Pentavapeditricslent and MR vaccine.pptx

Neonatal Dermatosis

1. DPT, Hepatitis B and Hib vaccine and MR vaccine Presented by: Prajmi Khanal Pramisha Poudel (Intern 2017)

2. DPT, Hepatitis B and Hib vaccine

3. Content Overview Components DPT vaccine Acellular Pertussis Vaccine (DTaP) Reduced Antigen Acellular Pertussis Vaccine ( Tdap ) and Reduced Antigen Diphtheria Toxoid Vaccine (Td) Tetanus Vaccine Hepatitis Vaccine Hemophilus influenzae b ( Hib ) vaccine

4. Overview: First developed by Leina Denamrk in 1930s. DPT was introduced in Nepal in 1979 A.D In Nepal, Hepatitis B and Hib was introduced along with DPT as pentavalent vaccination in 2002 A.D and 2009 A.D respectively. Current prophylactics: Combined or mixed vaccines: DPT (diphtheria- pertusis -tetanus vaccine) DTwP (diphtheria, tetanus, whole cell pertusis ) DTaP (diphtheria, tentanus , acellular pertusis ) DT (diphtheria-tetanus, toxoid ) dT (diphtheria-tetanus, adult type)

5. Components Diphtheria Toxoid : Inactivated toxins produced by Corynebacterium diphtheriae . Tetanus Toxoid : Inactivated toxins produced by Clostridium tetani . Pertussis Antigens Hepatitis B surface antigen ( HBsAg ) Hemophilus influenzae type b ( Hib ) Antigens

6. Benefits of Pentavalent vaccine Comprehensive protection, it provides protection against multiple diseases with a single shot. Reduced vaccination visits, making it more convenient for parents and caregivers. Cost-effective, minimizes the cost associated with administering individuals vaccines. Herd immunity

7. Diphtheria, Tetanus and Pertussis vaccine This vaccine contains diphtheria toxin inactivated by formalin and adsorbed on aluminum hydroxide, the adjuvant. The quantity of toxoid in the vaccine, expressed as limit of flocculation (Lf) content is 20-30 Lf of DT , 55-25 Lf of tetanus toxoid (TT) and >4IU of whole cell killed pertusis . Primary immunization with 3 doses, given 4-8 weeks apart, induces satisfactory response to DT and TT in 95-100% infants. However, the efficacy is lower against Pertussis , at 70-90 % and wanes over 6-12 years.

8. This primary immunization does not eliminate C. diphtheriae from skin and nasopharynx , so booster doses are required. Booster doses required to sustain a protective antibody titre of 0.1 IU/ml and also to protect against the disease in the first decade of life. Individuals where DTP is contraindicated, should complete the immunization with DT , but it lacks Pertussis component. DT is recommended upto 7 years, beyond which Td must be used.

9. Dose: 0.5 ml Route: Intramuscular Site: Anterolateral aspect of mid-thigh ( gluteal region not given) National program: Primary dose: DTwP at 6,10 and 14 weeks Booster dose: 15-18 months and 5 years

10. Adverse effects: Common: local pain, swelling, fever. Rare: Hypotonic hyporesponsive episodes, inconsolable cry, fever >40.5 degree F, seizures, encephalopathy. Contraindication: Progressive neurological disease, anaphylaxis, encephalopathy within 7 days of previous dose. Precaution: Previous dose associated fever within 48 hours, hypotonic hyporesponsiveness episode <48 hours, persistent inconsolable crying for >3 hours,<48 hours, seizures <72 hours. Storage: 2-8 degree C, sensitive to light.

11. Acellular Pertussis Vaccine (DTaP) The suspicion, that active pertussis toxin and endotoxin causing adverse side effects with DTaP, led to the development of various types of purified cellular pertussis vaccine. Content: inactivated pertussis toxin, and one or more additional pertussis antigens, like filamentous hemagglutinin (FHA), pertactin , fimbrial protein and a nonfimbrial protein. Approved vaccines have atleast 3 pathogenic pertussis toxin and 6.7-25 Lf of DT. Efficacy is same as DTwP , but the local and systemic side effects are lower.

12. However, DTaP vaccine is not included in National Program, due to its prohibitive cost. IAP, previously suggested this vaccine to be offered to them who can offered but recent studies suggest that the efficacy of this vaccine as primary immunization is lower (46-92%), than DTwP (61-89%) Contraindications are similar to that of DTwP , and in these children immunization should be completed with DT.

