Vaccines: Vaccines given at birth
Vaccines given at birth
Introduction
Immunisation is one of the most important weapons used
to protect individuals and the community from serious
diseases. In South Africa, an expanded programme
on immunisation (EPI) starts at birth with the Bacille
Calmette-Guérin (BCG), and an attenuated oral polio
vaccine (OPV). In certain circumstances, a hepatitis B
vaccine may also be given at birth. In this article, we will
focus on the indications, administration, adverse effects
and precautions associated with use of the OPV and BCG
vaccinations.
Poliomyelitis
In 1988, the World Health Assembly resolved to eradicate
polio globally by the year 2000. Since then, three of the six
World Health Organizations (WHO) regions have been
certified free of wild-type polio. South Africa was declared
to be polio-free in October 2006. What is concerning is
that in 2009, worldwide, 23 countries reported more than
one case of wild-type polio. Of these, four are considered
to be polio-endemic countries in which circulation of
wide-type polio has not been eradicated. The remaining
countries were all previously considered to be polio-free,
but have since reported outbreaks caused by imported
wild-type polio from other countries.
Poliomyelitis is an acute illness caused by three poliovirus
serotypes, namely serotypes 1, 2 and 3. The poliovirus
enters the body through the gastrointestinal tract, and
replicates in the gut. It then spreads to susceptible tissues
and the central nervous system. Infected individuals shed
the virus in their stools, and are able to transmit it to
others. The virus spreads from person to person through
contaminated hands and food, in areas where sanitation
is poor.
It may also spread by means of airborne droplets through
close contact with infected individuals.
Up to 95% of polio infections are asymptomatic. Four-to-
eight per cent of infected individuals may develop a non-
specific illness, with symptoms that are indistinguishable
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Souter J, BPharm
Amayeza Info Centre
from other viral illnesses, such as an upper respiratory
tract infection, gastrointestinal upsets, or an influenza-
like illness. Patients usually recover rapidly. Only one-
to-two per cent of polio infections result in aseptic
meningitis. Symptoms lasts for a couple of weeks before
complete recovery takes place. Less than one per cent
of polio infections result in paralytic polio. In these rare
cases, respiratory paralysis and respiratory arrest occurs.
The typical neurological manifestation of paralytic polio
is acute flaccid paralysis of the limbs. Persistent paralysis
and resulting deformities are common sequelae of polio.
Oral polio vaccine
OPV is a live vaccine, consisting of attenuated poliovirus
serotypes 1, 2 and 3. It is given at birth, or soon after
birth. OPV given at birth (OPV 0) is known as zero-dose
because it does not count towards the primary series.
OPV is given at birth to increase the level of poliovirus
neutralising antibodies and seroconversion rates induced
by subsequent doses of the polio vaccine, and to induce
mucosal protection.
Administration
One dose consists of two drops, which are administered
directly into the mouth.
Infants shed poliovirus through nasopharyngeal
secretions and faeces for up to three weeks after they
have received an OPV vaccine. The polio vaccine viruses
can be transmitted to non-immune contacts, resulting in
inadvertent protection, or boosting of immunity in those
already protected. Everyone who has contact with infants
who have received OPV should be advised of the need for
strict personal hygiene, and particularly hand washing
after changing the infant’s nappy.
Adverse effects
OPV is a safe, and well-tolerated vaccine. However,
vaccine-associated paralytic poliomyelitis (VAPP) is
a serious, rare side-effect. VAPP may occur in OPV
recipients, and their unimmunised contacts. Cases of
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 Vaccines: Vaccines given at birth
VAPP can only be distinguished from polio caused by
wild-type poliovirus by laboratory analysis. The overall
risk of VAPP is estimated to be one case per 2.4 million
OPV doses. The risk of VAPP is higher with the first dose,
and this is estimated to be one case per 750 000 doses. It is
thought that giving OPV at birth, when the infant is still
protected by maternal antibodies, may prevent VAPP.
It is also possible for the shed polio vaccine virus to
mutate, and acquire the ability to cause damage to the
central nervous system, similar to that of the wild-type
poliovirus. This is called circulating vaccine-derived
poliovirus (cVDPV). If cVDPV is introduced into a
community that is not immune to polio, it could cause an
outbreak. Therefore, it is important to maintain high levels
of polio immunisation rates.
Precautions
General contraindications for all vaccines:
• Vaccination should be postponed in infants with a
moderate-to-severe febrile illness, until they have
recovered.
• Patients who have had an anaphylactic reaction to
a previous dose of the vaccine, or any components
thereof.
