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Vaccination: A Cornerstone of Public Health TH Tulchinsky MD MPH Braun School of Public Health BOX 4.3: VACCINES AND PREVENTION The Greeks had two gods of health. Aesculapius and Hygiea, therapy and prevention, respectively. Medicine in the twentieth century retains those two concepts, and vaccination is a powerful means of prevention. What follows is information on the vaccines that together with sanitation, make modern society possible, and that if wisely used will continue to bestow on mankind the gift of prevention, which according to proverb is worth far more than cure. Source: Plotkin SA, Mortimer EA. Vaccines. Philadelphia: WB Saunders, 1988 [Introduction]. Vaccination Issues • • • • • • • • • • Organization Reporting “up and down and sideways” (UDS) Coverage Herd immunity Strategies and target groups Program content Continuous up-dating International and “gold standards” Infectious and chronic diseases Costs and benefits Vaccine Preventible Diseases (VPDs) • World immunization coverage increased from 10% in 1970s to 80 in 1990s, then decreased to 77% in 1995-98 • Smallpox eradication 1982 ? • Polio eradication 2005? • Measles • still kills 1 million per year • need for a two dose policy • Cost and priorities • • • • • • Hepatitis B and A Hib MMRx2, DPTx4 - update policies Varicella Human papillovirus (HPV) and Cancer of cervix New vaccines and cocktails Vaccines: a suspension of live or killed microorganisms or antigenic portion of those agents presented to a potential host to induce immunity to prevent the specific disease cause by that organism. Preparation of Vaccines a. Live attenuated organisms which have been passed repeatedly in tissue culture or chick embryos so that they have lost their capacity to cause disease, but retained an ability to induce antibody response, such as polio (Sabin), measles, rubella, mumps, yellow fever, BCG, typhoid and plague. b. Inactivated or killed organisms which have been killed by heat or chemicals but retain and ability to induce antibody response. They are generally safe but less efficacious than live vaccines and require multiple doses; e.g. polio (Salk), influenza, rabies and Japanese encephalitis. c. Cellular fractions: usually polysaccharide fraction of the cell wall of a disease causing organism, such as pneumococcal pneumonia or meningococcal meningitis d. Recombinant vaccines: produced by methods in which specific DNA sequences are inserted by molecular engineering techniques, e.g. DNA sequences spliced to vaccinia virus grown in cell culture to produces an effective influenza vaccine, and Hepatitis B vaccine by similar methods. Passive Immunity “Vaccination” Toxoids or antisera: are modified toxins made non-toxic to stimulate formation of an antitoxin, such as those produced to protect against toxins of tetanus, diphtheria, botulism, gas gangrene, snake and scorpion venom. Immune globulin: An antibody containing solution derived from human blood in the form of pooled plasma, used primarily for immunity for passive immunization such as for immunocompromised persons e.g. smallpox response groups. Antitoxin: is an antibody derived from serum of animals after stimulation with specific antigens and used to provide passive immunity in humans. Target Groups • Newborns - Hep B, DPT, Polio, BCG • Infants – Hep B, DPT, Polio (IPV, OPV), Hib, Hep A, MMR • Pre-schoolers • School age children - dT, MMR • Adult women - Rubella • Chronically ill – Influenza, pneumococcal pneumonia • Travellers – yellow fever, polio, dT • Adults - dT • Elderly - Influenza, pneumococcal pneumonia, dT • Risk groups for bioterrorism – smallpox, anthrax Table 4.4: Annual Incidence of Vaccine Preventable Infectious Diseases in Rates per 100,000 Population, Selected Years, United States, 1950-1996 Disease 1950 1960 1970 1980 3.8 0.5 0.2 Pertussis 79.8 8.2 Poliomyelitis 22.0 1.8 Measles 211.0 245.4 Mumps na Rubella Hepatitis A Diphtheria Hepatitis B 1985 1990 1996 0 0 0 0 2.1 0.8 1.5 1.8 2.9 0 0 0 0 0 23.2 6.0 1.2 11.2 0.2 na 55.6 3.9 1.3 2.2 0.3 na na 27.8 1.7 0.3 0.5 0.1 na na 27.8 12.8 10.0 12.6 11.7 na na Source: Health, United States, 1990 and 1998. 