![Tdap vaccine
Diphtheria - a purely vaccine-preventable disease
It used to be a disease of children 5-7 years, but now a
shift to right in epidemiology
A huge resurgence in last few years
Cases in India far out number those of any other country
in the world according to WHO.
3343 and 4233 in 2010 &2011 respectively incidence
increasing [DGHS]
India contributes 86.66% of the
diphtheria cases reported globally](https://image.slidesharecdn.com/vaccinationfinal-170707104932/75/Immunization-for-INDIAN-Adolescents-Dr-Jyoti-Agarwal-Dr-Sharda-Jain-Dr-Jyoti-Bhaskar-15-2048.jpg)
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Immunization for INDIAN Adolescents Dr. Jyoti Agarwal Dr. Sharda Jain Dr. Jyoti Bhaskar
- 1. Immunization for INDIAN Adolescents …Caringhearts, healing hands Dr. Jyoti Agarwal Dr. Sharda Jain Dr. Jyoti Bhaskar
- 2. LEGENDS NEVER DIE……… Whenmeditating over a disease, I never think of finding a remedy for it, but, instead, a means of preventing it Louis Pasteur (1822-1895)
- 3. Vaccinations are amongthe greatest public health achievements of the 20th century • First recorded in 1890-95 • Imminization is the action of making a person immune to infection, typically by inoculation • Immunization prevents disability & death from infectious diseases • It also helps control the spread of infections within communities
- 4. Immunization ‘Is not justfor infants & children under five any more'
- 5.
- 6. How Quickly WeForget (Human Catastrophe From Infective Diseases ) • 1920s : 13,000 died yearly from diphtheria • 1940s : 8,000 died yearly from pertussis • 1952 : polio paralyzed 21,000 • 1963 : 3 million cases of measles and 500 died • 1964-65 : 12.5 million cases of rubella; 20,000 infants were born with congenital rubella • 1985: 12,000 meningitis cases by H. influenza type B All this could have been prevented If they were vaccinated
- 7. Protect the YOUTH ‘Nation’sFuture’ • Every fifth person in India is an adolescent (10-19 yrs) Every third – a young person (10-24 yrs) • They are our biggest competitive advantage,so their health care is of utmost importance. Somehow this group is totally neglected 30% Investing in Adolescent Health is a Win – Win situation for any society
- 8. Why Target Adolescents?? • Immune protection provided by childhood vaccinations may not cover adolescent period • This may happen because the effect of vaccination wanes off • May be the initial vaccination in childhood was not given or was given in inadequate doses • Underlying chronic diseases in adolescents or certain high risk groups also demand vaccination for their protection It is collective responsibility as gynecologists, paediatricians, teachers and parents to ENSURE that they are cared for and adequately vaccinated
- 9. Vaccination Coverage IsAround 65 %
- 11.
- 12. Age ► Vaccine ▼ Birth – 2 weeks 6wk 10 wk 14 wk 18 wk 6 mo 9 mo 12 mo 1 5 m o 18 mo 19-23 mo 2-3 Yr 4-6 Yr 7- 10Yr 11-12 Yr 13-18Yr BCG BCG Hep B Hep B1 Hep B2 Hep B3 Polio OPV 0 IPV1 IPV2 IPV3 OPV 1 OPV2 IPV B1 OP V3 DTP DTP 1 DTP 2 DTP 3 DTP B1 DT P B2 Tdap Tdap Hib Hib 1 Hib 2 Hib 3 Hib-booster Pneumococca l PCV 1 PCV 2 PCV 3 PCV - booster PCV PPSV23 PPSV Rotavirus RV 1 RV 2 RV 3 MMR MMR 1 MMR 2 MM R 3 Varicella VAR 1 VA R 2 Hep A Hep A1 & Hep A2 Typhoid Typhoid CV (TCV) Booste r Influenza Influenza (yearly) HPV HPV Meningococc al Meningococcal Cholera Cholera 1 & 2 JE Japanese Encephalitis Rabies IAP Recommended immunization schedule for children aged 0-18 years 2016
