Vaccine4 influenza


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  • These symptoms were reported in 10 to 40 percent of both vaccine and placebo recipients. LAIV not licensed for children <60 months of age.
  • Vaccine4 influenza

    1. 1. <ul><li>Vaccine 3 </li></ul><ul><li>D-r Mitova </li></ul><ul><li>MU-Sofia </li></ul>
    2. 2. Influenza <ul><li>Highly infectious viral illness </li></ul><ul><li>Epidemics reported since at least 1510 </li></ul><ul><li>At least 4 pandemics in 19th century </li></ul><ul><li>Estimated 21 million deaths worldwide in pandemic of 1918-1919 </li></ul><ul><li>Virus first isolated in 1933 </li></ul>
    3. 3. Influenza Virus <ul><li>Single-stranded RNA virus </li></ul><ul><li>Family Orthomyxoviridae </li></ul><ul><li>3 types: A, B, C </li></ul><ul><li>Subtypes of type A determined by hemagglutinin and neuraminidase </li></ul>
    4. 4. Influenza Virus Strains <ul><li>Type A - moderate to severe illness - all age groups - humans and other animals </li></ul><ul><li>Type B - milder epidemics - humans only - primarily affects children </li></ul><ul><li>Type C - rarely reported in humans - no epidemics </li></ul>
    5. 5. <ul><li>Influenza Virus </li></ul>A/Fujian/411/2002 (H3N2) Neuraminidase Hemagglutinin Type of nuclear material Virus type Geographic origin Strain number Year of isolation Virus subtype
    6. 6. Influenza Antigenic Changes <ul><li>Hemagglutinin and neuraminidase antigens change with time </li></ul><ul><li>Changes occur as a result of point mutations in the virus gene, or due to exchange of a gene segment with another subtype of influenza virus </li></ul><ul><li>Impact of antigenic changes depend on extent of change (more change usually means larger impact) </li></ul>
    7. 7. Influenza Antigenic Changes <ul><li>Antigenic Shift </li></ul><ul><ul><li>Major change, new subtype </li></ul></ul><ul><ul><li>Caused by exchange of gene segments </li></ul></ul><ul><ul><li>May result in pandemic </li></ul></ul><ul><li>Example of antigenic shift </li></ul><ul><ul><li>H2N2 virus circulated in 1957-1967 </li></ul></ul><ul><ul><li>H3N2 virus appeared in 1968 and completely replaced H2N2 virus </li></ul></ul>
    8. 8. Influenza Antigenic Changes <ul><li>Antigenic Drift </li></ul><ul><ul><li>Minor change, same subtype </li></ul></ul><ul><ul><li>Caused by point mutations in gene </li></ul></ul><ul><ul><li>May result in epidemic </li></ul></ul><ul><li>Example of antigenic drift </li></ul><ul><ul><li>In 2002-2003, A/Panama/2007/99 (H3N2) virus was dominant </li></ul></ul><ul><ul><li>A/Fujian/411/2002 (H3N2) appeared in late 2003 and caused widespread illness in 2003-2004 </li></ul></ul>
    9. 9. <ul><li>Influenza Type A Antigenic Shifts </li></ul>Year 1889 1918 1957 1968 1977 Subtype H3N2 H1N1 H2N2 H3N2 H1N1 Severity of Pandemic Moderate Severe Severe Moderate Mild
    10. 10. Impact of Pandemic Influenza <ul><li>200 million people could be affected </li></ul><ul><li>Up to 40 million require outpatient visits </li></ul><ul><li>Up to 700,000 hospitalized </li></ul><ul><li>89,000 - 200,000 deaths </li></ul>
    11. 11. Influenza Pathogenesis <ul><li>Respiratory transmission of virus </li></ul><ul><li>Replication in respiratory epithelium with subsequent destruction of cells </li></ul><ul><li>Viremia rarely documented </li></ul><ul><li>Viral shedding in respiratory secretions for 5-10 days </li></ul>
    12. 12. Influenza Clinical Features <ul><li>Incubation period 2 days (range 1-4 days) </li></ul><ul><li>Severity of illness depends on prior experience with related variants </li></ul><ul><li>Abrupt onset of fever, myalgia, sore throat, nonproductive cough, headache </li></ul>