4.1 8.4 11.5 8.5 4.0 Diphtheria 0 5 0 1 1 3 3 0 2 5 2 0 1 5 1 0 + D i p h t h e r i a i n c i d e n c e 5 0 1 9 7 01 9 7 51 9 8 01 9 8 51 9 9 01 9 9 52 0 0 02 0 0 5 p Tetanus 0 5 0 1 1 4 0 . 4 . 3 5 0 . 3 . 2 5 0 . 2 . 1 5 0 . 1 . 0 5 + T e t a n u s i n c i 9 01 d e n c e p e r 0 1 9 7 01 9 7 51 9 8 01 9 8 51 9 9 9 52 0 0 02 0 0 5 Rubella 0 5 0 1 3 0 0 0 0 9 0 0 8 0 0 7 0 0 6 0 0 5 0 0 4 0 0 3 0 0 2 0 0 1 0 0 + R u b e l l a i n c i 9 01 d e n c e p e r 0 1 9 7 01 9 7 51 9 8 01 9 8 51 9 9 9 52 0 0 02 0 0 5 Congenital Rubella 0 5 0 1 1 7 . 1 4 . 1 2 0 . 1 . 0 8 . 0 6 . 0 4 . 0 2 + C o n g e n i t a l 51 9 9 r u b e l l a i 0 0 5 0 1 9 7 01 9 7 9 8 01 9 8 51 01 9 9 52 0 0 02 n Measles 0 5 0 1 1 1 3 5 0 3 0 0 2 5 0 2 0 0 1 5 0 1 0 0 5 + M e a s l e s i n c i d e n c e p e 0 0 1 9 7 01 9 7 51 9 8 01 9 8 51 9 9 01 9 9 52 0 0 02 0 0 5 AIDS Infection Rates 0 5 0 3 1 2 3 . + C l i n i c a l l y d i a g n o s e d 5 3 2 . 5 2 1 . 5 1 0 . 5 0 1 9 7 01 9 7 51 9 8 01 9 8 51 9 9 01 9 9 52 0 0 02 0 0 5 HIB Incidence Rates 0 4 0 3 1 6 2 . + H a e m o p h i l i u s i n f l u e 0 5 5 2 1 . 5 1 0 . 5 0 1 9 7 01 9 7 51 9 8 01 9 8 51 9 9 01 9 9 52 0 0 02 0 Regulation of Vaccines Inspection of vaccines for safety, purity, potency and standards is part of the regulatory function. Vaccines are defined as biologic products and are therefore subject to regulation by national health authorities. In US, this comes under the legislative authority of the Public Health Service Act, as well as the Food, Drug and Cosmetics Act, with applicable regulations in the Code of Federal Regulations. Federal agency empowered to carry out this regulatory function is the Center for Drugs and Biologics of the Federal Food and Drug Administration. Litigation re side effects of vaccines is costly, led to inflation of costs and efforts to limit court settlements. US federal Child Vaccine Injury Act of 1988 requires providers to document vaccines and report complications or reactions. Pays benefits to persons injured by vaccines faster and less expensive procedure than a civil suit for resolving claims in “no-fault system”, Eradication or Control of VPDs • Since eradication of smallpox, discussion of possibility of eradicating other diseases • Potential candidate diseases emerged; some were abandoned because of practical difficulties with current technology • Diseases under discussion for eradication - measles, TB, and some tropical diseases e.g. malaria and dracunculiasis • Eradication - no further cases of a disease occur anywhere in nature; continued control measures may be unnecessary e.g. smallpox, polio • Reducing epidemic and endemic VPDs in selected areas or target groups, may achieve local elimination • Local elimination is where domestic circulation of a virus is interrupted with cases occurring from importation only • Strong, sustained immunization program, adaptation to changing epidemiologic patterns e.g. age groups, impotation Vaccine Coverage Vaccine No. persons immunized in specified age group Coverage = --------------------------------------------- X 100 No. persons in the age group during that year HIGH RISK GROUPS RECOMMENDED FOR ANNUAL INFLUENZA VACCINATION Adults and children with chronic cardiovascular and respiratory conditions under medical supervision; Residents of long-term care facilities, such as nursing homes; Adults over 65 years of age; Patients on long term aspirin therapy who are at risk for Reye Syndrome following influenza infection; Persons with HIV infection or immuno-suppression; Medical personnel; Employees of nursing homes and long term care facilities; Home care staff and contacts of high-risk individuals Children. • Source: From Cassens B. Preventive Medicine and Public Health, Second Edition. Malvern PA: Harwal Co., 1992, p. 99. RISK GROUPS RECOMMENDED FOR PNEUMOCOCCAL VACCINE Given once to the following categories of