13. Reduced Antigen Acellular Pertussis Vaccine ( Tdap ) and Reduced Antigen Diphtheria Toxoid Vaccine (Td) In non-endemic countries, revaccination against diphtheria every 10 years may be necessary to sustain immunity, particularly among health care workers. Vaccine useful in such situations include diphtheria and tetanus toxoid (DT) in combination with reduced toxoid content (Td, Tdap ) Standard dose of DT is recommended as primary, but the reactogenecity of vaccine increases with age. If given, beyond 7 years of age, primary or booster should be in the form of either Tdap or Td.

14. Tdap offers prospect of reducing pertussis incidence in adults and also reduces the transmission of disease. The available Tdap vaccine contain 5Lf of tetanus toxoid , 2 Lf of diphtheria toxoid and 3 acellular pertussis components. Containdications are same as that of DTwP and DTaP Tdap can also be used as replacement for td/TT booster in children >10 years and adults of any age, if not received Tdap in the past and 5 years have elapsed since previous TT/Td vaccine

15. Tetanus Vaccine Immunizing pregnant women with two doses , second dose given 4 weeks apart , provides passive immunity to the baby. Each dose contain 5Lf of toxoid . Vaccine is heat stable and remain potent even at 37 degree C for few weeks. Efficacy varies between 88-100 %, while antitoxin level of 0.01 IU/ml considered protective. Children who have not received primary immunization, should receive 2 doses of TT 1 month apart.

16. Dose: 0.5 ml Route: Intramuscular Site: Deltoid region National program: 2 doses, each 0.5 ml 1 st dose, at 16 weeks of pregnancy 2 nd dose, 4 weeks later Single dose if the previous child is <5 years of age.

17. Tetanus prophylaxis following wound Past doses of TT Clean minor wound All other wounds TT Tetanus immunoglobulin TT Tetanus immunoglobulin Unknown: <3 doses or immunodefecient Yes No Yes Yes > 3 doses No* No No** No Give tetanus toxoid (TT) if more than *10 years or **5 years have elapsed since last dose

18. Hepatitis B vaccine HBV contains the surface antigen HbsAg , produced by recombinant DNA technology in yeast, adsorbed on aluminum salt as adjuvant. Immunization at birth, prevents vertical transmission, if the mother’s HbsAg status not known. In case the mother is found to be reactive , the child should be vaccinated within few hours of birth and hepatitis B immunoglobulin (HBIG) within first 24 hours at separate site. In case, HBIG not administered , baby should be vaccinated in an accelerated schedule at 0, 1 and 2 months and an additional dose at 9-12 months .

19. Seroconversion rates exceed 95% after 3 doses and antibody titre of >10 mIU /ml is protective. Vaccines induce long term immunity and booster doses are not routinely recommended. However, double dose of vaccine and booster doses may be required in patients with chronic kidney disease or immunodefecient individuals.

20. Vertical transmission Immunization Mother is HBs negative Give as pentavalent vaccine at 6,10 and 14 weeks Mother HBs is unknown At birth and continue in 6,10 and 14 weeks Mother is HBs positive Give immunoglobin HBIG (0.5 ml) within 24 hours and vaccinate child at birth and continue in 6,10 and 14 weeks Immunization in vertical transmission

21. Dose: 0.5 ml, 1ml in immunocompromised children, malignancy, hemodialysis and adults. Route: Intramuscular Site: Anterolateral aspect of thigh National Program: 6,10 and 14 weeks Catch up: 3 doses at 0, 1 and 6 months, preferred gap between first two doses is >4 weeks, 2 nd and 3 rd dose is >8 weeks. Adverse reaction: Local soreness, fever, fatigue Contraindication: Anaphylaxis, after previous dose Storage: 2-8 degree C.

22. Hemophilus Vaccine Hemophilus influenzae b ( Hib ) causes invasive infections like pneumonia, meningitis and bacteremia . Vaccination prevents 33% of pneumonia, 90% meningitis related to Hib . The chief antigen is Hib capsular polysaccharide, polyribosylribitol phosphate (PRP), conjugated to tetanus toxoid (PRP-T), mutant diphtheria toxin CRM-197 ( Hib -OC) Both monovalent and combination with DTP and hepatitis B vaccines are safe and immunogenic.

23. Dose: 0.5 ml Route: Intramuscular Site: Anterolateral aspect of thigh National program: Pentavalent vaccine with DTP and hepatitis B, 3 does given at 6,10 and 14 weeks Catch up: 6-12 months: 2 doses >8 weeks apart, one booster at 15-18 months 12-15 months: one dose and one booster at 15-18 months 15-60 months: one dose, not recommended >5 year old except, if hypo/ asplenia Adverse reactions: Fever, rash, local pain or redness Contraindication: Hypersensitivity to previous dose Storage: 2-8 degree C

24. Refrences Ghai Essential Pediatrics 9 th Edition Park’s Textbook of Preventive and Social Medicine 24 th Edition https://publichealthupdate.com/national-immunization-schedule-nepal/ https://www.ncbi.nlm.nih.gov/

