826330476-Vaccine-Preventable-Diseases-in-India-New.pptx

medine important topic for mbbs students

1. Vaccine preventable diseases in India (Epidemiology and Trends) Presenter: Moderator:

2. National Immunization Schedule (NIS) Age Vaccines given At birth BCG, OPV-0, Hep-0 6 weeks OPV-1, Pentavalent-1, Rotavirus Vaccine (RVV)-1, Fractional dose of Inactivated Polio Vaccine (fIPV)-1, Pneumococcal Conjugate Vaccine (PCV) -1 10 weeks OPV-2, Pentavalent-2, RVV-2 14 weeks OPV-3, Pentavalent-3, fIPV-2, RVV-3, PCV-2 9-12 months Measles & Rubella (MR)-1, JE-1 , PCV-Booster 16-24 months MR-2, JE-2, Diphtheria, Pertussis & Tetanus (DPT)-Booster-1, OPV – Booster 5-6 years DPT-Booster-2 10 years Tetanus & adult Diphtheria (Td) 16 years Td Pregnant women Td-1/2/Td booster 22-05-2024 2

3. Vaccine preventable diseases in India covered under Universal Immunization Programme Polio Tetanus Diphtheria Pertussis Severe childhood TB Hepatitis B Rubella Measles Mumps Pneumonia (Pneumococcal pneumonia) Meningitis (H. Influenza) Rotavirus diarrhoea Japanese encephalitis 22-05-2024 3

4. Each vaccine preventable disease will cover the following: Introduction Transmission Signs and symptoms Complications Treatment Prevention Epidemiology of the disease and current trends 22-05-2024 4

5. Diphtheria Introduction: It is a bacterial infection caused by Corynebacterium diphtheriae . Affects the throat and sometimes the tonsils. It affects people of all age groups but mostly attacks the unimmunized children. Transmission: Person to person transmission through close contact or respiratory droplets. 22-05-2024 5

6. Epidemiology 22-05-2024 6 Gram positive, non-motile, non- caAP Person to person transmission: Close contact/ respiratory droplets.

7. Signs and Symptoms Mild fever Sore throat Pseudomembrane in the throat or tonsils Swollen neck glands Weakness and loss of appetite 22-05-2024 7

8. Complications Neurological manifestations like polyneuropathy, cranial nerve involvement, ciliary paralysis. Myocarditis associated with arrythmias and dilated cardiomyopathy. 22-05-2024 8

9. Clinical Features Signs and Symptoms Mild fever Sore throat Pseudomembrane (throat / tonsils) Swollen neck glands Weakness and loss of appetite Complications Neurological manifestations: Polyneuropathy, cranial nerve involvement, ciliary paralysis. Myocarditis a/w arrythmias and dilated cardiomyopathy 22-05-2024 9

10. Treatment Anti- diphtheric serum: IV or IM Early stage (< 48 hours): 20000 to 40000 IU Pharyngeal membranes: 40000 to 60000 IU Late stage (> 3 days or bull neck): 80000 to 120000 IU Antibiotics: - DOC: Azithromycin; Erythromycin * Increased resistance to penicillin 22-05-2024 10

11. Prevention Vaccination: The vaccine is available in combination Pentavalent : Given at 6, 10 and 14 weeks after birth DPT: 2 boosters given at 16-24 months and 5-6 years Td: Given at 10 years and 16 years and during pregnancy 22-05-2024 11

12. Epidemiology Agent: Corynebacterium diphtheriae- Gram positive, non motile, non capsulated, club shaped bacilli. The primary virulence factor for causing diphtheria is Diphtheria Toxin Host: Human- Diphtheria is toxemia and not bacteremia . Bacilli are non invasive present only at local site. The toxin is secreted which enters the bloodstream, spreads to organs and causes the clinical manifestations. 22-05-2024 12

13. Environment: Diphtheria is spread by droplets, secretions or direct contact. Carriers are the source of infection more commonly than the cases. Nasal carriers are more shedding than throat carriers. Humans are the only reservoir and the infection is most commonly seen in unvaccinated children of age 1-5 years. 22-05-2024 13

14. Current trends Due to wide spread immunization, cases were drastically declined by >95% over last 3 decades. However there has been recent resurgence of diphtheria in 2019- outbreaks have been reported in states of Tamil Nadu, Kerala and Karnataka and other states, which could be because of low vaccination coverage. In 2023, in the villages of Palwal and Nuh, three children aged 4, 7 and 11 years died due to diphtheria. 22-05-2024 14