- 13. Recommended Adolescent Immunizations inINDIA (2016) 11-12 Years Tdap HPV Annual influenza Catch-Up MMR Hepatitis B Typhoid Varicella Hepatitis A High Risk Pneumococcal Meningococcal JE Cholera Rabies Yellow fever
- 14. Vaccines Recommended for Alladolescents at age 11 to 12 years
- 15. Tdap vaccine Diphtheria- a purely vaccine-preventable disease It used to be a disease of children 5-7 years, but now a shift to right in epidemiology A huge resurgence in last few years Cases in India far out number those of any other country in the world according to WHO. 3343 and 4233 in 2010 &2011 respectively incidence increasing [DGHS] India contributes 86.66% of the diphtheria cases reported globally
- 16. Why do Adolescentsneed Pertussis Vaccine? • Pertussis is endemic • Outbreaks are still occurring the general trend has been upward • Adolescents are responsible for spread of pertussis in the community • Immunity to pertussis last 3-10 years India contributes > 43 % of pertussis cases reported globally
- 17. International Consensus GroupOn Pertussis & Global Pertussis Initiative Recommendation • There is a need to vaccinate ALL adolescents at 11 – 12 yrs of age against pertussis • Vaccination ensures an increase in herd immunity
- 18. Tdap vaccine • Administer1 dose of Tdap vaccine to ALL adolescents aged 11 through 12 years • Or at any greater age if it has not been given earlier • Boosters after that are Td given every 10 years • Can be administered at the same time as other adolescent vaccines Efficacy of Tdap vaccine - 92%
- 19. HPV vaccination • Everywoman is at risk of Cervical Cancer • 1 out of 4 women who die due to Cervical Cancer in the world is an Indian
- 20. Risk of cervicalcancer is strongly related to the age at first intercourse 1 2 3 4 5 6 7 CIN Invasive Cervical Cancer RelativeRiskEstimatesa ≤17 18–22 aMantle-Haenszel estimates adjusted for age only. 1. La Vecchia C et al. Cancer. 1986;58:935–941. Relative risks for CIN and invasive cancer increase with decreasing age of first sexual intercourse. Age at First Intercourse (Years) (n=206) (n=327) Reference Population: First intercourse 23 years of age or never
- 21. Evidence and justification •IAP had recommended use of HPV vaccine in its immunization schedule way back in 2007 • There is NO coverage data on uptake of this vaccine • Common perception is that acceptance is poor and the coverage still remains miniscule
- 22. In India, bothIAP and FOGSI recommend the HPV vaccine • Minimum age: 9 years • For girls aged 9-14 yrs only 2 doses of either of the two HPV vaccines • For 2 dose schedule, the minimum interval between doses should be 6 months • Catch up vaccination is permitted up to the age of 45 years • For girls 15 years and older, and immunocompromised 3 doses are recommended • For 3 dose schedule, administer the 2nd dose 1 to 2 months after the 1st dose and the 3rd dose 6 months after the 1st dose Use The Same Brand of Vaccine For The Entire Series
- 23. The WHO’s StrategicAdvisory Group of Experts (SAGE) has recommended revision of HPV vaccination schedule for pre-adolescent girls from three primary doses to two April 2014 ‘The move to revise HPV vaccine immunization schedule from three to two doses would not only be cost- saving, but would also help in improving acceptance, and enhancing coverage of the vaccine’
- 24. Genital Warts Vulvar/ VaginalPrecancers (Grade 1- 3) Cervical Cancer & Precancers (Grade 2/ 3) 99% 98% 100% HPV induced lesions Protection 1. The Future II Study Group. Lancet 2007; 369: 1861–68 2.Garland SM et al. New Engl J Med. 2007;356:1928–1943. Efficacy of Quadrivalent HPV Vaccine
- 25.
