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Childhood Immunisations

Childhood Immunisations. Dr Rukhsana Hussain 9 th November 2010. “ Whoever wants to give people what is due from him, let him love for them what he loves for himself ”. Objectives. To outline the new UK routine childhood immunisation schedule including changes

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Childhood Immunisations

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  1. Childhood Immunisations Dr Rukhsana Hussain 9th November 2010

  2. “Whoever wants to give people what is due from him, let him love for them what he loves for himself ”

  3. Objectives • To outline the new UK routine childhood immunisation schedule including changes • To raise awareness of specific and general contraindications to vaccines • To mention important facts regarding certain vaccines • To describe the BCG immunisation policy • To highlight where to access information for self and parents

  4. Content • Introduction • Quiz • Classification of vaccines • Table of UK childhood schedule • Changes to UK immunisation program • General contraindications to immunisation • Information regarding specific vaccines • Summary • Sources of information and answers to Quiz

  5. Immunisation • Proven tool for controlling and eliminating life-threatening infectious diseases • Cost effective public health measure • Childhood immunisation schedule is primary prevention measure, aiming to vaccinate children prior to exposure • High levels uptake confers “herd immunity” and saves lives

  6. Immunisation • Herd immunity - Protects unvaccinated individuals, through having sufficiently large proportion of population vaccinated • Vaccinated individuals stop transmission of organism • Proportion required to be immune depends on transmissibility and infectiousness of organism and social mixing in population

  7. Immunisation • Important for health professionals to promote immunisation in population to reduce outbreaks • In general, adverse effects due to vaccines much milder than complications if acquire disease

  8. Edward Jenner vaccinating a boy. Oil painting by EE Hillemacher, 1884

  9. Quiz 1) A 12 month old is due for his routine immunisations. What should be given at this stage? • MMR and PCV • MMR and Hib • MMR +Dtap +IPV • MMR +Men C • Hib + Men C

  10. 2) How many doses of tetanus vaccine should a child receive as part of the routine UK schedule? • None • 3 • 6 • 4 • 5

  11. 3) After first MMR vaccination if side effects do occur which are most likely? • Diarrhoea after 5-10 days, lasting 2-3 days • Arthralgia after 5-10days, lasting 2-3 days • Malaise, fever and rash after 5-10 days lasting 2-3 days • Malaise, fever and rash after 2-3 days lasting 1-2 days

  12. 4) Premature babies should be vaccinated according to their post-conceptional age rather than chronological age (Time from birth) • True • False

  13. 5) A mother brings in her child for DTaP booster. Which one of the following would make it inappropriate to vaccinate today? • Below 2nd centile for weight • Family history of allergy to DTaP • Planned general anaesthesia in 2 weeks time • Recent onset of seizure disorder being investigated

  14. 6) Regarding the BCG vaccine, which of the following are true? • Is a killed vaccine • Recommended at 10-14 years age • Provides more consistent protection against TB meningitis that pulmonary disease • Typically given in right upper arm • Is a subcutaneous injection

  15. 7) A 10 year old Bangladeshi boy is a recent immigrant to the UK. He is well but has been advised to have the BCG vaccine. What should you do? • Arrange for him to have BCG vaccine • Reassure parents that he doesn’t need it • Arrange CXR • Arrange tuberculin skin test • Prescribe a course of rifampicin

  16. 8) Which of the following regarding the HPV vaccine is incorrect? • Cervarix is given in 3 doses • Given at legal age of consent for sex • Gardasil protects against HPV 6, 11, 16 and 18 • HPV is main aetiological factor in development of cervical cancer

  17. 9) Which of the following would be contraindications to Dtap/IPV/Hib vaccine? • URTI with no fever • Previous anaphylactic reaction to vaccine • Severe eczema • Acute febrile illness • Family history epilepsy

  18. 10) MMR is a live vaccine • True • False

  19. Classification of vaccines • Killed vaccines - Pertussis (aP – acellularpertussis) - IPV (inactivated polio vaccine) • Live attenuated - MMR - BCG • Toxoids - Diptheria (D) - Tetanus (T) • Components - Hib - Men C - PCV (pneumococcal conjugate vaccine) - HPV

  20. UK childhood immunisation schedule

  21. Changes to UK schedule (1) • BCG vaccine no longer routinely given teenagers in school. Only high risk groups + neonates from high risk categories • HPV immunisation introduced September 2008 in 12-13 year old girls • IPV replaces live oral polio vaccine -IPV has no risk of vaccine associated polio -risk of imported polio now low so can switch from OPV (better community protection) to IPV (effective individual protection)

  22. Changes to UK schedule (2) • Pertussis - acellular pertussis (ap) vaccine replaces whole cell pertussis vaccine - as effective as previous vaccine with fewer side effects • Pneumococcal conjugate vaccine - new vaccine introduced 2006 as pneumococcal disease important cause of morbidity and mortality in children <2yr - booster doses needed after 12mths age to continue protection

  23. Changes to UK schedule (3) • Hib and Men C - Men C vaccine introduced November 1999, UK first country in world to give as routine schedule - Hib introduced 1992 to protect against meningitis (60%), epiglottitis (15% cases), septic arthritis, osteomyelitis, cellulitis, pneumonia - addition of new booster at age 12months (Nov 07 due to increase in cases) - changes to timing of Men C – now 3 and 4 months only

  24. General contraindications • Confirmed anaphylaxis to previous dose of vaccine with same antigens • Confirmed anaphylaxis to another component in relevant vaccine • Delay vaccination in febrile/intercurrent illness