    13. 13. Influenza Complications <ul><li>Pneumonia </li></ul><ul><ul><li>primary influenza </li></ul></ul><ul><ul><li>secondary bacterial </li></ul></ul><ul><li>Reye syndrome </li></ul><ul><li>Myocarditis </li></ul><ul><li>Death 0.5-1 per 1,000 cases </li></ul>
    14. 14. Impact of Influenza <ul><li>~36,000 excess deaths per year </li></ul><ul><li>>90% of deaths among persons > 65 years of age </li></ul><ul><li>Higher mortality during seasons when influenza type A (H3N2) viruses predominate </li></ul>
    15. 15. Impact of Influenza <ul><li>Highest rates of complications and hospitalization among young children and person > 65 years </li></ul><ul><li>Average of >200,000 influenza-related excess hospitalizations per year since 1969 </li></ul><ul><li>57% of all hospitalizations among persons <65 years of age </li></ul><ul><li>Greater number of hospitalizations during type A (H3N2) epidemics </li></ul>
    16. 16. Influenza Diagnosis <ul><li>Clinical and epidemiological characteristics </li></ul><ul><li>Isolation of influenza virus from clinical specimen (e.g., nasopharynx, throat, sputum) </li></ul><ul><li>Significant risk in influenza IgG by serologic assay </li></ul><ul><li>Direct antigen testing for type A virus </li></ul>
    17. 17. Influenza Epidemiology <ul><li>Reservoir Human, animals (type A only) </li></ul><ul><li>Transmission Respiratory Probably airborne </li></ul><ul><li>Temporal pattern Peak December – March in temperate area May occur earlier or later </li></ul><ul><li>Communicability Maximum 1-2 days before to 4-5 days after onset </li></ul>
    18. 18. Influenza Vaccines <ul><li>Inactivated subunit (TIV) </li></ul><ul><ul><li>Intramuscular </li></ul></ul><ul><ul><li>Trivalent </li></ul></ul><ul><li>Live attenuated vaccine (LAIV) </li></ul><ul><ul><li>Intranasal </li></ul></ul><ul><ul><li>Trivalent </li></ul></ul>
    19. 19. Composition of the 2007-2008 Influenza Vaccine* <ul><li>A/Solomon Islands/3/2006 (H1N1)-like virus; </li></ul><ul><li>A/Wisconsin/67/2005 (H3N2)-like virus ; </li></ul><ul><li>B/Malaysia/2506/2004-like virus ; </li></ul>
    20. 20. Inactivated Influenza Vaccine Efficacy <ul><li>70%-90% effective among healthy persons <65 years of age </li></ul><ul><li>30%-40% effective among frail elderly persons </li></ul><ul><li>50%-60% effective in preventing hospitalization </li></ul><ul><li>80% effective in preventing death </li></ul>
    21. 21. <ul><li>Influenza and Complications Among Nursing Home Residents </li></ul>RR=1.9 RR=2.0 RR=2.5 RR=4.2 *Inactivated influenza vaccine. Genesee County, MI, 1982-1983 Vaccinated* Unvaccinated
    22. 22. LAIV Efficacy in Healthy Children <ul><li>87% effective against culture-confirmed influenza in children 5-7 years old </li></ul><ul><li>27% reduction in febrile otitis media (OM) </li></ul><ul><li>28% reduction in OM with accompanying antibiotic use </li></ul><ul><li>Decreased fever and OM in vaccine recipients who developed influenza </li></ul>
    23. 23. LAIV Efficacy in Healthy Adults <ul><li>20% fewer severe febrile illness episodes </li></ul><ul><li>24% fewer febrile upper respiratory illness episodes </li></ul><ul><li>27% fewer lost work days due to febrile upper respiratory illness </li></ul><ul><li>18%-37% fewer days of healthcare provider visits due to febrile illness </li></ul><ul><li>41%-45% fewer days of antibiotic use </li></ul>
