This document provides information about immunization and vaccine-preventable diseases. It discusses: 1. Immunization is a process that uses vaccines to stimulate immunity against infectious diseases. It has proven effective at controlling and eliminating diseases like smallpox. 2. Major vaccine-preventable diseases that kill children include measles, polio, pertussis, Hib, and pneumococcal diseases. Immunization is one of the most cost-effective health interventions. 3. The document then provides details on specific diseases like pertussis, its symptoms, complications, and treatment with antibiotics or immunization. It emphasizes the importance of clinical diagnosis and avoiding severe outcomes in infants.

5. WELCOME
ALL

6. E. P. I. TARGET
DISEASES
(DPT POLIO HIB MR PCV: 8)

7. Introduction
IMMUNIZATION is a process of making a person immune to
an ID, typically by a vaccine which stimulates the
immune system to protect against that ID
• It is a proven tool for controlling & eliminating (e.g. Small
Pox) life-threatening ID. It can avert 2-3 mln. deaths/y
• It is one of the most cost-effective investments, & can be
made available to even hard-to-reach target groups; &
does not require any major lifestyle change

8. Why immunisation?
To stop preventable ID
 Measles, polio-, DPT, Hib, S. pneumoniae, rotavirus, TB,
etc. are killers. HBV & rubella are not U-5 killer
• 2015: 16k U-5 death/d (50% in SS Africa; 30% in S. Asia).
>50% are preventable/treatable by simple, measures
Children in SS Africa are >x14 more likely to die
than those in HICs
 S. Asia has done strong progress: >50% reduction since ‘90
Leading c/of U-5 death: preterm, pn., BA, D & malaria. 45%
of all child deaths are linked to malnutrition
SS: sub Saharan. HICs: high income countries.BA: birth asphyxia. D: diarrhoea. Mn: malnutrition

9. World Distribn. of Deaths: U-5y: 2012
6.6million death: >50% preventable/Rx with simple, affordable
interventions

10. World Burden of Vax.-Preventable U-5 death
Pertussis
13%
Hib*
13%
Measles
8%
Tetanus
4%
Pneumococca
l diseases*
32%
Rotavirus*
30%
• 17% of global total death
• 1.5million deaths in children
preventable through vaccination
*WHO estimates

11. EPI target Ds in Bangladesh (10)
• TB
• Diphtheria, Pertussis, Tetanus (DPT)
• Poliomyelitis: OPV, IPV
• HBV
• HIB
• Measles, Rubella (MR)
• S pneumoniae

12. Other vax. available in Bangladesh
• HPV
• HAV
• Varicella-zoster
• Influenza
• Typhoid
• Cholera
• Rota virus
• Yellow fever
• Meningococcus
• Rabies
Not Available in BD
• Dengue
• Hepatitis E
• Japanese encephalitis
• Malaria
• Tick-borne encephalitis

13. Vaccines in pipeline
• Malaria
• HEV
• Ebola (effective vax. in pipeline)
• HIV
• Improved BCG, pertussis
• Zica, etc.
• Campylobacter jejuni
• Chagas Disease
• Chikungunya
• Enterotoxigenic E coli
• Enterovirus 71 (EV71)
• Group B Streptococcus
• Herpes Simplex Virus
• Human Hookworm D
• Leishmaniasis
• Nipah Virus
• Nontyphoidal Salmonella D
• Norovirus
• Paratyphoid
• Respiratory Syncytial Virus
• Schistosomiasis D
• Shigella
• S aureus
• S pyrogenes
• Improved TB
• Universal Influenza Vaccine

14. Intracranial hge
Severe Cough

15. Post-tussive emesis
Very tenacious sticky sputum
Broken BV in eyes & face
What is the Dx?

16. ‘Whooping’ Cough/100
days’ cough
• Highly contagious
• ‘Killer’ in small infants
PERTUSSIS
(persistent intense cough)

17. Pertussis: an ARI characterized by 3 stages:
catarrhal, paroxysmal, & convalescence
Aetiology
• B. pertussis (Classical)
• Others:
– B. parapertussis, B. bronchiseptica
– Adenovirus 1, 2, 3, 5
– M. pneumoniae; C. trachomatis & - pneumoniae