persons at high risk: 1. People over 65 years of age; 2. The chronically ill e.g. with cardiovascular, respiratory, liver, renal disease or diabetes mellitus; 3. Asplenic patients; 4. Adult immuno-compromised patients, including HIV positive persons; 5. Children 2 years or older who are chronically ill, or immuno-compromised; 6. Persons travelling abroad. • • Source: Cassens B. Preventive Medicine and Public Health, Second Edition. Malvern PA: Harwal Co, 1992, p 95. CRITERIA FOR ASSESSING ERADICABILITY OF DISEASES, INTERNATIONAL TASK FORCE FOR DISEASE ERADICATION (ITFDE) Scientific Feasibility a. Epidemiologic vulnerability; lack of non-human reservoir, ease of spread, no natural immunity, relapse potential; b. Effective practical intervention available; vaccine or other primary preventive or curative treatment, or vectoricide that is safe inexpensive, long lasting and easily used in the field; c.Demonstrated feasibility of elimination in specific locations, such as an island or other geographic unit. 1. 2. Political Will/Popular Support a. Perceived burden of the disease; morbidity, mortality, disability and costs of care in developed and developing countries; b. Expected cost of eradication; c. Synergy of implementation with other programs; d. Reasons for eradication versus control. • Source: Morbidity and Mortality Weekly Review, 1992;41:40-2. A decade after the eradication of smallpox was achieved, And International Task Force for Disease Eradication (ITFDE) WHO 1998 Health Targets of Infectious Disease Eradication/Control Eradication of Chaga's disease by 2010; Eradication of neonatal tetanus by 2010; Eradication of leprosy by 2010; Eradication of measles by 2020; Eradication of trachoma by 2020; Reversing the current trend of increasing tuberculosis and HIV/AIDS Footnotes for Recommended Adult Immunization Schedule 1. Tetanus and diphtheria (Td): A primary series for adults is 3 doses: the first 2 doses given at least 4 weeks apart and the 3rd dose, 6-12 months after the second. Administer 1 dose if the person had received the primary series and the last vaccination was 10 years ago or longer. MMWR 1991; 40 (RR-10): 1-21. The ACP Task Force on Adult Immunization supports a second option: a single Td booster at age 50 years for persons who have completed the full pediatric series, including the teenage/young adult booster. Guide for Adult Immunization. 3rd ed. ACP 1994: 20. 2. Influenza vaccination: Medical indications: chronic disorders of the cardiovascular or pulmonary systems including asthma; chronic metabolic diseases including diabetes mellitus, renal dysfunction, hemoglobinopathies, immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus [HIV] ), requiring regular medical followup or hospitalization during the preceding year; women who will be in the second or third trimester of pregnancy during the influenza season. Occupational indications: health care workers. Other indications: residents of nursing homes and other long-term care facilities; persons likely to transmit influenza to persons at high-risk (in-home care givers to persons with medical indications, household contacts and out-of-home caregivers of children birth to 23 months of age, or children with asthma or other indicator conditions for influenza vaccination, household members and care givers of elderly and adults with high-risk conditions); and anyone who wishes to be vaccinated. MMWR 2002; 51 (RR-3): 1 -31. 3. Pneumococcal polysaccharide vaccination: Medical indications: chronic disorders of the pulmonary system (excluding asthma), cardiovascular diseases, diabetes mellitus, chronic liver diseases including liver disease as a result of alcohol abuse (e.g., cirrhosis), chronic renal failure or nephrotic syndrome, functional or anatomic asplenia (e.g., sickle cell disease or splenectomy), immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkins disease, generalized malignancy, organ or bone marrow transplantation), chemotherapy with alkylating agents, anti-metabolites, or long-term systemic corticosteroids. Geographic/other indications: Alaskan Natives and certain American Indian populations. Other indications: residents of nursing homes and other long-term care facilities. MMWR 1997; 47 (RR-8): 1-24. 