    24. 24. Timing of Inactivated Influenza Vaccine Programs <ul><li>Actively target vaccine available in September and October to persons at increase risk of influenza complications, children <9 years, and healthcare workers </li></ul><ul><li>Vaccination of all other groups should begin in November </li></ul><ul><li>Continue vaccinating through December and later, as long as vaccine is available </li></ul>
    25. 25. <ul><li>Inactivated Influenza Vaccine Schedule </li></ul>Age Group 6-35 mos 3-8 yrs > 9 yrs Dose 0.25 mL 0.50 mL 0.50 mL No. Doses 1* or 2 1* or 2 1 *Only one dose is needed if the child received influenza vaccine during a previous influenza season
    26. 26. Inactivated Influenza Vaccine Recommendations <ul><li>All persons 50 years of age or older </li></ul><ul><li>Children 6-23 months of age </li></ul><ul><li>Residents of long-term care facilities </li></ul><ul><li>Pregnant women </li></ul><ul><li>Persons 6 months to 18 years receiving chronic aspirin therapy </li></ul><ul><li>Persons >6 months of age with chronic illness </li></ul>
    27. 27. Inactivated Influenza Vaccine Recommendations <ul><li>Routine annual TIV vaccination for persons 50 years and older </li></ul><ul><ul><li>Up to a third of persons 50-64 years have high-risk conditions </li></ul></ul><ul><ul><li>Only 35% received influenza vaccine in 1999 </li></ul></ul><ul><ul><li>May increase coverage in HCWs </li></ul></ul><ul><ul><li>Reduced sick days </li></ul></ul>
    28. 28. Inactivated Influenza Vaccine Recommendations <ul><li>Persons with the following chronic illnesses should be considered for inactivated influenza vaccine: </li></ul><ul><ul><li>pulmonary (e.g., asthma, COPD) </li></ul></ul><ul><ul><li>cardiovascular (e.g., CHF) </li></ul></ul><ul><ul><li>metabolic (e.g., diabetes) </li></ul></ul><ul><ul><li>renal dysfunction </li></ul></ul><ul><ul><li>hemoglobinopathy </li></ul></ul><ul><ul><li>immunosuppression, including HIV infection </li></ul></ul>
    29. 29. Pregnancy and Inactivated Influenza Vaccine <ul><li>Risk of hospitalization 4 times higher than nonpregnant women </li></ul><ul><li>Risk of complications comparable to nonpregnant women with high-risk medical conditions </li></ul><ul><li>Vaccination (with TIV) recommended if pregnant during influenza season </li></ul>
    30. 30. HIV Infection and Inactivated Influenza Vaccine <ul><li>Persons with HIV at higher risk of complications of influenza </li></ul><ul><li>TIV induces protective antibody titers in many HIV infected persons </li></ul><ul><li>Transient increase in HIV replication reported </li></ul><ul><li>TIV will benefit many HIV-infected persons </li></ul>
    31. 31. Influenza Vaccine Recommendations <ul><li>Healthcare providers, including home care (TIV only) </li></ul><ul><li>Employees of long-term care facilities (TIV only) </li></ul><ul><li>Household members of high-risk persons including children 0-23 months (TIV or LAIV*) </li></ul>*household and other close contacts of immuno- suppressed persons should not receive LAIV
    32. 32. Influenza Vaccine Recommendations* <ul><li>Providers of essential community services </li></ul><ul><li>Foreign travelers </li></ul><ul><li>Students </li></ul><ul><li>Anyone who wishes to reduce the likelihood of becoming ill from influenza </li></ul>*these groups may receive TIV, and some may be eligible for LAIV
    33. 33. Influenza Vaccination of Children <ul><li>Children <24 months at increased risk of hospitalization </li></ul><ul><li>Inactivated influenza vaccination of healthy children 6-23 months is recommended </li></ul><ul><li>Vaccination of household contacts and out-of-home caretakers is encouraged </li></ul>
    34. 34. In the 2001 National Health Interview Survey, only 36% of healthcare workers reported receiving influenza vaccine in the previous 12 months.