18. Epidemiology
Fastidious, Gram-ve, pleomorphic rod. No growth on ordinary
media (lab to be informed beforehand !)
• Does not survive in environment (P2P spread)
• Only human reservoir
70% cases in <1y age. Endemic every 3-5y
• Mild/atypical in adults  source for children
• Highly contagious in stage 1 (~100%)
• Immunity is i n c o m p l e t e
• I P: 7-10d. PI varies (-2 +6w of cough)
IP: incubation period. PI: period of infectivity

20. B pertussis aka Bordet-Gengou bacillus

21. Pathogenesis
• Basically b r o n c h i t i s
• Locally invasive; toxin mediated:
– severe inflam.: necrosis, infiltration: debris  sticky
s c a n t y sputum  severe cough
• May cause Br. Pn., bronchiectasis, collapse
• Brain: cortical atrophy from IC hge. & anoxia
Pertussis toxins: pertactin, lymphocytotic factor,
hemagglutinin, fimbrial proteins agglutinogens)

22. Bronchiolar plugging & alveolar dilatation in pertussis in an infant

23. Clinical Stages
A. Catarrhal stage: ~1-2w. Mimics coryza: LGF, cough, red
watering eyes. Dx usually missed. ABT can abort it
B. Paroxysmal stage: 2-4w/longer
• Forceful cough of  severity; 5-10 bouts/expn. whoop & vomiting
• Flushed/cyanosed face, bulging bloody watering eyes
• Protruded tongue, dribbling, distended neck veins
• Fever is absent/minimal
Severity: immune status, previous pertussis, ABT
C. Convalescence stage

24. Paroxysmal stage …
• Paroxysmal cough 100%
• Post-tussive emesis 80%
• Prolonged dyspnoea (neonate) 80%
• Whoop 70%
• Convulsion 25%
Mortality <4mo age 40%
Atypical presentation:
• <6 mo age: apnea, no whoop. Severest in preterm
• Older children & adults: milder-shorter, prolonged
cough ± paroxysms. No whoop in adults

25. S/he is apathetic, loses wt. rapidly
Triggers of paroxysms
– eating, drinking
– sneezing, yawing, wind
– laughing, playing,
– smoke
–Suggestion!
PE: generally uninformative; May be no signs
• Diffuse rales, & ronchi may be noted
• Petechiae may be seen

26. Bilateral subconjunctival hge. in an infant with pertussis

27. Convalescence stage
• Signs of improvement over weeks-months
• Resp. Tract can stay irritated for months-years:
Paroxysms may occur with each RTI during this time
Complications
• Respiratory:
• CNS:
• Alimentary system:
• Others:

28. Complications: Respiratory Sys.
• Pneumonia: primary, secondary
• Reactivation of TB
• Bronchiectasis
• Collapse
• Emphysema
• Pneumothorax
• AOM

29. 4w-old: pertussis pn. with air trapping & collapse
(segmental/lobar collapse not uncommon)

30. 4-w. Died of pertussis pn. (2y S. aureus): air trap. He had SD hge.

31. Pertussis pn. in a
7-y. Obliteration
of cardiac
borders is
common

32. Complications: CNS
• Hemorrhage, SD hematoma, brain atrophy
• Seizures (Pertussis encephalopathy: hge+atrophy+seizures)
• SIADH
Complications: Alimentary Sys.
• Frenulum ulceration
• Rectal prolapse
• Umbilical/inguinal hernia
• Intussusception
• Melena
• Malnutrition

33. SD hge in pertussis. Past: 36,000 died/y in US, most in first 6 mo of life

37. Melena

38. Complications: Others
• Over exhaustion
• Dehydration
• Tetany
• Hypoglycemia
• Epistaxis, sub-conj. bleeds, purpura
• Diaphragmatic rupture

39. Rupture of diaphragm:
A. mimics loculated pneumothorax. B. NGT in herniated stomach

40. Prolonged QT
Tetany

42. Dx: mainly clinical
• High index of suspicion in stage 1: immunity, contact,
neighborhood
• Classical paroxysm is very suggestive
• Cough >2w with post-tussive emesis is an important clue
Lab.
• CS:
• CBC: absolute lymphocytosis (20-50K) is typical (not in B
parapertussis & immunized). It parallels the severity
• CXR: perihilar infiltrates, Br.Pn., emphysema, etc.
• PCR for rapid Dx

43. CS: should be done in all cases. Takes 10-14d
Negative: after 4thw of illness, immunized, ABT
• NP secretions (aspiration/Dacron/Ca alginate swab)
• Media: Regan-Lowe (transport) & B.G.
• Inform lab* beforehand
DD:
• Other c/of bronchitis
• Foreign body
• Toxic damage to RT by gases
• Lipoid/chemical pneumonia
*Inform lab as these media are not routinely available

