Primary immune deficiency diseases( PID) comprise a heterogeneous group of genetic disorders that affects distinct components of the innate and adaptive immune system such as:
-neutrophils
-macrphages
-dendritic cells
-natural killer cells
-T and B lymphocytes
-complement components
More than 200 distinct PID disorders have been identified and 276 gene have been associated with these diseases.
Spectrum of these diseases can vary from mild presentation to lethal disorders. Lethality is due to increase susceptibility to infections and malignancies.
Primary immune deficiency diseases( PID) comprise a heterogeneous group of genetic disorders that affects distinct components of the innate and adaptive immune system such as:
-neutrophils
-macrphages
-dendritic cells
-natural killer cells
-T and B lymphocytes
-complement components
More than 200 distinct PID disorders have been identified and 276 gene have been associated with these diseases.
Spectrum of these diseases can vary from mild presentation to lethal disorders. Lethality is due to increase susceptibility to infections and malignancies.
Pediatric Home Service Medical Director, Dr. Roy Maynard discusses deficiencies of innate immune system and other well-defined immunodeficiency syndromes.
A brief overview of the process of vaccine production, clinical trials, and licensing, along with a summary of the different vaccines platforms and vaccine candidates.
This is a brief review of autoimmune epilepsies, especially autoimmune encephalitis, SREAT, NORSE, FIRES and Rasmussen's encephalitis. A brief overview of investigations and treatment is included.
Presentación de la inmunodeficiencia comun variable. Definición, criterios diagnósticos, fisiopatología, cuadro clínico y tratamiento con inmunoglobulina.
Pediatric Home Service Medical Director, Dr. Roy Maynard discusses deficiencies of innate immune system and other well-defined immunodeficiency syndromes.
A brief overview of the process of vaccine production, clinical trials, and licensing, along with a summary of the different vaccines platforms and vaccine candidates.
This is a brief review of autoimmune epilepsies, especially autoimmune encephalitis, SREAT, NORSE, FIRES and Rasmussen's encephalitis. A brief overview of investigations and treatment is included.
Presentación de la inmunodeficiencia comun variable. Definición, criterios diagnósticos, fisiopatología, cuadro clínico y tratamiento con inmunoglobulina.
Zyvac TCV - The Indian Typhoid Conjugate VaccineGaurav Gupta
Presented at Ambala in Jan 2020. Is TCV needed, and is it better than Polysaccharide vaccine. Indian data and studies by Dr. Gaurav Gupta, Pediatrician from Charak Clinics, Mohali
Covid-19 Brief Review | A holistic review at pandemic Akhtar Hussain
Presentation holistically and briefly covers the technical aspects of global pandemic. To put things in perspective a comparison woth recent pandemics is also included.
I have tried to make the presentation as rational and unbiased. Though with the ever coming developments daily some things might become redundant even in 10 days only. would love to get suggestions for improvement.
Zyvac tcv the Indian typhoid conjugate vaccination - Yamunanagar aug 2018Gaurav Gupta
Zyvac TCV by Zydus Vaccines is the Indian Typhoid Conjugate vaccination with Indian Carrier TT protein.
Recent data from Lancet regarding TCV efficacy is featured in this presentation
Optimizing antimicrobial therapy for hospitalized pneumonia: Focus on PK/PD p...WAidid
Professor Blasi slideset is about the optimization of antimicrobial therapy for pneumonia and it underlines how the appropriate early antibiotic therapy reduces mortality rates in patients with bloodstream infection.