- 26. What about Influenza(flu) Vaccine • Flu can be serious, even for healthy adolescents • Adolescents with high- risk conditions more likely to suffer flu complications • Flu seasons are unpredictable and can be severe • There are 2 influenza viruses, types A and B • Type A :subtypes based on two surface antigens Hemagglutinin (H) Neuraminidase (N) eg H1N1 • Influenza type B is not categorized into subtypes
- 27. Influenza vaccine Two typesof flu vaccine available • Injection: Trivalent Inactivated killed Influenza Vaccine (TIV) • Intranasal: Live, Attenuated Influenza Vaccine (LAIV) • Both vaccines are made from viruses grown in eggs • Avoid in allergy to chicken or egg protein • An egg-free vaccine is also now available Both vaccines includes Two type A strains (H3N2 and H1N1) & One type B strain
- 28. Influenza Vaccine Recommendations Adolescents shouldreceive a single dose of influenza vaccine Every Year Best time to vaccinate As soon as the new vaccine is released and available in the market or Just before the onset of rainy season Recommended strains may change annually so in view of changing strains the antigens configuration for Influenza need a new model vaccine every year Influenza – Needs very frequent updating
- 29. IAP Recommendation for CatchUp Immunization for adolescent For those who fall behind or start late, provide catch-up vaccination at the earliest opportunity
- 30. IAP Recommendation forCatch Up Immunization for adolescent Vaccine Schedule MMR 2 doses at 4 - 8 weeks interval I@ HepatitisB # 3 doses at 0, 1 and 6 months Hepatitis A 2 doses at 0,6 months (prior check for ## anti – HAV IgG may be cost effective) Typhoid 1 dose every 3 years** Varicella 2 doses at 4 – 8 weeks interval @ one dose if previously vaccinated with one dose #, ## Combination of hepatitis B and A may be use in 0, 1, 6 schedule **A minimum interval of 3 years should be observed between 2 doses of typhoid vaccine
- 31. MMR vaccine • Allschool-going children and adolescents should have at least 2 doses of MMR vaccine • one dose if previously vaccinated with one dose • Minimum interval between the 2 doses is 4 wks “Stand Alone” vaccine given to infants during outbreaks, should not be counted
- 32. Chicken pox (CDC2007) Most cases are mild but adolescents and adults are at risk for severe disease Prior to vaccination – 4 million cases annually – 10,600 hospitalization – 100 – 150 deaths Since vaccination – 88% decrease in cases – 88% decrease hospitalization – 90% decrease deaths
- 33. Varicella vaccine -Catch-upvaccination • Ensure that all adolescents aged 7 through 18 years should have 2 doses of the vaccine • For children till 12 years, the recommended minimum interval between doses is 3 months • For children 13 years and older, the minimum interval between doses is 4 weeks
- 34. The Expert Groupfor Hepatitis A • Universal immunization for hepatitis A is not recommended as yet • Sero-positive rates exceed 50% • Prior check for Hepatitis A antibody titre IgG is cost effective & recommended
- 35. Hepatitis – Avaccine , 2 types • Live attenuated H2 strain hepatitis A vaccine • Killed inactivated Hep A vaccine • Either of the two vaccines can be used • Administer 2 doses of inactivated vaccine 6 months apart • Only single dose of live attenuated H2-strain vaccine Highly immunogenic & Highly efficacious Essentially 100% have protective levels of antibody after second dose
- 36. Hepatitis – Bprevalence in India • 1 - 2% (Lodha et al) • Overall chronic HBsAg +ve rate in India is 4.7% • Catch-up vaccination • Recombinant hepatitis B virus vaccine • 90% successful 3-doses to be given to those previously not vaccinated at 0 – 1 – 6 months Combination of Hepatitis B & Hepatitis A may be used at 0 – 1 – 6 months
- 37. Typhoid Vaccination The committeestrongly urges the GOI to include universal typhoid vaccination in its UIP all over the country at the earliest
- 38. Typhoid vaccine catch-upvaccination • Recommended throughout the adolescent period, i.e. up to 18 years of age • Vi conjugate typhoid vaccine should be preferred over Vi-PS vaccine wherever feasible • The need and exact timing of the booster doses are not yet determined • Typhoid revaccination every 3 years, if Vi-polysaccharide vaccine is used • An interval of at least 4 weeks with the MMR vaccine should be maintained while administering Typhoid vaccine
- 39. IAP Recommendations for adolescent Immunizationin High Risk Cases
- 40. High-risk category ofchildren • Congenital or acquired immunodeficiency (including HIV infection) • Chronic cardiac ,pulmonary (including asthma if treated with prolonged high-dose oral corticosteroids),renal (including nephrotic syndrome) liver disease; • hematologic • Children on long term steroids, salicylates, immunosuppressive or radiation therapy • Diabetes mellitus, • Cerebrospinal fluid leak • Cochlear implant • Malignancies • Children with functional/ anatomic asplenia/ hyposplenia; • Travelers • Children having pets in home