44. • Erythromycin x14d is DoC
– Aborts paroxysm in Stage 1
– Shortens duration, reduces spread, prevents relapse
– In Stage 2 ABT has no effect
• Azithromycin & clarithromycin are alternative
• Resistance is rare
Penicillins, cephalosporins ineffective
TREATMENT
Azithro.10–12mg/kg/d, max. 600mg/d x5d
Clarithro. 15–20 mg/kg/d, in 2 dd; max. 1 g/d x7d

45. Nursing is v. important
– Avoid triggers, hydration, nutrition
– suction clearance, O2
– Betamethasone, albuterol may  severity
No cough suppressants
Admission: Infants <6 mo
– to manage apnea, hypoxia
– feeding difficulties, dehydration
– other complications
– ICU

46. IMMUNISATION
• 5 doses: 4th at 15-18mo; 5th at school entry
• Immunity is not absolute/permanent
• It may not prevent infection. Mild illness may not be
recognized & can spread
• DPT vax.: requires booster/10y
Prognosis
• Mortality ~40 % in infants <5mo
Death:
• Anoxia, rapid dehydration
• Malnutrition, hypoglycemia
• Over exhaustion, encephalopathy

47. Points to Ponder
• Pertussis is fatal in small babies
• Severe damage to RT cilia  RT is reactive for 1year
• It causes innumerable complications
• Immunity is neither complete/permanent
• Cl. Dx is essential
• No growth on ordinary media
• Rx can abort the disease in coryzal stage
• Can reactivate TB

48. This unvaccinated child has severe
cough & vomiting
1.What is the Dx?
2. What is the c/of such bleeding in
this child?
3. What are other complications?
OSPE

49. MCQ
Classical pertussis
• causes neutrophilic leukocytosis
• causes leukemoid reaction
• is complicated by apnea in neonates
• immunization confers excellent protection
• causes death by septicemia
• the bacteria grows in common media
• makes blood culture positive
• Whoop is characteristic in all ages

50. ‘Bull neck’ (LAP &edema)

51. What is the Dx?
Pharyngeal D: membranes covering
tonsils &uvula in a 15y F

52. DIPHTHERIA
a serious d. c/by only locally invasive C. diphtheriae
– fatal: local obstruction and
– fatal: systemic toxicity
• Spreads P2P. Fate depends on:
– strain (toxic/not), circulation, immunity
• Man only
• Both non-/toxigenic strains cause obstruction
• Only toxigenic strain causes toxemia
• 50% mortality. Now rare
P2P: person to person

53. Common site: URT
• Also skin, eye, ear, genitalia, wound
• Exotoxin: degeneration/necrosis of heart, nerves (paralysis)
kidneys, adrenals
– Interval: myocarditis 2w. neuritis 3-7w
Characteristic pseudomembrane
• Necrosed tissue + exudate + bacteria
• Tough-fibrinous; adherent
• Gray to black (~bleed)
• Attempt to remove it causes bleeding

54. Diphtheritic
tracheobronchial
membranes

55. Conjunctival D.: membranous conj.: strep., pneumo., D; chemical,
ligneous conj., adenovirus or HSV

56. Nasal diphtheria: 5y

57. Diphtheria in wound

58. Tonsilopharyngeal D
Insidious: LGF, disproportionately toxic, malaise, sore
throat, irritable, dysphagia, bull neck, rapid pulse, ±
respiratory & CV collapse
Very distinctive membrane: pharynx to palate. Palatal palsy:
nasal voice +/-regurgitation. May die in 7–10d
Laryngeal D
Usually extension from pharynx
• Croup, severe chest retraction, hoarseness
• Restless, but soon becomes weak, drowsy
• A grave situation! Urgent tracheostomy/intubation

59. Clinical Dx is urgent!
• Extended membrane, disproportionately toxic; noisy
breaths, stridor, hoarseness, bull neck, palatal palsy
• Serosanguinous nasal discharge
• Confirmed by CS, FAB staining
• Toxigenicity test by using guinea pigs
IMPORTANT!
• Diphtheria like MO on smear does not establish Dx. CS is
essential. But Cl. Dx is enough to start Rx
• Mortality is ~5%. Untreated ~50%