  25. Live vaccines - contraindications • Pregnancy • On high dose (oral/rectal) steroids (1mg/kg/day for last mth or 2mg/kg/day for last week) – Inhaled/topical/intra-articular steroids not considered immunosuppressive • HIV/immunosuppression (primary or treatment causing immunosuppression) • Previous live vaccine by injection in last 3/52 • Received immunoglobulin or blood product in last 3 mths

  26. NOT CONTRAINDICATIONS! • Asthma/eczema • History of seizures • Breastfed child • Previous history pertussis, measles, mumps, rubella • Neonatal jaundice • FH autism • Stable neurological conditions –eg. Cerebral Palsy, Downs • Low birthweight/prematurity • Patient on replacement steroids eg CAH

  27. DTaP/Hib/IPV • Common/mild reactions are: • Injection site pain, swelling or redness • Small painless nodule at injection site • Mild fever • Vomiting, diarrhoea and loss of appetite • Rare but severe reactions (not CIs) • High fevers • Febrile convulsions (recognised after 3rd dose DTap/IPV/Hibesp if personal history or family history febrile seizures) • HHEs (hypotonic-hyporesponsiveepisodes) • Unusual high pitched screaming • Anaphylaxis – rare 0.65-3 cases in a million doses

  28. PCV (Pneumococcal) • 2 forms of vaccine - 7 valent PCV for infants and children under 5 years. - 23 valent adult PPV (pneumococcal polysaccharide vaccine) for everyone over 65yrs and at risk children over 2 years • “Catch up” programme for children born too late for new vaccine or if missed it Current age < 1yr – give 2 doses PCV at least 2 mths apart + booster between 1-2yrs age at least 2 mths after second PCV Current age 1-2 yrs – single dose PCV

  29. MMR (1) • Live vaccine • Can be given to children of any age whose parents request it • Optimum age 12-15mths • 1st dose not effective in 5-10% of children • Egg allergy – measles virus grown in cultures of fibroblasts from chick embryos, increasing evidence can give MMR safely even if previous anaphylactic reaction to egg

  30. MMR (2) • Refer for vaccination in hospital if: - previous exposure to eggs caused cardiorespiratory reaction - child with egg allergy and coexisting active chronic asthma - if parental concerns – immunisation under controlled conditions

  31. MMR(3) • No link between MMR and autism! • Reactions - very mild form measles common 1 in 10 to 1 in 15 children 7-10 days after MMR rash, fever , malaise for 2-3 days - parotid swelling/mild mumps may occur 1 in 50 children, 3-4 weeks after MMR

  32. MMR (4) • Mild febrile reaction to rubella component may occur 1-3 weeks after MMR, fever, sore throat, lymphadenopathy, rash • Less common - arthritis due to rubella component 1-3 weeks after MMR, lasting up to 3 days • Serious adverse effects rare - febrile convulsions 6-11 days after MMR 1 in 3000 ( 1in 200 if have MMR infection!) - thrombocytopenia 1 in 24000, usually resolves spontaneously ( 1 in 3000 with rubella infection) - anaphylaxis 1 in 100,000. No deaths

  33. Cervarix (HPV) • 12-13 year old girls prior to sexual activity • Catch up plan for girls up to 18yrs • Protects against cervical cancer • Not live vaccine therefore can’t get warts/infection • 3 doses – second after 1 month and 3rd dose after 6months of first dose • Only protects against HPV 16 and 18 (6 and 11 cause warts – Gardasil protects against all 4)

  34. BCG (1) • Greenbook specifies groups to immunise as follows: • All infants (0-12mths) living in area of UK where annual incidence TB is 40/100,000 or greater • All infants (0-12mths) with parent/grandparent born in country where annual incidence TB 40/100,000 or greater • As above for older children also but if >6yrs age need tuberculin skin test • Previously unvaccinated TB negative contacts of cases of respiratory TB • Previously unvaccinated TB negative new entrants under 16yrs age who were born in or who have lived for prolonged periods in country with above incidence TB (3mths or more)

  35. BCG (2) • Healthcare workers • Prison staff • Staff of care homes for elderly • Those who work with homeless • Intradermal injection typically in left upper arm • Efficacy approx 80% against complications of TB eg miliary TB/TB meningitis, less consistent against pulm TB.

  36. BCG(3) • Contraindications are: Previous BCG vaccine Past history TB HIV Pregnancy Positive Tuberculin test (Heaf or mantoux)

  37. Summary • Childhood immunisation is an important public health measure which saves lives • Health professionals need to have adequate knowledge to educate/counsel parents appropriately and promote vaccination in order to confer “herd immunity” • Risk/benefit ratios of preventable diseases vaccinated against hugely favour vaccination

  38. Sources of Information www.who.int/topics/immunization/en www.dh.gov.uk/en/publichealth/immunisation (Green book) NHS choices website www.nhs.uk (good for patient leaflets) www.doctors.net.uk www.passmedicine.com

  39. Answers to Quiz • Hib and MenC • 5 • Malaise, fever and rash after 5-10days lasting 2-3 days • False • Recent onset of seizure disorder currently being investigated • Provides more consistent protection against TB meningitis • Arrange tuberculin test • Given at legal age of consent • Acute febrile illness, previous anaphylaxis • True

  40. “A positive attitude may not solve all your problems, but it will annoy enough people to make it worth the effort” Herm Albright

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