Module 1: Review of Selfstudy

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• Module 1 Review of Self-study
• Vaccine Preventable Diseases

OSU College of Pharmacy Immunization Delivery
Certification Program National Immunization
Program Centers for Disease Control and Prevention
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submandibular edema (bullneck)
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Thick gray coating over back of throat
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Dermal Lesion on Neck
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Diphtheria Clinical Features

• Incubation period 2-5 days (range, 1-10 days)
• Reservior Asympomatic human carriers
• (can shed virus via respiratory transmission for
  6 months or more)
• May involve any mucous membrane

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Painful Muscle Contractions
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Tetanus Epidemiology

• Reservoir Soil and intestine of
  animals and humans
• Transmission Contaminated wounds Tissue
  injury
• Temporal pattern Peak in summer or wet
  season
• Communicability Not contagious

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Tetanus Clinical Features

• Incubation period 8 days (range, 3-21 days)
• Interferes with neurotransmitter release to block
  inhibitor impulses
• Generalized tetanus descending symptoms of
  trismus (lockjaw), difficulty swallowing, muscle
  rigidity, spasms
• Spasms continue for 3-4 weeks complete recovery
  may take months

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TetanusUnited States, 1947-2005
Year
2005 provisional total
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TetanusUnited States, 1980-2005
Year
2005 provisional total
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TetanusUnited States, 1980-2003Age Distribution
N1,277
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Tetanus1998-2000Injuries and Conditions
Data available for 129 of 130 reported cases.
Source MMWR 200352(SS-3)1-12
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Routine Td ScheduleUnvaccinated Persons 7 Years
of Age
Booster dose every 10 years
ACIP recommends that one of these doses
(preferably the first) be administered as Tdap
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Broken Blood Vessels in Sclera Facial Bruising
From Intensive Coughing
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Pertussis Pathogenesis

• Attachment to cilia of ciliated epithelial cells
  in respiratory tract
• Pertussis antigens allow evasion of host defenses
  (lymphocytosis promoted but impaired chemotaxis)
• Local tissue damage in respiratory tract

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Pertussis Clinical Features

• Incubation period 7-10 days
• (range 4-21 days)
• Insidious onset, similar to minor upper
  respiratory infection with nonspecific cough
• Fever usually minimal throughout course of
  illness
• Adolescents and adults account for more than half
  of reported cases

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Pertussis Complications by Age
Cases reported to CDC 1997-2000 (N28,187)
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• PertussisUnited States, 1940-2005

Year
2005 provisional total
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• PertussisUnited States, 1980-2005

Year
2005 provisional total
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Acellular Pertussis Vaccines

• Purified "subunit" vaccines
• Pediatric formulations (DTaP) licensed for full
  series in 1996
• Adolescent and adult formulations (Tdap) licensed
  in 2005

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Acellular Pertussis Vaccines
ProductDaptacel Sanofi Pasteur (DTaP) Infanrix
GlaxoSmithKline (DTaP) Tripedia Sanofi
Pasteur (DTaP) Approved for use in children lt
7yrs of age All are suspensions stored in the
refrigerator
mcg per dose
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Interchangeability of Different Brands of DTaP
Vaccine

• Series should be completed with same brand of
  vaccine if possible
• Limited data suggest that mix and match DTaP
  schedules do not adversely affect safety and
  immunogenicity
• Use different brand of DTaP if necessary

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Boostrix 1st Teenage Pertussis Vaccine

• Boostrix Tetanus Toxoid, Reduced Diphtheria
  Toxoid and Acellular Pertussis Vaccine, Adsorbed
  (Tdap) as a single dose active booster
  immunization against tetanus, diphtheria, and
  pertussis in individuals 10 through 18 years of
  age.

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DTP Combined with Other Vaccines

• TriHIBit (DTap-Hib)
• DTaP-Hib combination
• DO NOT USE for primary immunization at 2, 4, or 6
  months of age
• May be used as the booster dose of the Hib series
  at gt12 months of age following any Hib vaccine
• Pediarix (DTap-HBV-IPV)
• DTaP Hep B IPV combination
• Approved for 3 doses at 2, 4 and 6 months
• Not approved for booster doses
• Licensed for children 6 weeks to 7 years of age

booster dose should follow prior dose by gt2
months
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• Routine DTaP Primary Vaccination Schedule

Minimum Interval --- 4 wks 4 wks 6 mos
Dose Primary 1 Primary 2 Primary 3 Primary 4
Age 2 months 4 months 6 months 15-18 months
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DTaP Fourth Dose

• Recommended at 15-18 months
• May be given at 12 months of age if
• child is 12 months of age, and
• 6 months since DTaP3, and
• unlikely to return at 15-18 months

17-20 months for Daptacel
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School Entry (Fifth) Dose

• Fifth dose recommended when 4th dose given before
  age 4 years
• Infanrix and Tripedia licensed for 5th dose after
  DTaP series

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Provisional ACIP Recommendations for Tdap
Vaccines

• Adolescents 11-18 years of age should receive a
  single dose of Tdap instead of Td, preferably at
  11-12 years of age
• Adolescents who received a Td booster should
  receive a single dose of Tdap to provide
  protection against pertussis

if the person has completed the recommended
childhood DTaP/DTP vaccination series
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Provisional ACIP Recommendations for Tdap Vaccines

• Adults should receive a single dose of Tdap to
  replace a single dose of Td
• Adults who have or who anticipate having close
  contact with an infant 12 months of age or
  younger (e.g., parents, child care providers,
  healthcare providers) should receive a single
  dose of Tdap
• Any woman who might become pregnant is encouraged
  to receive a single dose of Tdap

if the person has completed the recommended
childhood DTaP/DTP vaccination series
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DTaP Adverse Reactions