60. Gram-positive C diphtheriae, stained using the methylene blue technique.

62. White Patch Over Tonsils
 Follicular tonsillitis
 D i p h t h e r i a
 Inf. Mono.
 Agranucytosis
 Leukemias
 Candidiasis
 Herpangina
• Vincent’s angina
• Post tonsillectomy
membrane
• Ac. Toxoplasmosis
• Ac. CMV

63. Follicular tonsillitis

64. Inf. mononucleosis

65. Herpangina: coxsackie A16

66. Oral thrush

67. Treatment
A. Neutralize toxin
• Equine ADS for blood toxins (not fixed) after
desensitization if sensitive (5-20%)
Dose varies: site, circulation, toxicity, duration, LAP
• Pharyngeal/laryngeal ≤48hr  20-40 thousand i.u.
• Nasopharyngeal disease  40-60 ,,
• Extensive for 3d/bull neck  80-120 ,,
B. ABT : Penicillin/erythromycin DoC x14d
C. Supportive: life support
ADS: antidiphtheric serum. ABT: antibiotic therapy

68. Complications
Obstruction:
• Hypoxia, CV collapse
• Bull neck, dysphagia
• Pn., hemorrhagic pn.
Toxemia:
Neuritis: paralysis of palate,
pharynx, eye, diaphragm,
ciliary B, GBS
Myocarditis
Gastritis
Hepatitis
Nephritis, ATN

69. MCQ
In diphtheria:
• most strains are toxigenic
• natural inf. does not exclude vaccination
• greatest obstruction occurs with pharyngeal D
• antibiotic alone is curative
• positive Albert Stain is diagnostic
• cardiac failure occurs due to toxic myocarditis
• the pseudomembrane is easily separable

70. WelcomeAll
WelcomeAll

76. POLIOMYELITIS
• Enterovirus. 3 strains: damage AH cells: partial/full palsy
• Spreads: P2P, mucus/phlegm, feces
• Enters gut & URT, multiplies in throat & gut, spread to
nerve by blood & lymph
• IP: 5-35d. 3 patterns: subclinical (commonest)
nonparalytic, paralytic (1%)
• Massive vax.: practically eradicated it from most countries
except a few Afro-Asian countries. Bangladesh is free
AH: anterior horn

77. CF
• Fever, myalgia, HA, abnormal reflexes, back stiffness, stiff
neck, ANS features
• Tests: cultures from throat, stools, or CSF
ANS: autonomic nervous system
Rx
• Only supportive:
– moist heat for muscle pain &spasms
– Analgesic (no narcotics)
– Physiotherapy, orthopedic appliances & surgery
• If severe: lifesaving measures

78. Tripod sign

79. Complications
• Paralysis, aspiration pn., pulmonary edema
• Myocarditis, shock
• Paralytic ileus, disability, deformity, urine retention, UTI
Prognosis
• Depends on the clinical type & area affected
• Most cases recover
• CNS involvement is a medical emergency
• Disability is more common than death
Prevention: OPV (live) & IPV (inactive). No OPV in HIC
• OPV: herd immunity. Pulse dosing in LICs
HIC: high income countries. LIC: low income countries

81. MCQ
• Both OPV & IPV are live vax
• OPV is used globally
• Both polio vax. gives herd immunity
• OPV pulse dosing is used in LICs only
• Most polio cases are subclinical
• Polio is eradicable
• Polio paralysis is usually symmetrical
• Bangladesh is polio free
• Vaccine polio virus may cause paralysis (VAPP)
• Polio causes ascending type of paralysis

84. What is the Dx?

85. ‘The Severe’
Measles
(rubeola)
David Morley

86. Measles is a killer &
blinding d. specially for
malnourished children

87. Measles is a viral ID of man. Spreads P2P
• Main sign: cough, an itchy MPR (exanthem) & tiny white
spots in mouth (enanthem). 3 stages:
catarrhal, eruptive, convalescence
• HGF, cough, rhinitis, conjunctivitis
• Rash on 4th day of fever
• Severely ill. Serious complications
• Vax. prevents it
• IP: 7-18d. But SSPE: ~10.8y; not contagious
• PI: -5 +5 d of rash
MPR: maculopapular rash. PI: period of infectivity

