Tdap Vaccine
1 dose of Tdap to all adolescents aged 11 – 12 years.

Tdap during each pregnancy (Preferably 27 – 36 weeks


gestation) regardless of the number of years from prior
Td / Tdap vaccination.

For catch up vaccine above 7 years, for DTP series

Tdap, Td, Td at 0, 1 and 6 months

NOTE : Tdap should not be used as second booster for


DTP series.
Yes

Administration of booster TT/Td doses frequently


leads to increased frequency and severity of local
and systemic reaction, as preformed antitoxins
binds with the toxoid and leads to immune
complex reaction (eg. Arthus reaction)
MMR VACCINE

Due to diseases occurring earlier in children


3 doses – 9 – 12 months, 15 – 18 months, 4 – 6 years

Since time since vaccination is a factor on mumps outbreaks


the 3rd dose of MMR should be at 4 – 6 years to prevent
mumps outbreaks in older children and adolescents.
Catch up vaccination:

School age / adolescent – 2 doses MMR


4 weeks apart

During measles outbreaks – Measles / MMR can be


administered 6-8 months

However, this dose should not be counted


VARICELLA VACCINE
Routine
2 doses : 15 – 18 months, 4 – 6 years

Catch-up
12 months - 12 years : 2 doses, minimum interval 3 months

13 years and older : 2 doses, minimum interval 4 weeks

NOTE:
ACVIP approves of all the available Monovalent Varicella Vaccine
brands.

However, the evidence in favour of efficacy and safety of two


brands – Variped and Varilrix far outweigh the other brands.
MMRV

ACVIP recommends MMR and Varicella separately as


MMR + V at 15 months.

MMR + V or MMRV at 4 – 6 years of age

Convincing data on efficacy to all 4 components. However,


fever, rash, febrile seizure at age 12 – 23 months is two
fold higher incidence.

MMRV licensed till 12 years only.


HEPATITIS A VACCINES
Available in India are

1. Inactivated (HM175 strain) vaccine

2. Live attenuated (H2 strain) vaccine


SCHEDULE OF HEP-A VACCINE
 Minimum age for vaccination – 12 months
 Inactivated Hep-A vaccine
 First dose at 12 months
 Second dose at an interval of 6-18months
 Live attenuated vaccine
 Any time between 12-23 months – single dose
subcutaneous only
HEP-A VACCINE IN CHILDREN ABOVE 10 YEARS
 Screening for Hepatitis A antibody IgG prior
to immunisation is recommended in children
above 10 years
 54 % of children in this age group are sero positive

in India
PCV
PCV 10 and PCV 13 licensed for use from 6 weeks to 5 years.
Schedule
Primary doses (both PCV 10 and PCV 13)
6, 10, 14 weeks – booster 12 through 15 months

Catch up Vaccination:
PCV 13 : 6 – 12 months : 2 doses 4 weeks apart + one
booster
12 – 23 months : 2 doses 8 weeks apart
24 months and above : single dose
PCV 10 : 6 – 12 months : 2 doses 4 weeks apart + one booster
12 months to 5 years : 2 doses 8 weeks apart
Vaccination of person with high-risk conditions:

PCV and Pneumococcal polysaccharide vaccine 23 – PPSV


both are used.

Note : PCV 13 is licensed for prevention of


pneumococcal diseases in adults
> 50 years of age
ENT refers a child planned for Cochlear implant to you for
pneumococcal vaccine – What is the schedule ?
Children aged 24 through 71 months.
If 3 doses PCV received previously.
1 dose of PCV 13 →8 weeks → PPSV 23
If not received PCV
PCV 13 → 8 weeks → PCV 13 → 8 weeks → PPSV 23