    35. 35. Simultaneous Administration of LAIV and Other Vaccines <ul><li>Inactivated vaccines can be administered either simultaneously or at any time before or after LAIV </li></ul><ul><li>Other live vaccines can be administered at the same visit as LAIV </li></ul><ul><li>Live vaccines not administered on the same day should be administered >4 weeks apart </li></ul>
    36. 36. Inactivated Influenza Vaccine Adverse Reactions <ul><li>Local reactions 15%-20% </li></ul><ul><li>Fever, malaise not common </li></ul><ul><li>Allergic reactions rare </li></ul><ul><li>Neurological very rare reactions </li></ul>
    37. 37. Live Attenuated Influenza Vaccine Adverse Reactions <ul><li>Children </li></ul><ul><ul><li>no significant increase in URI symptoms, fever, or other systemic symptoms </li></ul></ul><ul><ul><li>significantly increased risk of asthma or reactive airways disease children 12-59 months of age </li></ul></ul><ul><li>Adults </li></ul><ul><ul><li>significantly increased rate of cough, runny nose, nasal congestion, sore throat, and chills reported among vaccine recipients </li></ul></ul><ul><ul><li>no increase in the occurrence of fever </li></ul></ul><ul><li>No serious adverse reactions identified </li></ul>
    38. 38. Inactivated Influenza Vaccine Contraindications and Precautions <ul><li>Severe allergic reaction to a vaccine component (e.g., egg) or following a prior dose of vaccine </li></ul><ul><li>Moderate or severe acute illness </li></ul>
    39. 39. Live Attenuated Influenza Vaccine Contraindications and Precautions <ul><li>Children <5 years of age* </li></ul><ul><li>Persons > 50 years of age* </li></ul><ul><li>Persons with underlying medical conditions* </li></ul><ul><li>Children and adolescents receiving chronic aspirin therapy* </li></ul>*These persons should receive inactivated influenza vaccine
    40. 40. Live Attenuated Influenza Vaccine Contraindications and Precautions <ul><li>Immunosuppression from any cause </li></ul><ul><li>Pregnant women* </li></ul><ul><li>Severe (anaphylactic) allergy to egg or other vaccine components </li></ul><ul><li>History of Guillian-Barré syndrome </li></ul><ul><li>Moderate or severe acute illness </li></ul>*These persons should receive inactivated influenza vaccine
    41. 41. LAIV Storage and Handling <ul><li>Must be stored at < +5 ° F (-15 ° C ) at all times </li></ul><ul><li>Do NOT store in a frost-free freezer </li></ul><ul><li>Store ONLY in a MANUAL defrost freezer </li></ul><ul><li>If no manual defrost freezer, must store LAIV in special freezer box supplied by the manufacturer </li></ul>
    42. 42. Influenza Vaccine Missed Opportunities <ul><li>Up to 75% of persons at high risk for influenza or who die from pneumonia and influenza may have received care in a physician's office in the previous year. </li></ul><ul><li>In one study all non-nursing home persons who died from pneumonia or influenza had at least one medical visit in the previous year. </li></ul>
    43. 43. Influenza Antiviral Agents* <ul><li>Amantadine and rimantadine </li></ul><ul><ul><li>effective against influenza A only </li></ul></ul><ul><ul><li>approved for treatment and prophylaxis </li></ul></ul><ul><li>Zanamivir and oseltamivir </li></ul><ul><ul><li>neuraminidase inhibitors </li></ul></ul><ul><ul><li>effective against influenza A and B </li></ul></ul><ul><ul><li>oseltamivir approved for prophylaxis </li></ul></ul>*see influenza ACIP statement for details
    44. 44. Haemophilus influenzae type b <ul><li>Severe bacterial infection, primarily in infants </li></ul><ul><li>During late 19th century believed to cause influenza </li></ul><ul><li>Immunology and microbiology clarified in 1930s </li></ul>
    45. 45. Haemophilus influenzae <ul><li>Aerobic gram-negative bacteria </li></ul><ul><li>Polysaccharide capsule </li></ul><ul><li>Six different serotypes (a-f) of polysaccharide capsule </li></ul><ul><li>95% of invasive disease caused by type b </li></ul>