88. Pathology
• MPR: starts at hair line, behind ears; eyes, RT & GIT
Spreads ; stays 7–10d: post measles staining
• Rash reaches feet: Fever goes!
• Rash may bleed (black measles)
• Mouth: Koplik spots; devastating ulcers
• Severe depletion of Vitamin A
• RT: Pn., bronchiolitis; bronchitis, bronchiectasis, AOM
• CNS: Encephalitis, SSPE
• GIT: Diarrhea, malabsorption

89. Pathology …
Immune system
• Immunoparesis (T&B cell)
• Diarrhea
Appendix
• Lymphoid hyperplasia
• Pathognomic Warthin-Finkeldey giant cell
• Appendicectomy not needed
Eyes: VADX, Keratoconjunctivitis, Keratomalacia
Nutrition: VADX, Enteritis

90. Post measles staining

91. Noma/
cancrum
oris

92. SEQUELAE CAN BE RESTORED with
APPROPIATE TECHNOLOGY

94. DIAGNOSIS
Mainly clinical. Giant cells in nasal smear
• Culture of virus (urine, blood, nasopharynx)
• Specific IgM in serum
Rx: No sp. Rx. Only supportive:
• Most important: Vitamin A
– 200k i.u. day1, d4 & d8. It decreases MM
• FEB, feeding, oral hygiene
• Rx of complications. ABT only for 2y infx.
• Ig may benefit in severe malnutrition
MM: morbidity & mortality. FEB: fluid & electrolyte balance . ABT: antibiotc therapy

95. • VADX, blindness
• AOM
• Laryngotracheitis
• Bronchitis
• Bronchiectasis
• Bronchiolitis
• Giant Cell Pn.
Pn: pneumonia. SSPE: subacute sclerosing
panencephalitis
• PM enteropathy
• Mouth ulcers
• Appendicitis
• Myocarditis
• Encephalitis
• SSPE (1/1000)
Complications
by virus itself

96. Eye damage (by virus & VADX)
– Conjunctivitis, keratitis, keratomalacia. Was the
commonest nutritional blindness in our country
Secondary inf.
• Unmasking of TB
• Bronchitis, bronchiolitis, bronchiectasis
• ALTB (croup), bacterial pneumonia
• AOM, diarrhea
Pneumoniain measles: viral, giant cell (Hecht),
bacterial, tuberculous

97. Complications: immunoparesis
• Unmasking of TB
• Depressed CMI (Pseudo-ve MT)
• Low response to vaccines
• Diarrhea, malabsorption, 2y inf. (v. common)
• If fever recurs suspect 2y inf.
Causes of death
• Fulminant course, pn., diarrhea, severe Mn., VADX
• Neurologic complications
Any non-accidental death within 1 mo of measles is measles

98. Subac. Sclerosing Panencephalitis (SSPE)
• A rare, chr., progressive encephalitis in children & young
adults (?mutation of virus)
• There is restricted expression of envelope proteins: no
infectious particles like the M protein produced:
no immune response. No spread!
Progression
• Stage 1: irritable, altered personality, dementia, MR
• .. 2: fit, ataxia, more MR, speech problems, dysphagia
• .. 3: steady decline in body function, blindness. Pt. is
likely to be mute and/or comatose
No cure. Inosine pranobex, ribavirin, IF alpha/beta
Aka Dawson Disease, Dawson E or measles E

99. SSPE: MRI at Dx (A, B) & 3mo
later (C, D)
A & C are T1; B & D T2
A B: focal abnormality in white
m. of L frontal lobe,
with hypointense signal
on T1 & a hyperintense
signal on T2
FU scan: this is less obvious ,
but advanced diffuse
cortical atrophy is seen,
(ventriculomegaly,
markedly enlarged sulci
(arrowheads in C)

102. MCQ
• Measles can deplete VA totally
• It is the commonest c/of nutritional blindness
• MT can be negative after measles
• Vaccines should not be deferred after measles
• Noma is a recognized complication of measles
• 2 doses of measles vaccine are required
• SSPE is a slow virus infection
• SSPE is infectious
• Appendicitis in measles usually need operation
• Secondary bacterial infection is common in measles

103. Severe muscular
spasms with
trismus from
contamination of
umbilical stump

104. Risus
sardonicus

105. Opisthotonos: back is bent backward with forward bowing
What is Dx?

106. TETANUS
• Fatal ! Neurotoxin from vegetative form of anerobic spore
forming G+ve C. tetani. IP: 3d–3w-months (~14d)
• Ubiquitous; soil, dust, dung
• Grows in deep wound, dead tissues; no tissue damage/inflam
•  contamination  shorter IP  severer disease
• Painful generalized myospasm. Death is usually from
suffocation. Subsides over weeks if recovers
• Brain not affected. Mentally c l e a r !
• NT: 5-14 d (8 days disease)
NT: neonatal tetanus