Children aged 6 through 18 years


PCV 13 → 8 weeks → PPSV23

Note: Same schedule for children with high-risk conditions like


Nephrotic syndrome, Sickle cell disease
HIV infection or CSF leak
CATCH – UP ADOLESCENT IMMUNIZATION
Vaccine Schedule
MMR 2 doses at 4 – 8 weeks interval
Varicella 2 doses at 4 – 8 weeks interval
Hep B 3 doses at 0, 1 and 6 months
Hep A 1 dose or 2 doses 0, 6 months
(prior check Anti HAV Ig may be
cost effective.
Typhoid 1 dose TCV or 1 dose ViPS every 3 years
Tetanus / Diphtheria / If not immunized - Tdap, Td, Td at 0, 1and 6
Pertussis months or
Previously immunized
One dose Tdap and Td every 10 years
HPV 2 or 3 doses depending on the age
Question 16

What are the HPV related diseases ?

Genital warts and cervical cancer

Cancers of vulva and vagina, penis and anus, oropharyngeal


cancer and RRP
HPV VACCINE

HPV – 2 - Types 16 and 18

HPV – 4 - Types 16, 18 + 6 and 11

Note :
HPV - 9

GARDASIL 9 HPV – 4 + Types 31, 33, 45, 52 and 58

HPV 4 and HPV 9 can be given as 3 doses series for males


aged 11 – 12 years through 26 years – but not yet licensed for
use in males in India
HPV VACCINE
Schedule:
Girls 9 – 14 years : 2 doses of HPV 2 or HPV 4
1st dose - 6 months - 2nd dose.
15 years and older : 3 dose – series
HPV 4 : 0, 2, 6 months
HPV 2 : 0, 1, 6 months

Special precautions:
Syncope following vaccine counseled.
Vaccine in sitting or lying position.
Patient observed for 15 minutes post vaccination
Pre - EP
For high risk category of children
having pets at home
 With high threat of being bitten by dogs such as
hostellers, risk of stray dog menace while going
outdoor

Vaccine & schedule

Only modern tissue culture vaccines (MTCVs)

( 1 ml intramuscular IM in anterolateral thigh or deltoid


region ( never in gluteal region)

Day 0, 7, 21 or 28
Which of the animal bites require ARV ?

Dog, Cats, Cows, Buffaloes, sheep, goats, pigs, donkeys,


horse, camels, foxes, jackals, monkey, mongoose, squirrel,
bear and bats.

Domestic rodent (rat) do not require PEP in India.


Category- I

Treatment:
None, if reliable case history is available

35
Category II

Treatment
Administer Vaccine immediately

36
 Category III

Treatment………………….
Administer Rabies Immunoglobulin (RIG) and a Vaccine
Immediately If RIG is not available, administer two doses
of ARV on Day 0
37
Post exposure prophylaxis PEP
Wound care – Under running tap water for 10 minutes + application of soap.
Apply disinfectants – povidone iodine

Rabies immunoglobulin RIG


for Category III bites along with rabies vaccine
Human RIG 20 IU / kg
Equine RIG 40 IU / kg can be used if human RIG is not available
RABIES VACCINE
 MTCVs are recommended in all category II and III
bites.
 Dose 1 ml IM
 Intradermal – ID administration not recommended in
individual practice
 Schedule
 0,3,7,14 and 30
 Day 0 being the day of commencement of vaccination
 Sixth dose on day 90 is optional for those with severe
debility or those immuno suppressed
RE-EXPOSURE

After completed (and documented) pre or post EP


2 doses given on day 0 and day 3

RIG not required during this re-exposure.


TYPES OF TYPHOID VACCINE
 There are two types of typhoid vaccines
available in India

 Vi polysaccharide conjugate vaccines TCV

 Vi –PS polysaccharide vaccine


SCHEDULE OF TYPHOID
VACCINATION
TCV
 First dose 9-12 months, atleast 4 weeks away from
MMR
 Booster after 12 months at 2 years of age

 ViPS vaccine-
 at 2 years
 Revaccination every 3 years
 No hypo responsiveness with repeat vaccination
 TCV conjugate is preferred over ViPS
CATCH UP IMMUNIZATION TYPHOID
 Catch up vaccination can be given at any age
upto 18 years
 If TCV is used – one dose
 If ViPS is used, revaccination every 3 years
 ViPS should not be given as a booster to a
child who as received the first dose as TCV
 The need and exact timing of booster doses
are not yet determined
ROTAVIRUS VACCINE
Live attenuated human RV vaccine –
Monovalent RV-1 - ROTARIX

