Download Preventive Pediatrics

Preventive Pediatrics
Celia T. Sy, M.D.
Pediatric Pulmonologist
Department of Pediatrics
Fatima Medical Center
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Immunization
Vaccinations
Type of vaccine
Route of administration
Immune response
Post- exposure drug prophylaxis
Immunization
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Denotes the process of inducing or
providing immunity artificially by
administering an immunologic
substances
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Active
Passive
Active Immunization
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When it produces the desired beneficial
effects by stimulation of endogenous
antibody production by the patient
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Tetanous toxoid
MMR
BCG
Passive Immunization
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Administration of preformed human or
animal antibodies to individuals already
exposed or about to be exposed to
certain infectious agents
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Tetanus antitoxins
Immune globulins
Vaccination
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Denotes the physical act of
administrating any vaccine or toxoids
Immunobiologic Substances
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Vaccine - a suspension of live or inactivated
microorganism or fractions thereof
administered to induce immunity and prevent
infectious disease or its sequela
Toxoid – modified bacterial toxin that has
been made nontoxic but retains the ability to
stimulate the formation of antitoxins
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Antitoxins – a solution of antibodies
derived from the serum of animals
immunized with specific antigens
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Passive immunization
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Diphtheria antitoxin
Tetanus antitoxin
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Immune globulin (IG) - a sterile
solution containing antibodies from
human blood. Intended for IM use
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for passive immunization
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Measles immune globulin
hepatitis b immune globulin
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IV IG – a product derived from blood
plasma from the donor pools similar to
the IG pool but prepared for IV used
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Used in primary antibody-deficiency
disorders
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Kawasaki disease
ITP
Hypogammaglobulinemia
Immunologic Constituents
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Suspending fluids – sterile water, saline
Preservatives, Stabilizers, Antibiotics
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used to inhibit or prevent bacterial growth
Stabilize the antigens or antibodies
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albumin, phenols, neomycin, mercurial
Adjuvants – evoke suboptimal immunologic
response
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To enhance immunogenicity
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Al hydroxide, Al phosphate
Vaccines & Toxoids
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Live vaccines
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BCG
MMR
Oral polio
Varicella
Oral typhoid
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Killed antigens
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Toxoids
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DPT
Tetanus
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Killed antigens
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Inactivated Virus
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IPV (inactived polio
virus)
Influenza
Rabies
Hepatitis A
Hepatitis B
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Killed antigens
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Bacterial
polysaccharide
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Hib
Route of Administration
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Intramuscular (IM)
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DPT
IPV (as DPT-IPV-HIB
combination)*
Hep A & B
HiB
Influenza
Pneumococcal
Meningococcal
Typhoid
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Subcutaneous (SC)
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Measles
Mumps
Rubella
MMR
Varicella
IPV
Pneumococcal
Meningococcal
Route of Administration
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Oral
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OPV
Typhoid
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Intradermal
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BCG
Where to inject?
General rules:
 For children < 1 year old – lateral thigh
 For children > 1 year old - deltoid
 Buttocks should not be used for active
vaccinations because of the potential
risk of injury to the sciatic nerve
 If the buttocks are to used – use only
the upper outer quadrant
Fever:
To give or not to give?
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Minor febrile illness or malnutrition is
not a contraindication to immunization
Immunization is deferred in the
presence of severe febrile illness
Vomiting:
What to Do?
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Regurgitated oral vaccine
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If the child vomit or regurgitate within 5 –
10 mins after giving OPV – another dose
should be given at the same visit
If repeated dose is not retained,
re-administered at the next visit
Diarrhea:
Could OPV be given?
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Diarrhea should not be considered as a
contraindication for OPV but to ensure
full protection, doses given to children
with diarrhea SHOULD NOT BE
COUNTED as part of the series
Need to give 2 or more vaccines:
How to give?
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Multiple vaccinations
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Administer each vaccine at a different site
using different needles and syringes
If > 1 vaccine is to be used in a single
limb, use the thigh muscle and given at 1 2 inches apart
Interruption of Schedule
What to do?
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Interruption with a delay between
doses does not interfere with the final
immunity achieved
No need to start the series again
Contraindications?
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Live attenuated vaccines is
contraindicated in:
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Pregnant woman
Immunocompromised person – leukemia,
lymphoma, malignancy, therapy with
steroids, alkylating agents, antimetabolites
Radiotherapy
Trivia
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Which of the following are live
vaccines?
DPT
TOPV
IPV
BCG
Hep B
MMR
Measles
Pneumococcal
Meningococcal
Oral Typhoid
Guidelines for Giving Live
vaccines and killed Antigens
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2 or more killed antigens – may be
administered simultaneously or at any
interval between doses
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Example:
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DPT and Hep B
DPT and Hib
Hep A and Hep B
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Killed and live antigens – may be
administered simultaneously or at any
interval between doses
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Example:
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DPT and OPV
Hep b and MMR
DPT and Measles
DPT and varicella
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2 or more live antigens – may administered
simultaneously or at 4 week minimum interval
if not given simultaneously
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Example:
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Measles and varicella
MMR and varicella
** OPV can be administered at any time before,
with or after MMR if indicated
Guidelines for administration
of IG & Vaccines
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Simultaneous administration
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IG and killed antigen – given at the same
time or at any time between doses
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Hepatitis B immune globulin and hepatitis B
vaccine
Tetanus antitoxins and anti-tetanus vaccine
IG and live antigen – should generally NOT
BE ADMINISTERED simultaneously
Guidelines…IG & Vaccines
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Non-simultaneous administration
First
IG
IG
Killed Ag
Live Ag
Second
Killed Ag
Live Ag
IG
IG
No interval needed
dose related
No interval needed
2 weeks
Interval between IG & Live
Measles Vaccine
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IVIG
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ITP 400 mg/kg
ITP 1000 mg/kg
Kawasaki
Interval
8 month
10 months
11 months
Blood transfusion
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Whole blood & packed RBC
Plasma/platelets
6 months
7 months
Interval…IG & live measles
vaccine
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IG measles prophylaxis
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Normal contact 0.25ml/kg
Immunocompromised 0.50ml/kg
5 mons
6 mons
Trivia
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Which of the following vaccines can be
given simultaneously?