107. LT secondary to parent’s attempt to drain a boil with a contaminated thorn
A preschool boy with Localized Tetanus 2y to parent’s attempt to drain
a boil with a contaminated mesquite thorn

108. TREATMENT
Medical e m e r g e n c y ! M u s t hospitalize
• Supportive: control spasm, FEB, nutrition
• Control of ANS instability if any:
– ventilator SOS:
• Wound management:
Control of spasms is most important
• Anticonvulsant: best survival is achieved by flaccid
paralysis & mechanical ventilation
• TIG 3000-6000iu im for all. No local infiltration (cannot
neutralize fixed toxin)

109. Anticonvulsants
• Diazepam, Midazolam, Chlorpromazine
• Baclofen & other muscle relaxants
ANS instabilities
• Temp. instability, cardiac arrhythmias
• Unstable BP, excessive secretions
Temperature instability
HGF in tetanus: spasms, sympathetic over-stimulation,
infection, dehydration

110. TETANUS PRONE WOUND
• Containing dirt, feces, soil, or saliva
• Has necrotic or gangrenous tissue
Aggressive care is essential: part of prevention
Aim: eradication of the MO
• Remove dead tissue & FB
• No extensive débridement for punctures
• No wide excision of cord stump
WOUND MANAGEMENT

111. ABT
• Metronidazole is the DoC. Pen. G is alternative
• Duration: 10-14d
TIG
• Give TIG in HIV, regardless of h/of TT
• TT: child 7y: use Td; <7y: DTaP/DTP/DT
• Separate sites for TT &TIG
• TIG does not preclude immunization
• TIG does not impair immunogenesis
PO/IV metronidazole (30 mg/kg/d/6-h. Pen. G (100 000 U/kg/d/4-6h; max. 12 million U/day) IM

112. Past Doses Clean, Minor Tetanus prone
Td TIG Td TIG
<3 or unknown Yes2 No Yes Yes3
34 No5 No No6 No
2 Children <7 y, DTaP. DT if pertussis is CI. 7 y: Td
3 Equine ATS used when TIG is NA
4 If only 3 doses a 4th is given
5 Yes, if >10 y since last dose
6 Yes, if >5 y since last dose
TT in Wound Management

113. COMPLICATIONS
• Aspiration pn.
• Dysphagia
• Dyspnea, apnea
• Secondary infx.
• IC Hge
• Fractures, soft tissue injury
• Hyperpyrexia
• Hypoglycemia
• Hyperglycemia
CAUSES OF DEATH
• Over-exhaustion, Aspiration pn., Hypoglycemia
• IC Hge, Dehydration

114. Immunization
• TT is toxoid; better as Td
• Very stable & effective. : months at room temp
• May be given with other vax.
• Given as DTP/DTaP, DT, Td ( diphtheria content)
– TT for pregnant & women of CBA
• Children 6w-7 y: x5 TT & diphtheria toxoid
• 5th before school entry. Then each 10y
• For wilderness expeditions: 1 booster if not taken in 5y
HIB conjugate vx. containing TT (PRP-T) are not substitutes for TT vx

115. POINTS TO PONDER
• Non-communicable
• Completely preventable
• Non-inflammatory toxic response
• Disease does not confer immunity
• Spasm control is the mainstay of Rx
• No herd immunity

116. MCQ
Tetanus
• is commonly focal
• is a communicable disease
• Dx mainly clinical
• The vaccine is highly effective & stable & very cheap
• Immunisation confers herd immunity
• is more common in elderly people
• Pt. stays mentally clear
• can cause hyperpyrexia
• can cause aspiration pn.
• can cause hypoglycemia

117. Hemophilus influenzae type b (Hib/HIB)
• Severe sepsis, particularly among infants
• It was believed to cause flu
• Aerobic G-ve. Has polysaccharide capsule
• 6 different serotypes (a - f)
• 95% inf. is c/by type b (Hib)
• Colonizes nasopharynx: affects local & distant sites
• Antecedent URTI may be a contributing factor

118. Cellulitis
6%
Arthritis
8% Bacteremia
2%
Meningitis
50%
Epiglottitis
17%
Pneumonia
15%
Osteomyelitis
2%
HIB: Clinical Features*
*prevaccination era