• Local reactions (pain, redness, or swelling at
  the site of injection)
• Low-grade fever
• More severe adverse reactions not common
• Local reactions more common following 4th and 5th
  doses

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Adverse Reactions Following the 4th and 5th DTaP
Dose

• Local adverse reactions and fever increased with
  4th and 5th doses of DTaP
• Reports of swelling of entire limb
• Extensive swelling after 4th dose NOT a
  contraindication to 5th dose

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DTaP Precautions

• Moderate or severe acute illness
• Temperature gt105F (40.5C) or higher within 48
  hours with no other identifiable cause
• Collapse or shock-like state (hypotonic
  hyporesponsive episode) within 48 hours
• Persistent, inconsolable crying lasting gt3 hours,
  occurring within 48 hours
• Convulsions with or without fever occurring
  within 3 days

may consider use in outbreaks
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Tdap Precautions

• History of Guillain-Barré syndrome within 6 weeks
  after a previous dose of tetanus
  toxoid-containing vaccine
• Progressive neurological disorder until the
  condition has stabilized
• History of a severe local reaction (Arthus
  reaction) following a prior dose of a tetanus
  and/or diphtheria toxoid-containing vaccine
• Moderate or severe acute illness

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DTaP Contraindications

• Severe allergic reaction to vaccine component or
  following a prior dose
• Encephalopathy not due to another identifiable
  cause occurring within 7 days after vaccination

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Limb Deformities in Children in Sierra Leone,
Africa?
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Young Man with Withered Leg
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Poliomyelitis

• 21,000 paralytic cases reported in the USA in
  1952
• Replication in pharynx, GI tract, local
  lymphatics
• Hematologic spread to lymphatics and central
  nervous system
• Viral spread along nerve fibers
• Destruction of motor neurons

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Poliovirus Epidemiology

• Reservoir Human
• Transmission Fecal-oral Oral-oral
  possible
• Communicability 7-10 days before onset Virus
  present in stool 3-6 wks

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Inactivated Polio Vaccine

• Brand Name Ipol Sanofi Pasteur
• Contains 3 serotypes of vaccine virus
• Contains 2-phenoxyethanol, neomycin,
  streptomycin, polymyxin B
• Exclusive use recommended in 2000
• gt90 immune after 2 doses
• gt99 immune after 3 doses
• Duration of immunity not known with certainty

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Pediarix

• Contains IPV, DTaP, and hepatitis B vaccines
• Minimum age 6 weeks, maximum age 6 years
• Approved by FDA for first 3 doses of the IPV and
  DTaP series
• Not approved for booster doses

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Polio Vaccination of Adults

• Routine vaccination of U.S. residents gt18 years
  of age not necessary or recommended
• May consider vaccination of travelers to
  polio-endemic countries and selected laboratory
  workers
• Dosing IPV in Adults 3 doses 2 doses 4-8 wks
  apart, with third dose given 6-12 months later.
• May separate doses by 4 weeks if accelerated
  schedule needed

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Polio Vaccine Adverse Reactions

• Rare local reactions (IPV)
• No serious reactions to IPV have been documented

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Polio VaccineContraindications and Precautions

• Severe allergic reaction to a vaccine component
  or following a prior dose of vaccine
• Moderate or severe acute illness

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Polio Eradication

• Last case in United States in 1979
• Western Hemisphere certified polio free in 1994
• Last isolate of type 2 poliovirus in India in
  October 1999
• Global eradication goal

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Cellulitis in an Infant
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Haemophilus influenzae type b

• Severe bacterial infection, particularly among
  infants
• Organism colonizes nasopharynx
• In some persons organism invades bloodstream and
  cause infection at distant site
• Antecedent upper respiratory tract infection may
  be a contributing factor

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Haemophilus influenzae type b

• Reservoir Human Asymptomatic carriers
• Transmission Respiratory droplets
• Temporal pattern Peaks in Sept-Dec and
  March-May
• Communicability Generally limited
  but higher in some circumstances

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Haemophilus influenzae type b Meningitis

• Accounted for approximately 50-65 of cases in
  the prevaccine era
• Hearing impairment or neurologic sequelae in
  15-30
• Case-fatality rate 2-5 despite of effective
  antimicrobial therapy

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Haemophilus influenzae type b Polysaccharide
Conjugate Vaccine

• 3 conjugate vaccines licensed for use in infants
  as young as 6 weeks of age
• All utilize different carrier proteins
• 2 combination vaccines available that contain Hib
  vaccine

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Haemophilus influenzae type b Polysaccharide
Conjugate Vaccine

• HbOC Hibtiter
• -oligosaccharide conjugate
• PRP-T ActHIB, TriHIBit
• -Tetanus Toxoid conjugate
• PRP-OMP PedvaxHIB, COMVAX
• -outer membrane protein conjugate

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Combination Vaccines Containing Hib

• DTaPHib
• TriHIBit
• Approved for the fourth dose of the DTaP and Hib
  series only
• Hepatitis BHib
• COMVAX

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Hib vaccine

• Start at 2 months
• Recommended interval 8 weeks for primary series
  doses
• Minimum interval 4 weeks for primary series doses
• Vaccination at lt6 weeks of age may induce
  immunologic tolerance to Hib antigen
• Minimum age 6 weeks

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Hib Vaccine adverse reactions

• Swelling, redness, or pain in 5-30 of
  recipients
• Systemic reactions infrequent
• Serious adverse reactions rare

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Hib Vaccine contraindications and precautions

• Severe allergic reaction to vaccine component or
  following a prior dose
• Moderate or severe acute illness
• Age lt6 weeks