4. Revaccination with pneumococcal polysaccharide vaccine: one time revaccination after 5 years for persons with chronic renal failure or nephrotic syndrome, functional or anatomic asplenia (e.g., sickle cell disease or splenectomy), immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkins disease, generalized malignancy, organ or bone marrow transplantation), chemotherapy with alkylating agents, anti-metabolites, or long-term systemic corticosteroids. For persons 65 and older, one-time revaccination if they were vaccinated 5 or more years previously and were aged less than 65 years at the time of primary vaccination. MMWR 1997; 47 (RR-8): 1-24. 5. Hepatitis B vaccination: Medical indications: hemodialysis patients, patients who receive clotting-factor concentrates. Occupational indications: healthcare workers and public-safety workers who have exposure to blood in the workplace, persons in training in schools of medicine, dentistry, nursing, laboratory technology, and other allied health professions. Behavioral indications: injecting drug users, persons with more than one sex partner in the previous 6 months, persons with a recently acquired sexually-transmitted disease (STD), all clients in STD clinics, men who have sex with men. Other indications: household contacts and sex partners of persons with chronic HBV infection, clients and staff of institutions for the developmentally disabled, international travelers who will be in countries with high or intermediate prevalence of chronic HBV infection for more than 6 months, inmates of correctional facilities. MMWR 1991; 40 (RR-13): 1-25. (www.cdc.gov/travel/diseases/hbv.htm) 6. Hepatitis A vaccination: For the combined HepA-HepB vaccine use 3 doses at 0, 1, 6 months). Medical indications: persons with clotting-factor disorders or chronic liver disease. Behavioral indications: men who have sex with men, users of injecting and noninjecting illegal drugs. Occupational indications: persons working with HAV-infected primates or with HAV in a research laboratory setting. Other indications: persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A. MMWR 1999; 48 (RR-12): 1-37. (www.cdc.gov/travel/diseases/hav.htm) 7. Measles, Mumps, Rubella Vaccination (MMR): Measles component: Adults born before 1957 may be considered immune to measles. Adults born in or after 1957 should receive at least one dose of MMR unless they have a medical contraindication, documentation of at least one dose or other acceptable evidence of immunity. A second dose of MMR is recommended for adults who: are recently exposed to measles or in an outbreak setting were previously vaccinated with killed measles vaccine were vaccinated with an unknown vaccine between 1963 and 1967 are students in post-secondary educational institutions work in health care facilities plan to travel internationally Mumps component: 1 dose of MMR should be adequate for protection. Rubella component: Give 1 dose of MMR to women whose rubella vaccination history is unreliable and counsel women to avoid becoming pregnant for 4 weeks after vaccination. For women of child-bearing age, regardless of birth year, routinely determine rubella immunity and counsel women regarding congenital rubella syndrome. Do not vaccinate pregnant women or those planning to become pregnant in the next 4 weeks. If pregnant and susceptible, vaccinate as early in postpartum period as possible. MMWR 1998; 47 (RR-8): 1-57. 