    46. 46. Haemophilus influenzae type b Pathogenesis <ul><li>Organism colonizes nasopharynx </li></ul><ul><li>In some persons organism invades bloodstream and cause infection at distant site </li></ul><ul><li>Antecedent URI may be a contributing factor </li></ul>
    47. 47. Haemophilus influenzae type b Meningitis <ul><li>Accounted for approximately 50%-65% of cases </li></ul><ul><li>Hearing impairment or neurologic sequelae in 15%-30% </li></ul><ul><li>Case fatality rate 2%-5% in spite of effective antimicrobial therapy </li></ul>
    48. 48. Haemophilus influenzae type b Medical Management <ul><li>Treatment with an effective 3rd generation cephalosporin, or chloramphenicol plus ampicillin </li></ul><ul><li>Ampicillin-resistant strains now common throughout the United States </li></ul><ul><li>Hospitalization required </li></ul>
    49. 49. Haemophilus influenzae type b Epidemiology <ul><li>Reservoir Human Asymptomatic carriers </li></ul><ul><li>Transmission Respiratory droplets </li></ul><ul><li>Temporal pattern Peaks in Sept-Dec and March-May </li></ul><ul><li>Communicability Generally limited but higher in some circumstances </li></ul>
    50. 50. Haemophilus influenzae type b Polysaccharide Vaccine <ul><li>Available 1985-1988 </li></ul><ul><li>Not effective in children <18 months of age </li></ul><ul><li>Effectiveness in older children variable </li></ul>
    51. 51. Polysaccharide Vaccines <ul><li>Age-related immune response </li></ul><ul><li>Not consistently immunogenic in children ≤2 years old </li></ul><ul><li>No booster response </li></ul><ul><li>Antibody with less functional activity </li></ul>
    52. 52. Polysaccharide Conjugate Vaccines <ul><li>Stimulates T-dependent immunity </li></ul><ul><li>Enhanced antibody production, especially in young children </li></ul><ul><li>Repeat doses elicit booster response </li></ul><ul><li>Antibody is biologically active in vitro </li></ul>
    53. 53. HbOC Hibtiter PRP-T ActHIB, TriHIBit PRP-OMP PedvaxHIB, COMVAX Conjugate Hib Vaccines
    54. 54. Haemophilus influenzae type b Vaccine Routine Schedule Vaccine 2 mo 4 mo 6 mo 12-18 mo HbOC x x x x PRP-T x x x x PRP-OMP x x x
    55. 55. <ul><li>Vaccination at <6 weeks of age may induce immunologic tolerance to Hib antigen </li></ul><ul><li>Minimum age 6 weeks </li></ul><ul><li>Minimum interval 4 weeks for primary series doses </li></ul>Haemophilus influenzae type b Vaccine
    56. 56. Haemophilus influenzae type b Vaccine Use in Older Children and Adults <ul><li>Generally not recommended for persons >59 months of age </li></ul><ul><li>Consider for high-risk persons: asplenia, immunodeficiency, HIV infection </li></ul><ul><li>One pediatric dose of any conjugate vaccine </li></ul>
    57. 57. <ul><li>Swelling, redness, and/or pain in 5%-30% of recipients </li></ul><ul><li>Systemic reactions infrequent </li></ul><ul><li>Serious adverse reactions rare </li></ul>Haemophilus influenzae type b Vaccine Adverse Reactions
    58. 58. Haemophilus influenzae type b Vaccine Contraindications and Precautions <ul><li>Severe allergic reaction to vaccine component or following prior dose </li></ul><ul><li>Moderate or severe acute illness </li></ul><ul><li>Age <6 weeks </li></ul>
    59. 59. Streptococcus pneumoniae <ul><li>Gram-positive bacteria </li></ul><ul><li>90 known serotypes </li></ul><ul><li>Polysaccharide capsule important virulence factor </li></ul><ul><li>Type-specific antibody is protective </li></ul>
    60. 60. Pneumococcal Disease <ul><li>Most common cause of vaccine- preventable death </li></ul><ul><li>Most common cause of bacterial meningitis among infants and young children </li></ul><ul><li>Increasing antibiotic resistance </li></ul>
    61. 61. Pneumococcal Disease Clinical Syndromes <ul><li>Pneumonia </li></ul><ul><li>Bacteremia </li></ul><ul><li>Meningitis </li></ul>