WEBINAR - Zyvac tcv master class september 2018Gaurav Gupta
WEBINAR - Zyvac tcv master class september 2018. All indian webinar on the new Indian typhoid conjugate vaccination,
Broadcast throughout India with more than 500 pediatricians from across the country registering for viewing and asking questions
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
4. Questions
1. Which condition is considered as low level of immunodeficiency?
a) MTX 4 mg/kg/week
b) Intranasal budesonide 4 puffs/day
c) CVID
d) HIV adolescent with CD4 150 cells/mm3
2. Which DGS children could safely receive MMR vaccine?
a) CD4+Tcell 500 cells/mm3, CD8+Tcell 300 cells/mm3, normal PHA
b) CD3+Tcell 200 cells/mm3, CD8+Tcell 200 cells/mm3, normal PHA
c) ALC 500 cells/mm3, CD8+Tcell 300 cells/mm3, abnormal PHA
d) CD4+Tcell 300 cells/mm3, CD8+Tcell 500 cells/mm3, abnormal PHA
3. What vaccine is absolutely contraindicated in household members of PID patient?
a) Rotavirus
b) OPV
c) Varicella
d) MMR
5. Questions
4. A 10-months old boy just completed oral prednisolone 2.5 mg/kg/day (total 5 days
course). What is the appropriate time to administer MMR?
a) 4 weeks later
b) 2 weeks later
c) after the age of 1 year
d) today
5. CGD patients should absolutely avoid which vaccine
a) BCG
b) Small pox
c) Yellow fever
d) Rotavirus
6. Which vaccine has highest seroconversion rate?
a) PPSV
b) Meningococal vaccine
c) Diptheria toxoid
d) HBV
6. High levels Low levels
1.) CID (Severe CID or SCID)
1.) Mild Ab def.
(SAD, IgA def., IgG subclass def.)
2.) Severe Ab def. (CVID, Agammaglobulinemia) 2.) Complement def.
3.) Innate immunity (Phagocyte defect) 3.) Autoinflammatory disease
4.) Cancer chemotherapy 4.) Immune dysregulation
5.) Solid-organ transplantation within 2 mo.
6.) HIV with CD4 < 200 cells/mm3 for adults and adolescents or
<15% for infants and children
7.) Patients receiving daily corticosteroid with a dose of 20 mg (or > 2
mg/kg Wt <10 kg) of prednisone or equivalent for at least 14 d
8) MTX >0.4 mg/kg/week
AZA >3 mg/kg/day
6-MP >1.5 mg/kg/day
8.) Biologic immune modulators (such as TNF antagonists)
Bonilla FA J Allergy Clin Immunol Pract 2016;4:1066-75.
9. Tetanus and diphtheria toxoid
• These are potent immunogens with high seroconversion rates
– initial low determination in a fully immunized individual should have good predictive
value for diagnosis
• Normal individuals may have up to 20-30 fold increases in antibody
– Lower end of normal fold response range is not well-defined, depends on pre-
booster level
Bonilla FA. Journal of Allergy and Clinical Immunology (2018), doi: 10.1016/j.jaci.2017.12.980.
10. Bonilla FA. Journal of Allergy and Clinical Immunology (2018), doi: 10.1016/j.jaci.2017.12.980.
11. Adverse reactions to vaccines practice parameter 2012 update JACI 2012, Vol 130, No 1
12. PCV and PPSV
• Over 100 distinct serotypes
have been described
• Level considered protective
PCV 0.35 mcg/mL
PPSV 1.3 mcg/mL
• 2 or 4 fold rise is considered normal depending on pre-immunization level
(4 fold rise is less likely if pre-immunization level is high)
• Age factor
– <2 year-old: often good, but very unpredictable
– After age 5 is more consistent
Bonilla FA. Journal of Allergy and Clinical Immunology (2018), doi: 10.1016/j.jaci.2017.12.980.
13. PCV and PPSV
• Majority of vaccine response literature focuses on IgG
• However, IgA and IgM could also have predictive value for PID diagnosis
– readily be used in patients receiving IgG replacement
• These responses peak somewhat earlier than IgG
– 2 weeks for IgA
– 3 weeks for IgM
Bonilla FA. Journal of Allergy and Clinical Immunology (2018), doi: 10.1016/j.jaci.2017.12.980.
14. Orange et al. Use and interpretation of diagnostic vaccination in PID. JACI 2012;130:S1-24.
Bonilla FA. Practice parameter JACI 2015; 136:1186-205.doi: 10.1016/j.jaci.2017.12.980.