15. The COVID-19 pandemic impacted delivery of routine immunization services and surveillance activities.  These setbacks have left many children susceptible to vaccine preventable diseases such as diphtheria.  A reas with low immunization coverage with the diphtheria toxoid-containing vaccine allow the bacteria to circulate, increasing the likelihood of outbreaks and putting all unvaccinated and under vaccinated individuals at risk. 22-05-2024 15

16. According to a study conducted in 2022 in Haryana by Ahmed et. al. diphtheria mostly affected young unvaccinated or partially vaccinated children. Mortality was high in unimmunized or partially immunized young children and those with bull neck, pseudomembrane , delayed (≥5 days) administration of ADS, acute kidney injury, thrombocytopenia and leukocytosis. Myocarditis was strongly associated with high mortality. There has also been a shift of cases among adults from children in the past few years due to waning immunity and no vaccination by the diphtheria toxoid in adults. 22-05-2024 16

17. Tetanus It is a bacterial infection caused by bacteria Clostridium tetani . C. tetani produces two toxins Tetanolysin ( hemolysin -no role in pathogenesis) and Tetanospasmin (neurotoxin) Transmission: No person to person transmission. Transmission is through injuries (Abrasions, puncture wounds, RTAs), septic surgical wounds, neonates (during delivery if asepsis is not maintained). 22-05-2024 17

18. Signs and Symptoms Incubation period: 6-10 days. Earlier the manifestations, worse the prognosis. Symptoms start with increase in the tone of masseter muscle causing trismus followed by muscle ain and stiffness, back pain and difficulty in swallowing. As the disease progresses painful muscle spasm develops which maybe localised or generalised (descending spastic paralysis) Deep tendon reflexes are exaggerated. 22-05-2024 18

19. Autonomic disturbances are maximum during the second week of severe tetanus characterised by low or high blood pressure, tachycardia, intestinal stasis, sweating, increased tracheal secretions and acute renal failure. In neonates, difficulty in swallowing is the first symptom. 22-05-2024 19

20. Complications Risus sardonicus : Abnormal sustained spasm of the facial muscles that appear to produce grinning. Ophisthotonus position: Abnormal posture of the body due to generalised spastic contractions of extensor muscles. Respiratory muscle spasm may cause respiratory obstruction. 22-05-2024 20

21. Treatment Passive immunization: Human tetanus immunoglobulin 250 IU (HTIG) or Anti Tetanus Serum (ATS) 1500 IU as a single IM dose Antibiotics play a minor role in the treatment of tetanus. However they are useful in early treatment and prevention of further release of toxin. Metronidazole is the drug of choice given for 7-10 days. Alternatively, penicillin or doxycycline can also be given. 22-05-2024 21

22. Other measures: Symptomatic treatment: Endotracheal intubation to maintain the airway. Anti spasmodics to relieve spasms and beta blockers to control the sympathetic hyperactivity. Surgical debridement of the wound 22-05-2024 22

23. Prevention Under national immunization schedule: Pentavalent 1, 2, and 3 doses at 6, 10 and 14 weeks after birth. DPT booster 1 and 2 at 16-24 months and 5-6 years. Td vaccine at 10 years and 16 years. 2 doses of Td vaccine during pregnancy and single booster dose if conceived within 3 years of previous pregnancy, 22-05-2024 23

24. Post exposure prophylaxis given as Td vaccine 0.5ml IM in deltoid for adults and anterolateral thigh in children. 22-05-2024 24

25. Epidemiology Agent: Clostridium tetani- obligate anaerobic, gram positive bacilli with terminal spore. It produces two toxins- Tetanolysin which has no role in pathogenicity and Tetanospasmin which is neurotoxic. The tetanus toxin binds to receptors present on motor nerve terminals and inhibits the release of GABA and glycine which are inhibitory receptors which results in spastic contractions. 22-05-2024 25

26. Host: Humans get the infection through wounds. Post exposure prophylaxis is required to prevent tetanus Environment: The is no human to human transmission in tetanus. Soil is the main reservoir of C. tetani. Tetanus is more common in developing countries including India because of various risk factors such as-( i ) warm climate, (ii) rural area with fertile soil, and (iii) unhygienic surgeries or deliveries. 22-05-2024 26

27. Current trends India has achieved the status of elimination of neonatal tetanus in 2016 as declared by WHO. In 2018 according to WHO report, total of 15,103 cases of tetanus have been reported worldwide, out of which 7,000 (46%) cases were from India. In 2019, India had the most number of tetanus cases of 16,579, followed by Pakistan, Indonesia, and Nigeria, which were all developing countries with populations of more than 200 million. 22-05-2024 27

