Preventive Pediatrics

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Preventive Pediatrics

• Celia T. Sy, M.D.
• Pediatric Pulmonologist
• Department of Pediatrics
• Fatima Medical Center

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• Immunization
• Vaccinations
• Type of vaccine
• Route of administration
• Immune response
• Post- exposure drug prophylaxis

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Immunization

• Denotes the process of inducing or providing
  immunity artificially by administering an
  immunologic substances
• Active
• Passive

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Active Immunization

• When it produces the desired beneficial effects
  by stimulation of endogenous antibody production
  by the patient
• Tetanous toxoid
• MMR
• BCG

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Passive Immunization

• Administration of preformed human or animal
  antibodies to individuals already exposed or
  about to be exposed to certain infectious agents
• Tetanus antitoxins
• Immune globulins

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Vaccination

• Denotes the physical act of administrating any
  vaccine or toxoids

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Immunobiologic Substances

• Vaccine - a suspension of live or inactivated
  microorganism or fractions thereof administered
  to induce immunity and prevent infectious disease
  or its sequela
• Toxoid modified bacterial toxin that has been
  made nontoxic but retains the ability to
  stimulate the formation of antitoxins

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• Antitoxins a solution of antibodies derived
  from the serum of animals immunized with specific
  antigens
• Passive immunization
• Diphtheria antitoxin
• Tetanus antitoxin

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• Immune globulin (IG) - a sterile solution
  containing antibodies from human blood. Intended
  for IM use
• for passive immunization
• Measles immune globulin
• hepatitis b immune globulin

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• IV IG a product derived from blood plasma from
  the donor pools similar to the IG pool but
  prepared for IV used
• Used in primary antibody-deficiency disorders
• Kawasaki disease
• ITP
• Hypogammaglobulinemia

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Immunologic Constituents

• Suspending fluids sterile water, saline
• Preservatives, Stabilizers, Antibiotics
• used to inhibit or prevent bacterial growth
• Stabilize the antigens or antibodies
• albumin, phenols, neomycin, mercurial
• Adjuvants evoke suboptimal immunologic response
• To enhance immunogenicity
• Al hydroxide, Al phosphate

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Vaccines Toxoids

• Live vaccines
• BCG
• MMR
• Oral polio
• Varicella
• Oral typhoid

• Killed antigens
• Toxoids
• DPT
• Tetanus

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• Killed antigens
• Inactivated Virus
• IPV (inactived polio virus)
• Influenza
• Rabies
• Hepatitis A
• Hepatitis B

• Killed antigens
• Bacterial polysaccharide
• Hib

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Route of Administration

• Intramuscular (IM)
• DPT
• IPV (as DPT-IPV-HIB combination)
• Hep A B
• HiB
• Influenza
• Pneumococcal
• Meningococcal
• Typhoid

• Subcutaneous (SC)
• Measles
• Mumps
• Rubella
• MMR
• Varicella
• IPV
• Pneumococcal
• Meningococcal

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Route of Administration

• Oral
• OPV
• Typhoid

• Intradermal
• BCG

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Where to inject?

• General rules
• For children lt 1 year old lateral thigh
• For children gt 1 year old - deltoid
• Buttocks should not be used for active
  vaccinations because of the potential risk of
  injury to the sciatic nerve
• If the buttocks are to used use only the upper
  outer quadrant

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FeverTo give or not to give?

• Minor febrile illness or malnutrition is not a
  contraindication to immunization
• Immunization is deferred in the presence of
  severe febrile illness

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VomitingWhat to Do?

• Regurgitated oral vaccine
• If the child vomit or regurgitate within 5 10
  mins after giving OPV another dose should be
  given at the same visit
• If repeated dose is not retained,
• re-administered at the next visit

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DiarrheaCould OPV be given?

• Diarrhea should not be considered as a
  contraindication for OPV but to ensure full
  protection, doses given to children with diarrhea
  SHOULD NOT BE COUNTED as part of the series

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Need to give 2 or more vaccinesHow to give?

• Multiple vaccinations
• Administer each vaccine at a different site using
  different needles and syringes
• If gt 1 vaccine is to be used in a single limb,
  use the thigh muscle and given at 1 -2 inches
  apart

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Interruption of ScheduleWhat to do?

• Interruption with a delay between doses does not
  interfere with the final immunity achieved
• No need to start the series again

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Contraindications?

• Live attenuated vaccines is contraindicated in
• Pregnant woman
• Immunocompromised person leukemia, lymphoma,
  malignancy, therapy with steroids, alkylating
  agents, antimetabolites
• Radiotherapy

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Trivia

• Which of the following are live vaccines?
• DPT Measles
• TOPV Pneumococcal
• IPV Meningococcal
• BCG Oral Typhoid
• Hep B
• MMR

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Guidelines for Giving Live vaccines and killed
Antigens

• 2 or more killed antigens may be administered
  simultaneously or at any interval between doses
• Example
• DPT and Hep B
• DPT and Hib
• Hep A and Hep B

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• Killed and live antigens may be administered
  simultaneously or at any interval between doses
• Example
• DPT and OPV
• Hep b and MMR
• DPT and Measles
• DPT and varicella

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• 2 or more live antigens may administered
  simultaneously or at 4 week minimum interval if
  not given simultaneously
• Example
• Measles and varicella
• MMR and varicella
• OPV can be administered at any time before,
  with or after MMR if indicated

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Guidelines for administration of IG Vaccines

• Simultaneous administration
• IG and killed antigen given at the same time or
  at any time between doses
• Hepatitis B immune globulin and hepatitis B
  vaccine
• Tetanus antitoxins and anti-tetanus vaccine
• IG and live antigen should generally NOT BE
  ADMINISTERED simultaneously