8.Varicella vaccination: Recommended for all persons who do not have reliable clinical history of varicella infection, or serological evidence of varicella zoster virus (VZV) infection; health-care workers and family contacts of immunocompromised persons, those who live or work in environments where transmission is likely (e.g., teachers of young children, day care employees, and residents and staff members in institutional settings), persons who live or work in environments where VZV transmission can occur (e.g., college students, inmates and staff members of correctional institutions, and military personnel), adolescents and adults living in households with children, women who are not pregnant but who may become pregnant in the future, international travelers who are not immune to infection. Note: Greater than 90% of U.S. born adults are immune to VZV. Do not vaccinate pregnant women or those planning to become pregnant in the next 4 weeks. If pregnant and susceptible, vaccinate as early in postpartum period as possible. MMWR 1996; 45 (RR-11): 1-36, MMWR 1999; 48 (RR-6): 1-5. 9.Meningococcal vaccine (quadrivalent polysaccharide for serogroups A, C, Y, and W-135). Consider vaccination for persons with medical indications: adults with terminal complement component deficiencies, with anatomic or functional asplenia. Other indications: travelers to countries in which disease is hyperendemic or epidemic (“meningitis belt” of sub-Saharan Africa, Mecca, Saudi Arabia for Hajj). Revaccination at 3-5 years may be indicated for persons at high risk for infection (e.g., persons residing in areas in which disease is epidemic). Counsel college freshmen, especially those who live in dormitories, regarding meningococcal disease and the vaccine so that they can make an educated decision about receiving the vaccination. MMWR 2000; 49 (RR-7): 1-20. Note: The AAFP recommends that colleges should take the lead on providing education on meningococcal infection and vaccination and offer it to those who are interested. Physicians need not initiate discussion of the meningococcal quadravalent polysaccharide vaccine as part of routine medical care. Based on the Recommendations of the Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention Recommended Adult Immunization Schedule United States, 2002-2003 and Recommended Immunizations for Adults with Medical Conditions Summary of Recommendations Published by The Advisory Committee on Immunization Practices Department of Health and Human Services Centers for Disease Control and Prevention Recommended Adult Immunization Schedule, United States, 2002-2003 For all persons in this age group Age Vaccine Catch-up on childhood vaccinations 19-49 years For persons with medical / exposure indications 50-64 years Tetanus, Diphtheria (Td)* Recommended Immunizations for Adults with Medical Conditions, United States, 2002-2003 For all persons in this group Catch-up on childhood vaccinations Vaccine 65 years and older Medical Conditions 1 dose booster every 10 years1 TetanusDiphtheria (Td)* Pregnancy 1 dose annually for persons with medical or occupational indications, or household contacts of persons with indications 2 Influenza Pneumococcal (polysaccharide) 1 annual dose 1 dose for persons with medical or other indications. (1 dose revaccination for immunosuppressive conditions) 3,4 1 dose for unvaccinated persons 3 1 dose revaccination 4 Hepatitis B* 3 doses (0, 1-2, 4-6 months) for persons with medical, behavioral, occupational, or other indications 5 Hepatitis A 2 doses (0, 6-12 months) for persons with medical, behavioral, occupational, or other indications 6 Measles, Mumps, Rubella (MMR)* Varicella* Meningococcal (polysaccharide) 1 dose if measles, mumps, or rubella vaccination history is unreliable; 2 doses for persons with occupational, geographic, or other indications 7 2 doses (0, 4-8 weeks) for persons who are susceptible 8 1 dose for persons with medical or other indications 9 Diabetes, heart disease, chronic pulmonary disease, chronic liver disease, including chronic alcoholism Influenza For persons with medical / exposure indications Pneumo- Hepatitis coccal B* (polysaccharide) B E Renal failure / end stage renal disease, recipients of hemodialysis or clotting factor concentrates E Asplenia including elective splenectomy and terminal complement component deficiencies HIV infection *Covered by the Vaccine