Live human, bovine RV reassortant vaccine – Pentavalent RV – 5


– ROTATEQ

Live human, bovine RV reassortant vaccine RV – 116 E –


ROTAVAC / ROTASURE

Schedule:
For RV-1 only 2 doses – 10 and 14 weeks – This schedule is found
to be far more immunogenic than at 6 and 10 weeks.

RV-5 and RV 116E – total of 3 doses of RV vaccine.


at 6,10,14 weeks
CATCH-UP VACCINATION: RV VACCINE

What is the maximum age for first doses on the series ?


14 weeks, 6 days

Note : Vaccination should not be initiated for infants aged 15


weeks or older.

What is the maximum age for final dose ?


32 weeks for Rotateq
24 weeks 6 days for Rotarix.

Note : BF does not affect RV vaccine efficacy.


Doses regurgitated, spit out, vomited need not be repeated
RV can be co-administered with OPV
ADVERSE EVENTS FOLLOWING IMMUNIZATION -
AEFI

DR.NANDHINI KUMARAN
AEFI

Adverse Events Following Immunization

is defined as an untoward temporarily associated


event following immunization that may or may not be
caused by the vaccine or the immunization process.
AEFI

AEFI - Type Example


Vaccine product – related reaction Extensive limb swelling following DPT

Vaccine quality defect - Polio vaccine causing VAPP


related reaction
Immunization error – related Infection by contaminated vial – Thigh
reaction abscess after a vaccine
Immunization anxiety – Vasovagal Syncope in an adolescent
related reaction
Co-incidental event – after vaccine Fever after vaccine – Pneumonia or
Malaria – few days after vaccine
ANAPHYLAXIS

Medical Emergency

Clinical manifestation include cutaneous, respiratory,


cardiovascular and gastrointestinal symptoms.
ANAPHYLAXIS -MANAGEMENT
Call for help
Supine position – elevate the legs
EPINEPHRINE is the primary drug
0.01 ml / kg / dose - Maximum 0.5 ml
IM intramuscular / anterolateral thigh
Repeat in 5 – 15 minutes if there is no response
Airway - sos intubation / cricothyroidotomy
Breathing – O2 15 litres / min
Salbutamol nebulisation if wheeze / bronchospasm
Circulation - IV line – wide bore IV Catheters or intra osseous IO
If hypotensive – Normal saline 20 ml / kg bolus
ANAPHYLAXIS -MANAGEMENT
Secondary drugs

Antihistamines

H - 1 receptor blocking

Hydroxyzine / cetirizine

H-2 receptor blocking

Ranitidine IV - I mg/kg slowly over 15 minutes

CORTICOSTEROIDS

Methylprednisolone IV 1.5 – 2 mg/kg every 6 hours

Prednisolone - Oral 1.5 – 2 mg / kg


EGG ALLERGY - VACCINES
MMR does not contain significant amount of egg proteins. Hence vaccine
can be given without special precautions.

Influenza vaccine :
Inactivated influenza vaccine - IIV prepared from egg.
If allergic reaction was mild (hives only) administer vaccine with
preconditions (In-office observation for 30 minutes, appropriate
resuscitative equipment available)

If allergic reaction to egg was severe, advised not to use the vaccine and
allergist consultation.

Yellow fever : Vaccine contains larger amount of egg protein – Hence,


allergist consultation and skin testing of the patient before vaccine.
STEROID THERAPY AND VACCINES
Inactivated Vaccines

Can be administered while on chronic steroid therapy.

Can be deferred temporarily until steroids are discontinued, if the hiatus


is expected (to be brief)

Live virus vaccines

High dose steroids (i.e) > 2 mg/kg of prednisolone but less than14 days
Vaccines 2 weeks after discontinuation.