- 41. IAP Recommendations foradolescent Immunization in Special Circumstances Vaccine Age recommended Meningococcal vaccine 2 doses Japanese encephalitis vaccine Catch up to 15 years @ PPSV23 (Pneumococcal) vaccine 2 doses 5 years apart* Rabies vaccine 0, 3, 7, 14, 28 day As soon as possible after exposure Cholera & yellow fever @ Only in endemic area as catch up * Maximum number of doses – Two
- 42. Meningococcal Meningitis • Epidemics– 20 year cycles previously, now increasing frequency • Annual incidence of 3000 cases • 10% of these cases will die , high Case Fatality Rate • 20 % of those who survive suffer serious long term disability , hearing loss , organ failure & limb amputation • Often misdiagnosed as something less serious like “ flu” • Spreads rapidly , often within hours of first symptoms
- 43. MENINGOCOCCAL MENINGITIS 2 Types Polysaccharidevaccines • Bivalent (A&C) • Quadrivalent (A,C,Y & W135) Conjugate vaccines Quadrivalent Monovalent Conjugate vaccines are preferred over polysaccharide vaccines due to their potential for herd protection and their increased immunogenicity
- 44. Meningococcal Conjugate Vaccine •Two doses of MCV4 are recommended for adolescents aged 11 to 18 years First dose at age 11 - 12 years Booster dose at 16 years • Adolescents who receive their first dose at or after 16 years of age do not need a booster dose
- 45. Pneumococcal Vaccines Two typesavailable • Pneumococcal conjugate vaccine (PCV 10 , PCV 13) • Pneumococcal polysaccharide vaccine (PPSV 23 ) • Risk of serious Pneumococcal disease is relatively low • Not recommended for routine use in healthy individuals • Recommended only in high risk group of children
- 46. Pneumococcal Vaccines • Asingle dose of PCV13 is given to previously unvaccinated children who have anatomic or functional asplenia (including sickle cell disease), HIV infection , immunocompromised, cochlear implant or cerebrospinal fluid leak • Administer PPSV23 at least 8 weeks after the last dose of PCV • An additional dose of PPSV should be given after 5 years to children with anatomic/functional asplenia or if immunocompromised • PPSV should never be used alone (Maximum number of doses – 2 ) • Give PCV13 first and MCV4 four weeks later (NOT simultaneously) • Can be co-administered with live vaccines such as the influenza vaccine
- 47. Cholera Vaccine • Availableas inactivated whole cell Vibrio cholera vaccine • Not recommended for routine use in healthy individuals • Recommended only adolescents residing in highly endemic areas and traveling to areas where risk of transmission is very high like Kumbh mela • Two doses are given 2 weeks apart
- 48. Japanese Encephalitis Vaccines •Recommended only for individuals living in or planning to visit endemic areas till 18 years of age • All susceptible children up to 15 yrs should be administered during disease outbreak , ahead of anticipated outbreak in campaigns • Live attenuated, cell culture derived SA-14-14-2 NA • Inactivated cell culture derived SA-14-14-2 2 doses , 4 wks apart I/M Need of boosters still undetermined • Inactivated Vero cell culture-derived Kolar strain, 821564XY 2 doses I/M at 4 wks interval Need of boosters still undetermined
- 49. Rabies is oneof the oldest and most feared diseases reported in medical text •Pre exposure prophylaxis •Post exposure prophylaxis
- 50. Rabies vaccine • PracticallyALL children need vaccination against rabies ‘High-risk’ category for Pre-exposure prophylaxis • Children having pets at home • Children with higher threat of being bitten by dogs such as hostellers, • Risk of stray dog menace while going outdoor
- 51. WHO Approved Vaccines •Purified chick embryo cell vaccine (PCECV) Rabipur (novartis) (1.0 ml) • Human diploid cell vaccine (HDCV) Rabivac (serum institute) (1.0) • Purified vero cell vaccine (PVCV) Verorab (sonofi pasteur) (0.5 ml) Only Modern Tissue Culture Vaccines (MTCVs) and I/M routes are recommended for both ‘Post-exposure' and ‘Pre-exposure' Prophylaxis
- 52. Pre -Exposure ProphylaxisFor Rabies • 3 doses are given intramuscularly in deltoid/ anterolateral thigh on days 0 – 7 – 28 (day 21 if time is limited but day 28 preferred) • First booster dose at 1 year and thereafter every 5 years • For re-exposure at any point of time after completed and documented pre or post exposure prophylaxis, only 2 doses are given on days 0 and 3 • Rabies immunoglobulin is not required during re-exposure therapy
- 53. Post-exposure prophylaxis shouldbe started as soon as possible after exposure (5 day schedule ) • Schedule: 0 – 3 – 7 – 14 – 30 with day '0' being the day of commencement of vaccination • A sixth dose on day 90 is optional and may be offered to patients with severe debility or those who are immunosuppressed