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Hep B & Measles
BCG & DPT
Oral polio & measles
DPT & MMR
Measles & MMR
DPT & IPV + HiB
Immune Response
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Immune response to one live virus
vaccine might be impaired if
administered within 30 days of another
live virus vaccine
Only OPV and MMR can be
administered at anytime before, with or
after each other
Immune Response
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Live virus vaccines can interfere with
the response to a tuberculin test
Tuberculin testing can be done either
on the same day that live virus vaccines
are administered or 4 – 6 weeks later
Special Conditions…
Special Considerations
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Persons with hemophilia
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Increased risk of hepatitis B & hematomas
Assess the patient’s bleeding risk
Use fine needle & apply pressure to the
site
Special considerations…
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Altered immunocompetence
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Killed or inactivated vaccines can be
administered to all immunocompromised
patients
OPV should not be given to any household
contacts of an immunocompromised
patient
IPV can be given
Special considerations….
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Altered immunocompetence
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MMR is not contraindicated to close
contacts of immunocompromised persons
MMR vaccine is recommended for all
asymptomatic HIV-infected persons and
should be considered for all symptomatic
HIV-infected persons
Special consideratios…
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Preterm infants
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Regardless of birth weight should be
vaccinated at the same chronological age
and according to the same schedule
Use full recommended dose except BCG
OPV should be deferred until discharge
from the nursery
Special considerations…
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Pregnancy
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Combined tetanus and diphtheria toxoids
ARE THE ONLY vaccine indicated
Vaccines
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BCG (Bacille-Calmette-Guerin)
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Attenuated bovine strains of tubercle bacilli
Route: intradermal
Dose: 0.05 ml preterm
0.1 ml term
Complications
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Abscess
Indolent ulcer
lymphadenopathy
BCG
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Normal course
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Wheal diappear in 30
mins
Induration – after 23 wks
Pustular formation –
after 4 – 6 wks
Full scarification –
after 6 – 12 wks
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Accelerated
reaponse – 91100% correlation
with TB infection
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Induration – after 2
– 3 days
Pustular formation –
after 5 – 7 days
Scar – after 2 -3 wks
Polio vaccine
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OPV – live attenuated vaccine
IPV – inactive polio virus
Combination vaccine:
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DPT + IPV + Hib
DPT
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Toxoids of diphtheria & tetanus;
inactivated pertussis component
adsorbed into aluminum salts
Dose: 0.5 ml
Route: IM
Side effect: swelling at injection site
DTaP
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Diphtheria, tetanus, acellular pertussis
component
Decrease risk of neuroparalytic
reactions due to component of pertussis
Measles
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Live attenuated vaccine
Freeze dried
Dose: 0.5 ml SQ
Side effects: fever between 5th-14th day after
injection, rashes, arthritis
Prophylaxis: may be given within 72
hours after measles exposure
Measles IG – 0.25 ml/kg IM may be within 6
days of exposure
Hepatitis B Vaccine
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Infant born to HBs Ag-positive mother
should received:
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Hep b Vaccine + Hep B immune globulin
(HBIG) within 12 hours of birth at different
site
Next dose: Hep B at 1-2 months of age
and 3rd dose at 6th month of age
Schedule: 0, 1, 6
Hepatitis B Vaccine
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Infant born to mother whose HBsAg
status is unknown:
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Hep B vaccine within 12 hours of birth
Request for mother’s HBsAg status – if (+)
Infant should received HBIG Asap
(no later than 1 week of age)
Recommended Schedule
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BCG
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DPT, TOPV, IPV, Hib
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Hepatitis B
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Measles
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At birth or anytime after
birth
2, 4, 6 month of age
0, 1, 6 month of age
0, 1, 3 month of age
(endemic country)
9 month of age
( can be given at 6
month of age)
Schedule….
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MMR
Hepatits A
Pneumococcal (IPD
7 valent)
Pneumococcal (23valent)
Meningococcal
Typhoid
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15 month of age
After 1 year of age
2, 4, 6 months up to
9 years of age
2 years of age
2 years of age
3 years of age
Post-exposure Drug
Prophylaxis
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Diphtheria
Pertussis
Cholera
Plasmodia
N. gonorrhea
Meningococcemia
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Tuberculosis
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Erythromycin
Erythromycin
Tetracycline
Chloroquine
Amoxicillin/Penicillin
Rifampicin
Sulfisoxazole
Ceftriaxone
Isoniazid
Case 1
A 3 y/o child was exposed to a person with measles. Past
immunization hx: he had received 1 dose of BCG, 3 doses of
DPT, TOPV & Hepatitis B. If you are the attending physician,
how are you going to manage the patient?
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Give measles vaccine if the exposure is within 72 hours
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Give measles immunoglobulin if the exposure is more than 72
hours
 Give MMR if the exposure is within 72 hours
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Give Mesles vaccine and immune globulin at the same time
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Observe the patient