OPV is contraindicated in:
• Infants with rare congenital immune deficiency
syndromes.
• Those with a suppressed immune system, resulting
from certain types of cancers or medicines that
suppress the immune system, e.g. chemotherapy and
corticosteroids.
• Infants who have close household contact with
individuals who have primary immunodeficiencies
or suppressed immune responses. In these cases,
specialist advice should be sought.
• Infants who have had previous allergic reactions to
neomycin, streptomycin, or polymyxin B.
In infants with perinatal human immunodeficiency virus
(HIV) infection, early OPV vaccination seems to be well
tolerated, and no additional risks have been documented.
In South Africa, it is recommended that all individuals
who are infected with HIV (whether symptomatic or
asymptomatic), should be vaccinated with OPV according
to the standard immunisation schedule.
Tuberculosis
Human tuberculosis is caused by infection with the
bacteria Mycobacterium tuberculosis. Tuberculosis mostly
affects the lungs, but any organ of the body may be
affected. After inhalation of M. tuberculosis, the bacteria
grow in the alveoli, and the body mounts an inflammatory
response. In the majority of cases, this response halts
progression of the disease, resulting in an asymptomatic
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primary infection. The patient is unaware of being
infected. Therefore, initial infection is usually eliminated
by the body, but it may also remain latent, or progress
to active tuberculosis disease. In latent tuberculosis,
the individual has no tuberculosis symptoms, but M.
tuberculosis remains in the body. Tuberculosis infection
may be reactivated in later life, particularly in individuals
with a suppressed immune system.
Tuberculosis symptoms are varied, and depend on the site
of infection. M. tuberculosis can spread from the primary
infection site to other parts of the body. Infants and young
children are particularly susceptible to severe primary
disease, including miliary tuberculosis and tuberculosis
meningitis. (Miliary tuberculosis refers to clinical
disease resulting from uncontrolled haematogenous
dissemination of M. tuberculosis. The term, “miliary”,
derives from the millet seed-like appearance of the
involved lung, the surface of which is covered with firm,
small, white nodules). General symptoms of tuberculosis
include fever, loss of appetite, weight loss, night sweats,
and lassitude. Pulmonary tuberculosis typically causes
a persistent, productive cough, which may be blood-
streaked.
BCG vaccine
The BCG vaccine has been in existence for more than 80
years. It is one of the most widely used vaccines, reaching
more than 80% of babies in countries where it is part of the
national immunisation programme. There is conflicting
data as to whether the BCG vaccine prevents primary
infection. However, BCG is effective in preventing
tuberculosis meningitis and miliary (disseminated)
tuberculosis in infants and young children. Childhood
deaths from tuberculosis are usually caused by meningitis,
or disseminated disease.
Administration and dose
Infants should be vaccinated at birth. The dose is 0.05 ml,
and is given by intradermal administration. It should be
given on the deltoid region of the arm, at the level of the
insertion of the deltoid muscle (about one-third of the way
down the upper arm.) If it is given higher on the arm, and
particularly at the tip of the shoulder, it is more likely to
lead to keloid formation.
Adverse effects
Correct intradermal administration of the BCG vaccine
results in a tense, blanched “bleb”. This is normal. After
about three weeks, a red, inflamed, and infiltrated papule
appears. A crust develops, which then falls off, leaving
an ulcer that heals by approximately 13 weeks after
vaccination. The crusted ulcer develops into a small, flat
scar. However, not all infants develop a papule. A lack of
dermal reaction is not an indicator that the vaccine has
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 Vaccines: Vaccines given at birth
not worked. BCG vaccine should not be repeated in the
absence of a scar or dermal reaction.
Side-effects of the BCG vaccination include headache, fever,
and axillary lymph node enlargement. Severe injection-
site reactions, such as large, local ulcers, abscesses, and
keloid scarring are rare, and more commonly caused by
incorrect injection technique, overdosing, or vaccinating
an individual who is tuberculin-positive.
Other serious, but rare, side-effects, include:
• Suppurative adenitits (purulent discharge from an
inflamed gland)
• Disseminated or systemic BCG disease, which is
clinically indistinguishable from tuberculosis, and is
more likely to occur in immunosuppressed individuals.
Precautions specific to the BCG vaccine
BCG vaccine is contraindicated in:
• Infants with symptomatic HIV.
• Infants with immune suppression, caused by
congenital immunodeficiency syndromes, cancers,
and medications, such corticosteroids, cancer
chemotherapy and radiation.