119. Hib Meningitis
• 50-65% of meningitis in the prevaccine era
• Deafness or neurologic sequelae in 15-30%
• CFR: 2-5% despite of effective ABT
Rx: 3G cephalosporin, or chloramphenicol plus ampicillin.
Ampicillin-resistance is now common
• Reservoir: human; asymptomatic carriers
• Droplets
• Incidence has fallen 99% since prevaccine era
CFR: case-fatality rate

120. 0
5
10
15
20
25
1990 1992 1994 1996 1998 2000 2002 2004
Incidence
Incidence*of Invasive Hib Disease, 1990-2004
*Rate per 100,000 children <5 years of age
Year

121. 0
20
40
60
80
100
120
140
160
180
200
0-1 12-13 24-25 36-37 48-49 60
Age group (mos)
IncidenceHaemophilus influenzae type b, 1986
Incidence* by Age Group
*Rate per 100,000 population, prevaccine era

122. Polysaccharide Conjugate Vax.
• Enhanced Ab. production. Given with other vax.
• 3 primary from 6w; 2 boosters
• Generally not for >59mo of age
• Consider for high-risk: asplenia, immunodeficiency, HIV,
HSCT: 1 pediatric dose

123. S. pneumoniae
• Gram-positive S. pneumoniae
• Reservoir: human; spread by droplets
• 90 serotypes
• Polysaccharide capsule is important virulence factor
• Type-specific Ab is protective
Pneumonia, Bacteremia, Meningitis, AOM
• 2005: 1.6 million died; (0.7-1million U-5), mostly in LICs
• In HICs, <2y & the elderly mostly affected
• Immunodeficiencies greatly increase the risk
• Increasing ABR underlines urgent need for vax.
ABR: AB resistance

124. Pneumococcal Disease in Children
• Sepsis without focus is the commonest presentation
• Leading c/of bacterial meningitis among U-5; highest
among infants
• Most common c/of AOM (5million/y)
Pneumonia: 36% of adult CAP & 50% of HAP
Ac. onset: F, shaking chills, pleuritic chest p., moist
cough, SoB, tachypnea, hypoxia. 175k adm. In
US/y. Common bacterial complication of
flu & measles
CAP: community-acquired pn. HAP: hospital-acquired pn. AOM: acute otitis media

125. Pn. Sepsis
• >50,000/y in the USA
• More among elderly & very young
• CFR: ~20%; 60% among the elderly
Pn. Meningitis
• 3k-6k/y in the USA
• CFR: ~30%; 80% in the elderly
• Neurologic sequelae common

126. Children at more Risk of IPD
• Functional/anatomic asplenia, especially SCD
• Overcrowding, poor clothing, malnutrition
• HIV
• Cochlear implant
• Out-of-home group child care
Outbreaks not common: generally occur in crowding
IPD often has underlying illness & may have high fatality
SCD: sickle cell disease

127. Invasive Pn. D. (IPD): Incidence by Age
0
50
100
150
200
250
<1 1 2 3 4 5-17 18-34 35-49 50-64 65+
Age Group (Yrs)
Rate*
*Rate per 100,000 population
Source: Active Bacterial Core surveillance/EIP Network

128. Pneumococcal Vax.
• Growing ABR: urgent need for vax.
• Vax. is most effective for Px
– 4 doses of pn. conjugate vax. (PCV) covering 7, 10 & 13
serotypes (PCV7, 10, 13)
– 1 unconjugated polysaccharide vax. covering 23 strains
(PPV23)
• WHO recommends PCV
ABR: antibiotic resistance

129. Rubella
• Ac., contagious viral inf. that occurs most often in
children & young adults
• Rubella in pregnancy may cause fetal death or cong.
defects known as cong. rubella syn. (CRS: blindness,
deafness, heart defects)
• 1,10,000 babies are born with CRS/y
• Immunization
– Single dose of vax.: >95% immunity; 2nd dose 100%
– Usually combined with Measles, Mumps, and/or Varicella vaccine

130. MCQ
• Pneumococcus is a capsulated bacteria
• Rubella can cause deafness in adolescents
• Hib is a common c/of epiglottitis
• Pneumococcal vax. covers all strains
• AOM can cause meningitis

133. Next Lec.:
Childhood
Injury
(ACCIDENTS IN CHILDREN)

134. THANK YOU