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GuidelinesIG Vaccines

• Non-simultaneous administration
• First Second
• IG Killed Ag No interval needed
• IG Live Ag dose related
• Killed Ag IG No interval needed
• Live Ag IG 2 weeks

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Interval between IG Live Measles Vaccine

• IVIG Interval
• ITP 400 mg/kg 8 month
• ITP 1000 mg/kg 10 months
• Kawasaki 11 months
• Blood transfusion
• Whole blood packed RBC 6 months
• Plasma/platelets 7 months

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IntervalIG live measles vaccine

• IG measles prophylaxis
• Normal contact 0.25ml/kg 5 mons
• Immunocompromised 0.50ml/kg 6 mons

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Trivia

• Which of the following vaccines can be given
  simultaneously?
• Hep B Measles
• BCG DPT
• Oral polio measles
• DPT MMR
• Measles MMR
• DPT IPV HiB

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Immune Response

• Immune response to one live virus vaccine might
  be impaired if administered within 30 days of
  another live virus vaccine
• Only OPV and MMR can be administered at anytime
  before, with or after each other

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Immune Response

• Live virus vaccines can interfere with the
  response to a tuberculin test
• Tuberculin testing can be done either on the same
  day that live virus vaccines are administered or
  4 6 weeks later

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Special ConditionsSpecial Considerations

• Persons with hemophilia
• Increased risk of hepatitis B hematomas
• Assess the patients bleeding risk
• Use fine needle apply pressure to the site

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Special considerations

• Altered immunocompetence
• Killed or inactivated vaccines can be
  administered to all immunocompromised patients
• OPV should not be given to any household contacts
  of an immunocompromised patient
• IPV can be given

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Special considerations.

• Altered immunocompetence
• MMR is not contraindicated to close contacts of
  immunocompromised persons
• MMR vaccine is recommended for all asymptomatic
  HIV-infected persons and should be considered for
  all symptomatic HIV-infected persons

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Special consideratios

• Preterm infants
• Regardless of birth weight should be vaccinated
  at the same chronological age and according to
  the same schedule
• Use full recommended dose except BCG
• OPV should be deferred until discharge from the
  nursery

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Special considerations

• Pregnancy
• Combined tetanus and diphtheria toxoids ARE THE
  ONLY vaccine indicated

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Vaccines

• BCG (Bacille-Calmette-Guerin)
• Attenuated bovine strains of tubercle bacilli
• Route intradermal
• Dose 0.05 ml preterm
• 0.1 ml term
• Complications
• Abscess
• Indolent ulcer
• lymphadenopathy

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BCG

• Normal course
• Wheal diappear in 30 mins
• Induration after 2-3 wks
• Pustular formation after 4 6 wks
• Full scarification after 6 12 wks

• Accelerated reaponse 91-100 correlation with
  TB infection
• Induration after 2 3 days
• Pustular formation after 5 7 days
• Scar after 2 -3 wks

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Polio vaccine

• OPV live attenuated vaccine
• IPV inactive polio virus
• Combination vaccine
• DPT IPV Hib

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DPT

• Toxoids of diphtheria tetanus inactivated
  pertussis component adsorbed into aluminum salts
• Dose 0.5 ml
• Route IM
• Side effect swelling at injection site

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DTaP

• Diphtheria, tetanus, acellular pertussis
  component
• Decrease risk of neuroparalytic reactions due to
  component of pertussis

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Measles

• Live attenuated vaccine
• Freeze dried
• Dose 0.5 ml SQ
• Side effects fever between 5th-14th day after
  injection, rashes, arthritis
• Prophylaxis may be given within 72 hours
  after measles exposure
• Measles IG 0.25 ml/kg IM may be within 6 days
  of exposure

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Hepatitis B Vaccine

• Infant born to HBs Ag-positive mother should
  received
• Hep b Vaccine Hep B immune globulin (HBIG)
  within 12 hours of birth at different site
• Next dose Hep B at 1-2 months of age and 3rd
  dose at 6th month of age
• Schedule 0, 1, 6

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Hepatitis B Vaccine

• Infant born to mother whose HBsAg status is
  unknown
• Hep B vaccine within 12 hours of birth
• Request for mothers HBsAg status if ()
• Infant should received HBIG Asap
• (no later than 1 week of age)

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Recommended Schedule

• BCG
• DPT, TOPV, IPV, Hib
• Hepatitis B
• Measles

• At birth or anytime after birth
• 2, 4, 6 month of age
• 0, 1, 6 month of age
• 0, 1, 3 month of age (endemic country)
• 9 month of age
• ( can be given at 6 month of age)

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Schedule.

• MMR
• Hepatits A
• Pneumococcal (IPD 7 valent)
• Pneumococcal (23-valent)
• Meningococcal
• Typhoid

• 15 month of age
• After 1 year of age
• 2, 4, 6 months up to 9 years of age
• 2 years of age
• 2 years of age
• 3 years of age

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Post-exposure Drug Prophylaxis

• Diphtheria Erythromycin
• Pertussis Erythromycin
• Cholera Tetracycline
• Plasmodia Chloroquine
• N. gonorrhea Amoxicillin/Penicillin
• Meningococcemia Rifampicin
• Sulfisoxazole
• Ceftriaxone
• Tuberculosis Isoniazid

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Case 1

• A 3 y/o child was exposed to a person with
  measles. Past immunization hx he had received 1
  dose of BCG, 3 doses of DPT, TOPV Hepatitis B.
  If you are the attending physician, how are you
  going to manage the patient?
• Give measles vaccine if the exposure is within 72
  hours
• Give measles immunoglobulin if the exposure is
  more than 72 hours
• Give MMR if the exposure is within 72 hours
• Give Mesles vaccine and immune globulin at the
  same time
• Observe the patient

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