25. MEASLES- RUBELLA VACCINE

26. Contents Introduction Administration and doses Adverse drug reaction Contraindication Measles and HIV MMR Vaccine Measles-Rubella vaccination campaign 2080-81 References

27. Introduction Measles vaccine was developed by John F Enders in 1963 from the Edmonston -B strain of measles virus. It is now available as a monovalent preparation or in combination; With rubella(MR) With rubella and mumps(MMR) With rubella, mumps and varicella(MMR-V) The measles vaccination was first introduced in Nepal in 1979 and included only one dose of measles vaccine recommended at 9 months. In 2013,the measles-rubella vaccine was introduced in routine immunization following MR vaccination campaign.

28. MR vaccine Composition : Live attenuated, freeze- dried vaccine Each reconstituted dose of 0.5 ml contains: Measles virus(CAM-70 strain) propagated in chicken embryo fibroblasts cells >1000. Rubella virus( wistar RA 27/3 strain) propagated in MRC 5 cells >1000.

29. Lyophilized vaccine is reconstituted with sterile diluent before use(0.9% sodium chloride) Reconstituted vaccine loses 50% of its potency after 1 hour at 20 C and loses almost all potency after 1 hour at 37 C. Vaccine should be used within 6 hours of reconstitution. Storage : vaccine is stored at 2 to 8 degree celsius Vaccine is sensitive to sunlight ,hence it is kept in dark colored glass vials.

30. Monitoring of MR vaccine vials:

31. Indications Vaccination against measles and rubella is recommended for all the children for whom vaccine is not contraindicated. It helps to reduce morbidity and mortality from disease. Nepal has now achieved 97% administrative coverage with MR first dose and 95% with the second dose at the national level.

32. Administration and doses Dose: 0.5 ml administered through subcutaneous route at the upper part of left arm at the age of 9 months and 15 months . In case of missed vaccination: Up to 12 months: 1 dose is given 13 to 59 months: 2 doses are given 2 nd dose is given after 1 month of first dose.

33. Adverse drug reaction Pain and tenderness at the site of injection Fever mild rash Arthralgia Immune thrombocytopenic purpura Febrile seizure Anaphylaxis

34. Contraindications: Severe allergic reaction/anaphylaxis after previous dose of MR Pregnancy Severely immunocompromised due to congenital disease and severe HIV Advanced leukemia or lymphoma Serious malignant disease Immuno-suppressive treatments ( steroids, antimetabolites or chemotherapy) Vaccination should be delayed for 3-11 months after administration of blood or blood products.

35. Measles and HIV Measles vaccination should be routinely administered to potentially susceptible, asymptomatic HIV positive infants and children. Vaccination may be considered if not severely immunosuppressed (CD4 count >200) In areas where there is high incidence of measles and HIV infection, first dose may be given as early as 6 months of age .

36. Measles, Mumps and Rubella vaccination (MMR ) 1. Routine vaccination: 2 doses series at 12-15 months,4-6 years Dose 2 may be administered as early as 4 weeks after 1 st dose 2.Catch up vaccination: Unvaccinated children and adolescents: 2 doses at least 4 weeks apart .

37. 3. Special situations: International travel: infants age 6-11 months: 1 dose before departure; revaccinate with 2 doses at 12-15months(12 months for children in high risk areas and 2 nd dose as early as 4 weeks later. Unvaccinated children age 12 months and older: 2 dose series at least 4 weeks apart before departure

38. Measles-Rubella Vaccination Campaign 2080-81 The government of Nepal, Ministry of Health and Population, has decided to conduct a nationwide Measles-Rubella (MR) Vaccination campaign from 25 February to 20 March 2024 with aim of vaccinating approximately 5.7 million children. The guideline on MR Vaccination Campaign 2080-81 is formulated to provide comprehensive guideline for vaccination efforts ,with particular focus on health worker stationed at vaccination centers ensuring the effective execution of vaccination sessions.

39. Integrated with this campaign , pentavalent vaccine(DPT- HepB -Hib),pneumococcal conjugated vaccine and inactivated polio vaccine will also be provided for children who have missed these vaccines in routine immunization. Targeted population: 9 months to 59 months ;non-selective ,irrespective of measles vaccination history nationwide.2 doses at 9 months and 15 months

40. 5 to 14 years: non selective irrespective of measles vaccination history in 24 high risk districts(21 terai districts in border like Jhapa , Morang, Sunsari , etc and 3 in Kathmandu valley).2 doses are given at least 4 weeks apart.

41. References: Ghai Essential Pediatrics 9 th Edition Park’s Textbook of Preventive and Social Medicine 24 th Edition www.gov.np www.who.int www.cdc.gov