• Infants whose mothers (or close household contacts)
are on anti-tuberculosis medicine. These children
should receive tuberculosis prophylaxis antibiotics.
BCG can be given at a later stage.
It may be prudent to postpone BCG vaccination in
infants with serious skin disease. Refer such infants to a
paediatrician.
BCG and HIV
In most instances, the HIV status of a newborn infant is
not known. Clinical signs of HIV are uncommon in the
first weeks of life, making it difficult to decide whether or
not to vaccinate.
The current recommendation is that BCG should be given
in the following situations:
• To infants born to mothers of unknown HIV status
• To infants born to HIV-positive mothers, but who do
not have any signs or symptoms of HIV infection.
If the infant is born to an HIV-positive mother, and it is
strongly suspected that the infant is HIV-positive, or that
the infant has signs and symptoms of HIV infection, it is
recommended that BCG is postponed until a polymerase
chain reaction is performed at six weeks of age to determine
the HIV status of the infant. If the result is negative, BCG
can then be given.
Conclusion
OPV and BCG vaccines are safe, and well-tolerated
vaccines, that have been used for many years. The
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extensive use of OPV has resulted in polio eradication
in some parts of the world. However, as long as polio is
present elsewhere, South Africa needs to maintain high
levels of immunisation to protect against imported cases
from other countries.
In South Africa, due to high HIV and tuberculosis rates,
the country’s infants are at an increased risk of contracting
tuberculosis. The BCG vaccine plays an important role in
preventing the most severe forms of tuberculosis in infants
and young children.
Bibliography
1. World Health Organization. Polio vaccines and polio immunization
in the pre-eradication era: WHO position paper [homepage on the
Internet]. c2011. Available from: http://www.who.int/wer/2010/
wer8523.pdf
2. United States Center for Disease Control and Prevention. Vaccines
and immunisations: poliomyelitis. Epidemiology and prevention of
vaccine-preventable diseases [homepage on the Internet]. c2011.
Available from: http://www.cdc.gov/vaccines/pubs/pinkbook/polio.
html
3. National Department of Health. New EPI Guidelines. Revised
October 2010.
4. OPV-Merieux®. Package insert. Sanofi Pasteur.
5. AHFS Drug Information [homepage on the Internet]. c2011.
Available from: http://www.ahfsdruginformation.com
6. Department of Health. South Africa declared polio free. October
2006 [homepage on the Internet]. c2011. Available from: http://
www.doh.gov.za/docs/pr/2006/pr1020.html
7. UK National Health Services. Immunisation against infectious
disease: poliomyelitis [homepage on the Internet]. c2011.
Available from: http://www.dh.gov.uk/prod_consum_dh/groups/
dh_digital assets/@dh/@en/documents/digitalasset/dh_108823.
pdf
8. World Health Organization. BCG vaccine: WHO position paper
[homepage on the Internet]. c2011. Available from: http://www.
who.int/wer/2004/en/wer7904.pdf
9. World Health Organization. Revised BCG vaccination guidelines for
infants at risk for HIV infection [homepage on the Internet]. c2011.
Available from: http://www.who.int/immunization/wer8221bcg_
May07_position_paper.pdf
10. Hesseling AC, Johnson LF, Jaspan H, et al. Disseminated bacilli
Calmette-Guérin disease in HIV-infected South African infants.
Bulletin of the World Health Organization. 2009;87;505-511
[homepage on the Internet]. c2011. Available from: http://www.
who.int/bulletin/volumes/87/7/08-055657/en/index.html
11. Hesseling AC, Caldwell J, Cotton MF, et al. BCG vaccination in
South African HIV-exposed infants: risks and benefits. S Afr Med
J. 2009;99(2):88-91.
12. Bellet JS, Prose NS. Skin complications of Bacillus Calmette-Guérin
immunization. Curr Opin Infect Dis. 2005;18(2):97-100.
13. UK National Health Services. Immunisation against infectious
disease: tuberculosis [homepage on the Internet]. c2011. Available
from: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digital
assets/@dh/@en/documents/digitalasset/dh_128356.pdf
14. BCG vaccine SSI®. Package insert. Litha Vaccines.
15. Connelly Smith K, Orme IM, Starke JR. Tuberculosis vaccines. In:
Plotkin S, Orenstein W, Offit P, editors. Vaccines. 5th edition New
York: Elsevier, 2008; p.857-885.
16. Sutter RW, Kew OM, Cochi SL. Poliovirus vaccine-live. In Plotkin
S, Orenstein W, Offit P, editors. Vaccines. 5th edition. New York:
Elsevier, 2008; p.632-685.
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