Injury Compensation Program. A. If pregnancy is at 2nd or 3rd trimester during influenza season. B. Although chronic liver disease and alcoholism are not indicator conditions for influenza vaccination, give 1 dose annually if the patient is > 50 years, has other indications for influenza vaccine, or if the patient requests vaccination. C. Asthma is an indicator condition for influenza but not for pneumococcal vaccination. D. For all persons with chronic liver disease. E. Revaccinate once after 5 years or more have elapsed since initial vaccination. F. Persons with impaired humoral but not cellular immunity may be vaccinated. MMWR 1999; 48 (RR-06): 1-5. For additional information about the vaccines listed above and c ontraindications for immunization, visit the National Immunization Program Website at http://www.cdc.gov/nip/ or call the National Immunization Hotline at 800-232-2522 (English) or 800-232-0233 (Spanish). Approved by the Advisory Committee on Immunization Practices (ACIP), and accepted by the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP) C Congenital immunodeficiency, leukemia, lymphoma, generalized malignancy, therapy with alkylating agents, antimetabolites, radiation or large amounts of corticosteroids See Footnotes for Recommended Adult Immunization Schedule on the back cover. Report all clinically significant post-vaccination reactions to the Vaccine Adverse Event Reporting Sys tem (VAERS). Reporting forms and instructions on filing a VAERS report are available by calling 1-800-822-7967 or from the VAERS website at http://www.vaers.org. Measles Mumps Rubella (MMR)* Varicella* A *Covered by the Vaccine Injury Compensation Program. For information on how to file a claim call 1-800-338-2382. Please also visit http://www.hrsa.osp.gov/vicp accessed February 21, 2002. To file a claim for vaccine injury write: U.S. Court of Federal Claims, 717 Madison Place, N.W., Washington D.C. 20005. (202) 219-9657. This schedule indicates the recommended age groups for routine administration of currently licensed vaccines for persons 19 year s of age and older. Licensed combination vaccines may be used whenever any components of the combination are indic ated and the vaccine’s other components are not contraindicated. Providers should con sult the manufacturers' package inserts for detailed recommendations. Hepatitis A Contraindicated D F G E, H, I E, J K G. Hemodialysis patients: Use special formulation of vaccine (40 ug/mL) or two 1.0 mL 20 ug doses given at one site. Vaccinate early in the course of renal disease. Assess antibody titers to hep B surface antigen (anti-HBs) levels annually. Administer additional doses if anti-HBs levels decline to <10 milliinternational units (mlU)/ mL. H. Also administer meningococcal vaccine. I. Elective splenectomy: vaccinate at least 2 weeks before surgery. J. Vaccinate as close to diagnosis as possible when CD4 cell counts are highest. K. Withhold MMR or other measles containing vaccines from HIV-infected persons with evidence of severe immunosuppression. MMWR 1996; 45: 603-606, MMWR 1992; 41 (RR-17): 1-19. Bacterial Diseases • Control - Elimination as a Public Health Problem – – – – – – Pertussis Neonatal tetanus Congenital syphilis Trachoma Tuberculosis Leprosy • Eradicable- Regional/Global – Diphtheria – Hemophilus influenza b Viral Diseases • Control - Elimination as a Public Health Problem – – – – – Hepatitis B Hepatitis A Yellow fever Rabies Japanese encephalitis • Eradicable- Regional/Global – – – – Poliomyelitis Measles Rubella Mumps Parasitic Disease • Control - Elimination as a Public Health Problem – – – – – Malaria Chagas disease Helminthic infestation Schistosomiasis Leishmaniasis, visceral • Eradicable- Regional/Global – Echinococcus – Teniasis Non Infectious Disease • Control - Elimination as a Public Health Problem – – – – – – – – Lead poisoning Silicosis Protein energy malnutrition Micronutrient malnutrition Iodine deficiency Vitamin A deficiency Folic acid deficiency Iron deficiency Source: Goodman RA, Foster KL, Trowbridge FL, Figuero JP. Global Disease Elimination and Eradication as Public Health Strategies: Proceedings of a Conference Atlanta, Georgia, USA, 23-25 February 1998. Bulletin of the World Health Organization. 