28. Mumps It is a viral disease caused by paramyxovirus . It is the most common cause of parotid gland enlargement in children. Transmission: Person to person transmission through respiratory route via droplets, saliva. 22-05-2024 28

29. Signs and symptoms Incubation period: 1-3 weeks Non specific symptoms like fever, myalgia, anorexia. More commonly seen in adults. Parotitis : : Acute non- suppurative parotid gland enlargement is the most common specific manifestation, present in 70–90% of the cases. 22-05-2024 29

30. Complications Epididymo-orchitis Aseptic meningitis Oophoritis Pancreatitis 22-05-2024 30

31. Prevention and treatment No specific treatment is available. Treatment is symptomatic. Vaccine against mumps is available in combination with measles and rubella vaccine. The first dose should be given at 9 months and second dose at 12-16 months. However, the MMR vaccine has been discontinued and changed to MR vaccine removing the mumps component. 22-05-2024 31

32. Epidemioilogy Agent: Paramyxovirus of the rubulavirus family. Incubation period ranges from 7 to 21 days. Host: Humans are the only reservoir of infection. Primary replication occurs in the nasal mucosa or upper respiratory tract mucosa. Mumps has a special affinity for glandular epithelium. Target sites include salivary glands, testis, ovaries, pancreas, mammary glands and central nervous system. 22-05-2024 32

33. Environment: Both clinical and sub clinical cases are source of infections. There is no carrier state. The infection mostly occurs during spring and winters and common in overcrowded areas. It is spread by direct human contact and respiratory droplets. 22-05-2024 33

34. Current trends Mumps is endemic worldwide, sporadic cases occurring throughout the year, with a peak in cases typically in winter and spring. Epidemics occur every 3–5 years; typically associated with unvaccinated people living in overcrowded areas. About 5 lakh cases of mumps occur every year globally. Recently many parts of India have witnessed a mumps outbreak including Maharashtra. In 2017 India removed the Mumps vaccine component from MMR vaccine and started a MR vaccine campaign. 22-05-2024 34

35. As of March 2024 15,637 cases of mumps were reported in India. The hotspots for mumps infection were the states of Maharashtra, Andhra Pradesh, Telangana, Karnataka, Kerala and New Delhi. 22-05-2024 35

36. Measles Measles is an acute, highly contagious childhood disease, characterized by fever and respiratory symptoms, followed by typical maculopapular rash. The causative agent, measles virus is a RNA virus, belongs to Paramyxoviridae family. Transmission: Person to person through respiratory route via droplets. 22-05-2024 36

37. Signs and symptoms Fever, cough, coryza , conjunctivitis Koplik spots- White bluish spots surrounded by erythema in the buccal mucosa. Maculopapular rash appears 4 days after fever first behind ears then face, arm, trunk and legs. 22-05-2024 37

38. Complications Diarrhoea leading to malnutrition and vitamin A deficiency Dehydration Encephalitis Pneumonia Otitis media Acute laryngotracheobronchitis 22-05-2024 38

39. Treatment No specific treatment exists. Symptomatic treatment is given. Vitamin A has been effective in reducing morbidity and mortality due to measles 22-05-2024 39

40. Prevention MR vaccination: At 9 months and 12-16 months. The MR vaccination campaign was introduced in Feb 2017. In this campaign all children aged more than 9 months to 15 years were supposed to be vaccinated irrespective of their previous vaccination status. All children were also given 2 doses of Vitamin A. The MR campaign dose was in addition to the routine immunization dose. India has vaccinated around 348 million children from 2017 to march 2023. 22-05-2024 40

41. Epidemiology Agent: The measles virus is a RNA virus from the paramyxoviridiae family. Host: Humans are the only host. There is no animal reservoir. Environment: Measles is endemic throughout the world with epidemics which recur regularly every 2–3 years, typically in late winter and early spring. Cases are the only source of infection. It is transmitted via respiratory droplets. 22-05-2024 41

42. Current Trends The most effective and inexpensive way of preventing measles is vaccination. An estimated 136 000 people died from measles in 2022 – mostly children under the age of five years, despite the availability of a safe and cost-effective vaccine. In 2022-2023 there were 12773 confirmed cases of measles in india with 40 fatalities. Maharashtra had the largest no of cases (3075) and deaths followed by Jharkhand (2683) and Gujarat (1650). 22-05-2024 42

43. There was a drop in vaccinations in 2020 due to the COVID-19 outbreak and lockdown, from 2019-2021 only 56% of Indians received the MR vaccine and 2.6 million infants missed their first dose. Other factors include lack of hygiene, over crowding and vaccine hesitancy. 22-05-2024 43