15. ≥1.3 µg/mL or 4-fold
(probability of 4-fold response
approached zero if preimmunization
titer 4.4-10.3 µg/mL)
Orange et al. Use and interpretation of diagnostic vaccination in PID. JACI 2012;130:S1-24.
16. Siriraj: 4, 6B, 7F, 9N, 9V, 14, 18C, 23F
Perez E, Bonilla FA, Orange JS and Ballow M. Front . Immunol. 2017; 8:586.
2,8,9N,10A,11A,12F,15B,17F,20,22F,33F
only in PPSV 23
17. Neoantigens: phiX174, KLH
Bacteriophage is a virus that attacks bacteria. The
phiX174 bacteriophage attacks the common
human bacteria Escherichia coli, infecting the cell
and forcing it to make new viruses.
Keyhole limpet hemocyanin (KLH) s a large, multisubunit,
oxygen-carrying, metalloprotein that is found in the
hemolymph of the giant keyhole limpet (หอยหมวกเจ๊ก),
“Megathura crenulata”
(lives off the coast of California)
Orange et al. Use and interpretation of diagnostic vaccination in PID. JACI 2012;130:S1-24.
18. Neoantigen: Salmonella typhi Vi
• 96.3% of 2-5 year-old children have 4-fold increase of Ab with
– prevaccination mean titer 0.16 and postvaccination mean titer 3.23 µg/mL
• > 3-fold considered normal because low prevaccination titer in general population
Orange et al. Use and interpretation of diagnostic vaccination in PID. JACI 2012;130:S1-24.
Bonilla FA. Journal of Allergy and Clinical Immunology (2018), doi: 10.1016/j.jaci.2017.12.980.
19. Typhoid vaccine
• A 10-fold rise in IgG antibody to S.typhi served to distinguish CVID from controls
(90.9% sensitivity and 62.5% specificity)
• One study: better than Pneumococcal
– due to a high level of pre-immunization pneumococcal IgG
• Boon MN et al 2017 compared PPSV, S. typhi response and isohemagglutinin titers
in a cohort of 100 healthy (10-65 year-old)
Bonilla FA. Journal of Allergy and Clinical Immunology (2018), doi: 10.1016/j.jaci.2017.12.980.
20. Schaballie et al. Front. Immunol. May 2017, Volume 8, Article 546
Only 2/100 <5th percentile both
pneumococcus and S typhi
-suggest combination of responses:
better predictive value than either
alone
isohemagglutinin titers might not
serve as a useful surrogate for PPSV
for the diagnosis of PID
21. Neoantigen: Meningococcal vaccine
Summary 62: In contrast to rabies, it is unlikely that MCV will be a suitable neoantigen for patients receiving IVIg
↑ application of MCV in general US population lead to ↑meningococcal Ab in plasma pools
Orange et al. Use and interpretation of diagnostic vaccination in PID. JACI 2012;130:S1-24.
Bonilla FA. Journal of Allergy and Clinical Immunology (2018), doi: 10.1016/j.jaci.2017.12.980.
23. Patients receiving immunoglobulin therapy
Measure Ab response for
a) determine if a transient antibody deficiency has improved
b) a patient may be receiving the therapy unnecessarily
Several options exist
1. The bacteriophage X174 has been used for few decade
– main drawback is a lack of convenience, available only via a research protocol at a single
institution (University of Washington, Seattle, WA)
2. Rabies virus vaccine
– Advantage: both vaccine and assays for measuring IgG are readily available.
3. Typhoid vaccine -recently been demonstrated to be useful
4. Tick-borne encephalitis virus vaccine
Bonilla FA. Journal of Allergy and Clinical Immunology (2018), doi: 10.1016/j.jaci.2017.12.980.