    62. 62. Pneumococcal Pneumonia Clinical Features <ul><li>Abrupt onset </li></ul><ul><li>Fever </li></ul><ul><li>Shaking chills </li></ul><ul><li>Productive cough </li></ul><ul><li>Pleuritic chest pain </li></ul><ul><li>Dyspnea, tachypnea, hypoxia </li></ul>
    63. 63. Pneumococcal Pneumonia <ul><li>Estimated 175,000 hospitalized cases per year </li></ul><ul><li>Up to 36% of adult community-acquired pneumonia and 50% of hospital-acquired pneumonia </li></ul><ul><li>Common bacterial complication of influenza and measles </li></ul><ul><li>Case-fatality rate 5%-7%, higher in elderly </li></ul>
    64. 64. Pneumococcal Bacteremia <ul><li>More than 50,000 cases per year in the United States </li></ul><ul><li>Rates higher among elderly and very young infants </li></ul><ul><li>Case fatality rate ~20%; up to 60% among the elderly </li></ul>
    65. 65. Pneumococcal Meningitis <ul><li>Estimated 3,000 - 6,000 cases per year in the United States </li></ul><ul><li>Case-fatality rate ~30%, up to 80% in the elderly </li></ul><ul><li>Neurologic sequelae common among survivors </li></ul>
    66. 66. Pneumococcal Disease in Children <ul><li>Bacteremia without known site of infection most common clinical presentation </li></ul><ul><li>S. pneumoniae leading cause of bacterial meningitis among children <5 years of age </li></ul><ul><li>Common cause of acute otitis media </li></ul>
    67. 67. Pneumococcal Disease Epidemiology <ul><li>Reservoir Human carriers </li></ul><ul><li>Transmission Respiratory </li></ul><ul><li> Autoinoculation </li></ul><ul><li>Temporal pattern Winter–early spring </li></ul><ul><li>Communicability Unknown </li></ul><ul><li> Probably as long as organism in respiratory secretions </li></ul>
    68. 68. Pneumococcal Vaccines <ul><li>1977 14-valent polysaccharide vaccine licensed </li></ul><ul><li>1983 23-valent polysaccharide vaccine licensed </li></ul><ul><li>2000 7-valent polysaccharide conjugate vaccine licensed </li></ul>
    69. 69. Pneumococcal Polysaccharide Vaccine <ul><li>Purified capsular polysaccharide antigen from 23 types of pneumococcus </li></ul><ul><li>Account for 88% of bacteremic pneumococcal disease </li></ul><ul><li>Cross-react with types causing additional 8% of disease </li></ul>
    70. 70. Pneumococcal Conjugate Vaccine <ul><li>Pneumococcal polysaccharide conjugated to nontoxic diphtheria toxin (7 serotypes) </li></ul><ul><li>Vaccine serotypes account for 86% of bacteremia and 83% of meningitis among children <6 years </li></ul>
    71. 71. Pneumococcal Polysaccharide Vaccine <ul><li>Purified pneumococcal polysaccharide (23 types) </li></ul><ul><li>Not effective in children <2 years </li></ul><ul><li>60%-70% against invasive disease </li></ul><ul><li>Less effective in preventing pneumococcal pneumonia </li></ul>
    72. 72. Pneumococcal Conjugate Vaccine <ul><li>Highly immunogenic in infants and young children, including those with high-risk medical conditions </li></ul><ul><li>>90% effective against invasive disease </li></ul><ul><li>Less effective against pneumonia and acute otitis media </li></ul>
    73. 73. Pneumococcal Polysaccharide Vaccine Recommendations <ul><li>Adults > 65 years of age </li></ul><ul><li>Persons > 2 years with </li></ul><ul><ul><li>chronic illness </li></ul></ul><ul><ul><li>anatomic or functional asplenia </li></ul></ul><ul><ul><li>immunocompromised (disease, chemotherapy, steroids) </li></ul></ul><ul><ul><li>HIV infection </li></ul></ul><ul><ul><li>environments or settings with increased risk </li></ul></ul>
    74. 74. Pneumococcal Conjugate Vaccine <ul><li>Routine vaccination of children age <24 months and children 24-59 months with high-risk medical conditions </li></ul><ul><li>Doses at 2, 4, 6, months, booster dose at 12-15 months </li></ul><ul><li>Unvaccinated children >7 months require fewer doses </li></ul>