44. Rubella Rubella is a contagious viral infection that is spread by airborne droplets. It is one of the leading cause of vaccine preventable diseases worldwide accounting for approximately 1 lakh infants born with congenital rubella syndrome each year. Transmission: Via airborne droplets and mother to child transmission. 22-05-2024 44

45. Signs and symptoms In children the disease is usually mild characterised by low grade fever, rash, nausea, lymphadenopathy and conjunctivitis. Infected adults may also develop arthritis. The primary danger of rubella is the infection of pregnant women causing congenital rubella syndrome. The highest risk of transmission is up to 12 weeks and beyond 20 weeks the risk of transmission is rare. 22-05-2024 45

46. Common congenital defects of CRS include cataracts, congenital heart disease, hearing impairment, and developmental delay. Infants with CRS often present with more than one of these signs but may also present with a single defect, most commonly hearing impairment. 22-05-2024 46

47. Treatment and Prevention Rubella is a mild self-limiting disease and requires only symptomatic treatment. The best way to prevent the disease is by vaccinating the child at 9 to 12 months and then at 16-24 months with the MR vaccine. 22-05-2024 47

48. Epidemiology Agent: The rubella virus belongs to the Togaviridae family. It has a ssRNA surrounded by capsid protein and an envelope. Host: Humans are the only known host. Environment: Rubella occurs worldwide and through out the year with a peak in the spring. Epidemics occur every 6–8 years, with explosive pandemics every 20–25 years. The cases are the only source of infection. 22-05-2024 48

49. Current trends India has vaccinated over 348 million children between 2017 and March 2023 through nationwide Measles-Rubella vaccination campaign. Between 2017 and 2021 rubella cases decreased by 48%. In 2021, the incidence of Congenital Rubella Syndrome was 65.5%. 22-05-2024 49

50. Pertussis It is a bacterial infection caused by Bordatella pertussis. Pertussis is primarily a toxin mediated disease. Transmission: Through air-borne respiratory droplets. 22-05-2024 50

51. Signs and symptoms Incubation period: 7-10 days Catarrhal phase: It lasts for 1–2 weeks, and is characterized by common cold like nonspecifc symptoms, such as coryza , lacrimation, mild cough, low-grade fever and malaise. It is highly infectious stage. 22-05-2024 51

52. Paroxysmal phase: Tis stage lasts for 1–6 weeks. Patients are less infectious. It is characterized by specifc symptoms, such as whooping cough and post- tussive vomiting. Convalescent stage: Tis stage lasts for 1–3 months. It occurs following the paroxysmal stage, during which the frequency and severity of coughing gradually decreases. 22-05-2024 52

53. Complications Pressure efects during the violent spasms of coughing results in subconjunctival hemorrhage , hernias, pneumo -thorax, rib. Pneumonia Neurological complications, such as convulsions, encephalopathy. 22-05-2024 53

54. Treatment As pertussis is mainly toxin mediated, antibiotics are less useful once the infection is established. However, they play a vital role to eliminate the bacteria from nasopharynx . ‰ Macrolides are the drugs of choice (azithromycin for 5 days or erythromycin for 7–14 days).‰ Cotrimoxazole is recommended as an alternative in macrolide resistance or allergy. Erythromycin is widely recommended as chemoprophylaxis for household contacts of pertussis. 22-05-2024 54

55. Prevention Under national immunization schedule: Pentavalent 1, 2 and 3 doses at 6, 10 and 14 weeks. DPT booster 1 and 2 at 16-24 months and 5-6 years. 22-05-2024 55

56. Epidemiology Agent: It is caused by a bacteria Bordatella pertussis which is a gram negative cocco bacilli. The organism produces a wide array of toxins like the tracheal cytotoxin and pertussis toxin which is only produced by B. pertussis and is the main virulence factor. Host: Humans are the only host. There are no animal reservoirs. Environment: Pertussis occurs throughout the year but most cases are seen during spring and winter and in places where there is overcrowding. 22-05-2024 56

57. Pertussis is a highly communicable disease with high attack rates. Early cases are the main source of infection and the infection is spread by respiratory droplets. 22-05-2024 57

58. Current Trends There has been a resurgence in cases of pertussis. In 2016 India reported 37,274 cases while there were 1,74,177 cases worldwide. Pertussis has shifted from infants to older children and adolescence in countries with high vaccination coverage. This indicates that pertussis immunizations or natural infection do not provide lifelong immunity. 22-05-2024 58