25. JACI 2016/ 2018 Red book 2015 IDSA 2013
Major
Ab
deficient
IIV because
1. IVIg may not contain Ab to
circulating strains
2. Vaccine may induce some
beneficial cellular
immunity
additional measures (prophylaxis
during outbreaks)
• Annual IIV is the only
vaccine given to pt
receiving IVIg
• Routine inactivated
vaccines (not receiving
IVIg)
IIV not routinely but can be
administered (if some residual
Ab production)
X Live bacteria* and virus+
Live bacteria* and virus+ OPV (strong, moderate)
Other live vaccine (weak, low)
*Live bacterial vaccines : BCG and Ty21a Salmonella typhi
+Live virus vaccines: LAIV , MMR, Varicella, HZV, OPV , YF, smallpox, rotavirus
Humoral deficiency
¥Age ≥2 yr-old: PPSV23 ≥8 wk after
PCV13 and 2nd dose at 5 yr later
IIV Inactivated Influenza vaccine
26. JACI 2016/ 2018 Red book 2015 IDSA 2013
Minor
Ab
deficient
All All All
SAD should receive PCV¥
X OPV BCG(Live bacteria*), OPV,
yellow fever
OPV –not to IgA deficient
*Live bacterial vaccines : BCG and Ty21a Salmonella typhi
+Live virus vaccines: LAIV , MMR, Varicella, HZV, OPV , YF, smallpox, rotavirus
Humoral deficiency
¥Age ≥2 yr-old: PPSV23 ≥8 wk after
PCV13 and 2nd dose at 5 yr later
SAD Specific Ab defciency
29. HPV
• Showed immunogenic in immunosuppressed children
– Solid organ or stem cell transplantation
– On immunomodulators for autoimmune conditions
– WHIM syndrome and HIV patients
• Exhibit improvement in cutaneous warts
Bonilla FA. Journal of Allergy and Clinical Immunology (2018), doi: 10.1016/j.jaci.2017.12.980.
31. BCG
• SCID and defects of the IFN-γ/IL-12 axis
• significant localized disease (e.g., axillary lymphadenopathy) or FH of
BCG complication -potential warning sign of an underlying PID
Bonilla FA. Journal of Allergy and Clinical Immunology (2018), doi: 10.1016/j.jaci.2017.12.980.
34. MMR and Varicella vaccine
• Several studies have demonstrated safety and efficacy in milder forms of T cell
defects such as DiGeorge syndrome
• Criteria for live vaccine use in DiGeorge syndrome
a) CD4 T cells ≥ 500/mm
b) CD8 T cells ≥ 300/mm
c) normal/near-normal in vitro T cell response to mitogens and recall antigens
d) good response to non-viable vaccines
Bonilla FA. Journal of Allergy and Clinical Immunology (2018), doi: 10.1016/j.jaci.2017.12.980.
35. JACI 2016/ 2018 Red book 2015 IDSA 2013
Major Inactivated vaccines are of no value Inactivated vaccines-
Ineffective
•IIV can be administered (if
residual Ab production)
•PCV in AT
Inactivated vaccines should not
be routinely administered in pt
receiving IVIg
•IIV can be administered (if some
residual Ab production)
•PCV in AT
X All live vaccines
Mild Partial DGS
1. ≥500 cell/mm3CD4
2. ≥300 cell/mm3CD8
3. normal mitogen response
4. good response to non-viable
vaccines
should receive MMR, VAR
Partial DGS
1. ≥500 cell/mm3CD3, and
2. ≥200 cell/mm3CD8, and
3. normal mitogen response
should receive MMR, VAR
X All live vaccines except above
*Live bacterial vaccines : BCG and Ty21a Salmonella typhi
+Live virus vaccines: LAIV , MMR, Varicella, HZV, OPV , YF, smallpox, rotavirus AT; ataxia-telangiectasia
Cell-mediated and humoral deficiency
37. JACI 2016/ 2018 Red book 2015 IDSA 2013
All inactivated
recommend PCV, Hib, MCV
All inactivated
including IIV, PCV
All inactivated,
recommend HPV4, PCV, Hib, MCV
In children CD4 ≥15%
Older CD4+ ≥200 cells/mm3
Can receive MMR, VAR
Age <5 years CD4 ≥15%
Age ≥5 years CD4+ ≥200
cells/mm3
Can receive MMR, VAR
Age 1-13 yearsCD4 ≥15%
Age ≥14 years CD4 ≥200 cells/mm3
should receive MMR, VAR 2 doses 0,3 m
Not MMRV
X Live Live Live
*Live bacterial vaccines : BCG and Ty21a Salmonella typhi
+Live virus vaccines: LAIV , MMR, Varicella, HZV, OPV , YF, smallpox, rotavirus
HIV
38. Middleton textbook 8th edition
CD4+T cells<200/mm3 or <15% (in
children <6 yr) are contraindicated to
Yellow fever vaccine
39. MMR and Varicella vaccine
• A late complication of rubella vaccine in immunodeficient hosts reported
• Cutaneous granulomatous inflammation (granuloma annulare, occasionally with
ulceration) occurs in predominantly cellular dysfunction, mainly humoral defects
• U/d activated PI3 kinase delta syndrome, ataxia-telangiectasia, cartilage-hair
hypoplasia, RAG1 or RAG2 mutation, and unspecified CID
Bonilla FA. Journal of Allergy and Clinical Immunology (2018), doi: 10.1016/j.jaci.2017.12.980.