    75. 75. Pneumococcal Polysaccharide Vaccine Revaccination <ul><li>Routine revaccination of immunocompetent persons is not recommended </li></ul><ul><li>Revaccination recommended for persons age > 2 years at highest risk of serious pneumococcal infection </li></ul><ul><li>Single revaccination dose > 5 years after first dose </li></ul>
    76. 76. Pneumococcal Polysaccharide Vaccine Candidates for Revaccination <ul><li>Persons >2 years of age with: </li></ul><ul><ul><li>Functional or anatomic asplenia </li></ul></ul><ul><ul><li>Immunosuppression </li></ul></ul><ul><ul><li>Transplant </li></ul></ul><ul><ul><li>Chronic renal failure </li></ul></ul><ul><ul><li>Nephrotic syndrome </li></ul></ul><ul><li>Persons vaccinated at <65 years of age </li></ul>
    77. 77. Pneumococcal Vaccines Adverse Reactions <ul><li>Local reactions </li></ul><ul><ul><li>polysaccharide 30%-50% </li></ul></ul><ul><ul><li>conjugate 10%-20% </li></ul></ul><ul><li>Fever, myalgia </li></ul><ul><ul><li>polysaccharide <1% </li></ul></ul><ul><ul><li>conjugate 15%-24% </li></ul></ul><ul><li>Severe adverse reactions rare </li></ul>
    78. 78. Pneumococcal Vaccines Contraindications and Precautions <ul><li>Severe allergic reaction to vaccine component or following prior dose of vaccine </li></ul><ul><li>Moderate or severe acute illness </li></ul>
    79. 79. Rabies. Management and Prevention <ul><li>Pre-exposure prophylaxis - Inactivated rabies vaccine may be administered to persons at increased risk of being exposed to rabies e.g. vets, animal handlers, laboratory workers etc. </li></ul><ul><li>Post-exposure prophylaxis - In cases of animal bites, dogs and cats in a rabies endemic area should be held for 10 days for observation. If signs develop, they should be killed and their tissue. </li></ul><ul><li>Wild animals are not observed but if captured, the animal should be killed and examined. The essential components of postexposure prophylaxis are the local treatment of wounds and active and passive immunization. </li></ul><ul><li>Once rabies is established, there is nothing much that could be done except intensive supportive care. To date, only 2 persons with proven rabies have survived. </li></ul>
    80. 80. Postexposure Prophylaxis <ul><li>Wound treatment - surgical debridement should be carried out. Experimentally, the incidence of rabies in animals can be reduced by local treatment alone. </li></ul><ul><li>Passive immunization - human rabies immunoglobulin around the area of the wound; to be supplemented with an i.m. dose to confer short term protection. </li></ul><ul><li>Active immunization - the human diploid cell vaccine is the best preparation available. The vaccine is usually administered into the deltoid region, and 5 doses are usually given. </li></ul><ul><li>There is convincing evidence that combined treatment with rabies immunoglobulin and active immunization is much more effective than active immunization alone. Equine rabies immunoglobulin (ERIG) is available in many countries and is considerably cheaper than HRIG. </li></ul>
    81. 81. Rabies Vaccines <ul><li>The vaccines which are available for humans are present are inactivated whole virus vaccines. </li></ul><ul><ul><li>Nervous Tissue Preparation e.g. Semple Vaccine - associated with the rare complication of demyelinating allergic encephalitis. </li></ul></ul><ul><ul><li>Duck Embryo Vaccine - this vaccine strain is grown in embryonated duck eggs This vaccine has a lower risk of allergic encephalitis but is considerably less immunogenic. </li></ul></ul><ul><ul><li>Human Diploid Cell Vaccine (HDCV) - this is currently the best vaccine available with an efficacy rate of nearly 100% and rarely any severe reactions. However it is very expensive. </li></ul></ul><ul><ul><li>Other Cell culture Vaccines - because of the expense of HDCV, other cell culture vaccines are being developed for developing countries. However recent data suggests that a much reduced dose of HDCV given intradermally may be just be effective. </li></ul></ul>