1998;76 Supplement 2:1-161. New Vaccines-New Issues • • • • • • • Human Papilovirus HIV Malaria Dengue Salmonella E coli Streptococcal • • • • • Lyme disease Ebola virus Leishmaniasis Helicobacter Many others HPV Vaccine • • • • • Human Papillovirus Sexually transmitted disease High prevalence in uncircumcised men Cancer of cervix among top Ca’s of women Screening works but expensive and non-existent in many countries • Women’s health issue • HPV vaccine ready fro use within 3-5 years H Pylori H. pylori is among commonest bacterial infections in humans, and may be be transmitted by water and oral fecal spread. Genomics may help understanding the pathogenesis of H. pylori infection and development of new therapies, including H. pylori–specific antimicrobial agents and vaccines Enormous progress in studying the virulence factors of H. pylori and their variation, but not yet used in clinical practice Px and Rx vaccination have been successful in animal models, but the translation to human vaccine remains difficult These developments will be needed to prevent and treat this infection in areas of the world where there is a high prevalence of chronic infection Nobel Prize in Medicine 2005 – Bioterrorism and Vaccines • Anthrax • Smallpox • Hemorrhagic fevers e.g. Rift Valley Fever and many others • Polio Other National Considerations • • • • • • • Eradication of measles – high priority Control of mumps Control of rubella and rubella syndrome Haemophilus influenza B Hepatitis B and A Influenza and pneumonia Adult diphtheria and tetanus BASIC TERMS IN IMMUNOLOGY OF INFECTIOUS DISEASES Infectious agent: organism (e.g. virus, rickettsia, bacteria, fungus, protozoa or helminth) capable of producing infection or an infectious disease. Infection: the process of entry, development and multiplication of an infectious agent into the body of a living body (human, animal or plant) resulting in an inapparent or clinically manifest disease. Antigen: a substance (e.g. protein, polysaccharide) capable of inducing specific response mechanisms in the body. An antigen may be introduced into the body by invasion of an infectious agent, by immunization, inhalation, ingestion or through the skin, wounds or via transplantation. Antibody: a protein molecule formed by the body in response to a foreign substance (an antigen) or acquired by passive transfer. Antibodies bind to the specific antigen that elicits its production, causing the infective agent to be susceptible to immune mechanisms protecting against infectious disease. Immunoglobulins: antibodies which meet different types of antigenic challenges. They are present in blood or other body fluids, and can cross from a mother to fetus in utero, providing protection during part of the first year of life. There are 5 major classes and various subclasses are based on molecular weight. Antisera or antitoxin: are materials prepared in animals for use in passive immunization against infection or toxins. Vaccines administered simultaneously: directions for new combination vaccines based on historical review of the literature. Fletcher MA, Fabre P, Debois H, Saliou P. Combination vaccines needed to fill epidemiologic niches in EPI with, e.g. a measles-yellow fever, a measles-Japanese encephalitis or a pertussis-based paediatric combination rabies vaccine. Other combinations could broaden protection against the pathogens responsible for meningitis, pneumonia, or enteric diseases. Complex issues such as necessity, feasibility, or affordability will determine future combination vaccines Int J Infect Dis. 2004 Nov;8(6):328-38. Summary and Conclusion • • • • Vaccination is cornerstone of NPH Children and other groups Rapidly developing field First priority in public health after safe water and food • National programs must be revised annually