40. JACI 2016/ 2018 Red book 2015 IDSA 2013
All inactivated
Live virus+ should give for CGD,
congenital neutropenia
All inactivated
(Additional pneumococcal vaccine is not
indicated for CGD beyond standard
recommendations, because CGD not at
increased risk for pneumococcal disease)
Live virus+ probably safe and effective
All inactivated
(≥6 yr with phagocytic defect other than
CGD should receive PCV13)
(≥2 yr with phagocytic defect other than
CGD should receive PPSV23 after PCV13
and 2nd dose 5 yr later)
Live virus+ should give for CGD,
congenital neutropenia
X Live-bacteria vaccines* not to
CGD
Live virus+ not to LAD, cytotoxic
granule release defect eg.
Chediak-Higashi syndrome
Live-bacteria vaccines* and OPV,
smallpox, BCG, MMRV , LAIV)
•MMR and varicella in highly
immunocompromised
•YF depend on immune function
Live-bacteria vaccines* not to phagocytic
defect
Live virus+ not to LAD, cytotoxic granule
release defect eg. Chediak-Higashi
syndroime
*Live bacterial vaccines : BCG and Ty21a Salmonella typhi
+Live virus vaccines: LAIV , MMR, Varicella, HZV, OPV , YF, smallpox, rotavirus
Phagocytic defect
41. JACI 2016/ 2018 Red book 2015 IDSA 2013
All inactivated vaccines are safe
and effective
Consider encapsulated bacteria
(PCV/PPSV, Hib, MCV)
All inactivated and live-virus vaccines
are safe and probably are effective
1. PPSV23 at 2 years or older
2. MCV4 vaccine are recommended
in addition to standard vaccines
All routine vaccines
1) PCV and PPSV
2) 4-dose series of MCV4 and Hib,
reactivate with MCV4 every 5 years
X none none none
Complement defect
43. JACI 2016/ 2018 Red book 2015 IDSA 2013
All inactivated vaccines are safe
and effective
1. IRAK4- and MyD88-deficient:
PCV/PPSV
2. Congenital asplenia: PCV/PPSV,
Hib, MCV4
Should receive all inactivated as
schedule
Should receive all inactivated
Cytokine generation/response defect
should receive PCV13
X Live-bacteria vaccines* not to IFN-
γ/IL-12 pathways defect
Live virus+ not to type 1 IFN-α/β
All live not to NFkB pathway
defect
Live bacteria and virus vaccines not
to interferon production defect
Live-bacteria vaccines* not to IFN-γ/IL-
12 pathways defect
Live virus+ not to IFN (alpha or gamma)
production defect
*Live bacterial vaccines : BCG and Ty21a Salmonella typhi
+Live virus vaccines: LAIV , MMR, Varicella, HZV, OPV , YF, smallpox, rotavirus
Innate immunity defect
44. JACI 2016/ 2018 Red book 2015 IDSA 2013
All inactivated and live vaccines
except below
All inactivated vaccines and annual IIV or LAIV except
LAIV not if patient: HSCT recipient within 2 months or GVHD or SCID
Pregnant women at high risk of
having a baby with PID should
receive PCV, Hib, MCV
Should receive MMR, varicella
(Varivax, MMRV, and zoster),
rotavirus for infants 2 -7 months,
yellow fever and oral typhoid
vaccines for travel
-
X 1. OPV
2. If close contact develops a
rash after VAR, isolate PID
patient and give zoster Ig
1. OPV
2. avoid contact with persons who
develop skin lesions after receipt
VAR or ZOS until lesions clear
1. OPV
2. avoid contact with persons who
develop skin lesions after receipt
VAR or ZOS until lesions clear
3. Highly immunocompromised