High dose steroids and more than 14 days


Vaccines 4 weeks after discontinuation
IVIG AND VACCINES

Inactivated vaccines can be administered as per schedule

MMR / Varicella vaccines should be deferred for 11 months


because of possible interference with the immune response
Question 24

 A baby has been given the first dose of DPT on


the 25th of june. When is the earliest that
he/she can receive the 2nd dose?
 14th July
21st July
 21st July
 18th July
 12th July
 The minimum interval between 2 doses of
inactivated vaccines is usually 4 weeks
(exception rabies)
 Vaccine doses administered upto 4 days before
the minimum interval or age can be counted
as valid (exception rabies)
 If the vaccine is administered >5 days before
minimum period it is null
POST EXPOSURE PROPHYLAXIS – MEASLES
 Immunocompetent
 Measles vaccine / MMR vaccine given within
 72 hours post exposure can provide protection / modify
disease.
 Use of immunoglobulins I.M with in six days of
exposure in infants < 6 months, pregnant women and
immunocompromised persons
 Dose : IGIM
 In normal children 0.25ml/kg
 In immunocompromised 0.5ml/kg ( max dose 15ml)
 Measles vaccine can be given 5 or 6 months after the
immunoglobulin
POST EXPOSURE PROPHYLAXIS - VARICELLA
 All neonates born to mothers who have
developed varicella 5 days before or 2 days
after the delivery
 All preterm < 28 weeks or birth weight
<1000gms
 Should receive Varicella Zoster Immune
Globulin (VZIG) within 72 hours to 96 hours of
exposure
 Cost is prohibitive
VARICELLA EXPOSURE BEYOND 1 YEAR OF AGE

Non-immune person administer Varicella vaccine as soon as


possible preferably within 3 days and possible upto 5 days after
Varicella / Herpes Zoster exposure.

For immuno compromised, pregnant women .


Administer Varicella Zoster Immune Globulin – VZIG

Unavailability of VZIG – IVIG 400 mg/kg one dose.

If VZIG / IVIG not available


Chemoprophylaxis – Acyclovir 20 mg/kg/dose. 3 times / day
beginning 7 – 10 days after exposure and continue for 7 days.
POST EXPOSURE PROPHYLAXIS FOR HEP A
Time of
Age of patient Recommended prophylaxis
exposure

< 2 weeks <12months IG 0.02ml/kg IM

12 months – 40 years Hepatitis A vaccine

IGIM 0.02 ml/kg but Hep A


41 year or older Vaccine can be used if IGIM
is unavailable.

Younger than 12
> 2 weeks No Prophylaxis
months
No Prophylaxis
> 12 months But Hep A vaccine may be
indicated.
NEONATE BORN TO
HBsAg POSITIVE MOTHER
 Both active & passive immunization must be
given within 12 hours of birth
 First dose of vaccine within 12 hours
 Second dose 1 – 2 months
 Third dose - 6 months
 Hepatitis B immune globulin 0.5ml IM within
12 hours – separate site – separate needle
POST PROPHYLAXIS –HEP B
 Check HBsAg and anti-HBsAg at 9-18 months of age
 Results
 Anti HBsAg positive – immune
 HBsAg positive – HB infection
counsel, pediatric gastro consult
and follow-up
Both negative – Vaccine failure
Complete a second series of
Hepatitis B vaccine
DENGUE VACCINE
Dengvaxia (CYD – TDV)
Tetravalent live attenuated chimeric vaccine with yellow
fever virus as backbone.
Better protection against DENV 3 and 4
Less effective against DENV 1 and 2
3 doses 0 – 6 – 12 months
Sanofi – Pasteur vaccine
Age 9 – 45 years
Used in Mexico, Brazil, Philippines.
DENGUE VACCINE
India finished Phase II trials. Phase III not yet started.

Dengue vaccine introduction in India might be delayed.

We need a more effective vaccine that can be


administered safely to
esp. young children and has panserotype efficacy.

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