should avoid handling diapers of
infants vaccinated with rotavirus for
4 weeks after vaccination
Household members
45. JACI 2016/ 2018 Red book 2015 IDSA 2013
Before
CS
Inactivated ≥2 weeks prior
if feasible, or deferred until after
stopping therapy
Live n/a
Inactivated ≥2 weeks prior
live virus ≥4 weeks prior
After
CS
Topical, local injections, or aerosol use- no effect
Systemic ≥2 mg/kg/day or its equivalent, or ≥20 mg/day if Wt>10 kg
for<14 days-delay live virus vaccines 2 weeks
for ≥14 days-delay live-virus vaccines 4 weeks
after discontinuation
On immunosuppressive drugs
46. JACI 2016/ 2018 Red book 2015 IDSA 2013
Low
Dose
Safe
MTX ≤0.4 mg/kg/week (Thai 15 mg/m2/wk)
AZA ≤3 mg/kg/day
6-MP ≤1.5 mg/kg/day
High
Dose
Inactivated ≥2 weeks before or during therapy and
possibly repeating after terminating therapy
Live vaccines administered ≥4 weeks prior to initiation
n/a
On Immunosuppressive drugs
Common dosage
MTX 0.65-1 mg/kg/wk, 20-30 mg/m2/wk
AZA 1-3 mg/kg/day
6-MP 1.25-2.5 mg/kg/day
47. “Immunoglobulin preparation given within 2 weeks after virus
vaccination could prevent adequate immunization”
“MMR and varicella vaccines either should be administered ≥2
weeks before receipt of a blood product”
Middleton textbook 8th edition
CDC; general recommendations for vaccination and immunoprophylaxis
49. Transplantation and immunosuppression
• Within 2 months after SOT
• Within 2 months after HSCT and frequently for a much longer
period
– depending on type of transplant (longer for allogeneic than for
autologous)
– type of donor and stem cell source
– post-transplant complications such as GVHD and their treatments
Immunization in Immunocompromised Children. Red book 2015
50. HSCT recipients
• should receive inactivated vaccines (including IIV) interval to
conditioning period is ≥2 weeks
• Should receive live-virus vaccines if the patient is not already
immunosuppressed and interval to the start of the conditioning
period is ≥4 weeks
• Household members should be counseled regarding risks of
infection
Immunization in Immunocompromised Children. Red book 2015
51. • 1 dose of IIV 6 mo after HSCT and 4 mo after HSCT if a
community outbreak
• 3 doses of PCV13 3–6 mo, 1 dose of PPSV 12 mo after HSCT
• 3 doses of Hib, MCV4, HBV (if anti-HBs <10U/ml) 6-12 mo
after HSCT
• 3 doses of DTaP 6 mo after HSCT
Rubin LG, et al. 2013 IDSA Clinical practice guideline for vaccination of the immunocompromised host
HSCT recipients
52.
53. SOT recipients
• Withheld during first 2-month because of inadequate response
– However, IIV can be administered ≥1 month after transplant during a community
influenza outbreak
• inactivated vaccine should be administered 2 to 6 months after SOT consider PCV-
PPSV, HBV for chronic HBV recipients
• MMR VAR should generally not be administered because of insufficient safety and
effectiveness data
– except for VAR in children without evidence of immunity who are renal or liver
transplant recipients, are receiving minimal or no immunosuppression, and have
no recent graft rejection
Rubin LG, et al. 2013 IDSA Clinical practice guideline for vaccination of the immunocompromised host