Childhood Immunization

Infectious diseases and measeles

Dr. Ali Abdalla Khogali

 Terminology
• Immunization  induction of acquired
immunity:-
– Active immunization (vaccination): antigens
administered.
– Passive immunization: antibodies administered,
short lived immunity given prior to or soon after
exposure.

Dr. Mohammed Abdulrahman A Alhassan

 Terminology
• Vaccine:-
– Protective efficacy: ability to protect against
disease: low in BCG and Pertussis (80%), high in
others in EPI.
– Vaccine failure: disease occurs despite vaccination.
High with BCG & pertussis.
• Herd immunity: large number immunized to
break transmission  unimmunized are also
protected. A strategy in polio eradication.
Dr. Mohammed Abdulrahman A Alhassan
 Cold chain
• Proper transport, storage, distribution of
vaccines.
• At recommended temperatures.

Dr. Mohammed Abdulrahman A Alhassan

 Types of vaccines
• Live vaccines (live attenuated organisms):-
– Bacterial: BCG.
– Viral: OPV, measles, rotavirus.
• Killed (inactivated) vaccines:-
– Bacterial: pertussis.
– Viral: inactivated polio vaccine (IPV), rabies.
• Toxoids (modified toxins): tetanus, diphtheria.

Dr. Mohammed Abdulrahman A Alhassan

 Types of vaccines
• Subunit vaccines:-
– Bacterial capsular polysaccharide conjugate:
Hemoph influenzae type B (Hib),
pneumococcal, meningococcal.
– Viral: hepatitis B (surface antigen).

Dr. Mohammed Abdulrahman A Alhassan

 EPI schedule
Bacille Calmette- birth;
Guérin vaccine
(BCG)
OPV Oral polio vaccine birth; 6, 10, 14 weeks;
DTwP,Hib,HepB Diphtheria and 6, 10, 14 weeks;
tetanus toxoid with
whole cell
pertussis, Hib and
HepB vaccine

Rotavirus Rotavirus vaccine 6, 10 weeks;

Measles Measles vaccine 9, 18 months;
Pneumo_conj Pneumococcal 6, 10, 14 weeks;
conjugate vaccine
TT (women) Tetanus toxoid 1st contact at pregnancy; +1 month; +6
month; +1 year; +1 year;

Dr. Mohammed Abdulrahman A Alhassan

Dr. Mohammed Abdulrahman A Alhassan
 BCG
• Bacille Calmette-Guérin.
• Protective efficacy against severe or milliary
TB and TB meningitis= 80%, against pulm TB=
50% .

Dr. Mohammed Abdulrahman A Alhassan

Dr. Mohammed Abdulrahman A Alhassan
Dr. Mohammed Abdulrahman A Alhassan
Dr. Mohammed Abdulrahman A Alhassan
Dr. Mohammed Abdulrahman A Alhassan
 OPV cont.
• Supplementary immunization with OPV:
– a key strategy for polio eradication.
– conducted in large scale campaigns.
– two doses of OPV, one month apart.
– all children under five years of age regardless of
previous doses.
• If a child has diarrhoea, give extra 5th dose of
OPV >/= 4 weeks after last dose in schedule.

Dr. Mohammed Abdulrahman A Alhassan

 DTP-HepB+Hib vaccine
• Protects against five diseases: diphtheria,
tetanus, pertussis, hepatitis B, and
Haemophilus influenzae type b.

Dr. Mohammed Abdulrahman A Alhassan

Dr. Mohammed Abdulrahman A Alhassan
 Rotavirus vaccine
• Live oral vaccine (Rotarix).
• Two doses (1.5 ml orally):-
– 1st at 6wks, no later than 12 wks.
– 2nd at 10 wks, no later than 24 wks and at least 4
wks from 1st.
• PE= 92%.

Dr. Mohammed Abdulrahman A Alhassan

 Pneumococcal conjugate vaccine
• A capsular polysaccharide conjugate.
• Protects against most S. pneumonae infections:
– Pneumonia
– Otitis media
– Meningitis
• 0.5 ml IM left outer mid-thigh: 6, 10, 14 wks.

Dr. Mohammed Abdulrahman A Alhassan

 Measles vaccine

2 doses: 9 and 18 month 22

Dr. Mohammed Abdulrahman A Alhassan

Dr. Mohammed Abdulrahman A Alhassan
 Contraindications to immunization
• There are no many contraindications to immunization. All infants
should be immunized except in these three rare situations:
1. Anaphylaxis or a severe hypersensitivity reaction is an absolute
contraindication to subsequent doses of a vaccine. Persons with a
known allergy to a vaccine component should not be vaccinated.
2. Do not give BCG or yellow fever vaccine to an infant that exhibits the
signs and symptoms of AIDS.
3. DPT,Hib,HepB vaccine should NOT be given to children over 5 years
of age or to children who have suffered a severe reaction to a
previous dose of this vaccine. Instead, diphtheria and tetanus toxoids
(DT), and Hep B may be given seperately.
Note: an infant with known or suspected HIV infection and/or signs
and symptoms of AIDS should receive measles vaccine at six
months and then again at nine months
Dr. Mohammed Abdulrahman A Alhassan
Dr. Mohammed Abdulrahman A Alhassan
Dr. Mohammed Abdulrahman A Alhassan
 Few more notes
• Delay or lapse  resume from point of
interruption, don’t repeat schedule.
• Immunization status not known  give age
appropriate vaccines.

Dr. Mohammed Abdulrahman A Alhassan

 Recommended readings
• http://www.episudan.info/epi-vaccines.htm
• Who.int. search for immunization in practice
and download module 2 “the vaccines” (PDF
file).

Dr. Mohammed Abdulrahman A Alhassan

 Measles

Etiology: Measles virus - RNA virus, that belongs to the Paramyxoviridae family,
Morbillivirus genus.
Transmission

• Source of infection – infected person during

last 2 days of incubation period, catarrhal
period, and 4 days period of eruption (in case
of complications –10 days period of eruption).
• Infection is spread by inhalation of large and
small airborne droplets.
• Susceptible organism - no immunized
persons, older than 6 month, which never had
measles.
Pathophysiology

• Local replication in the respiratory epithelium.

• Viremia - virus is spread by leukocytes to the
reticuloendothelial system.
• necrosis of leukocytes, a secondary viremia occurs.
• specific antibody and cell-mediated responses - the
illness resolves.
• Measles causes an immune suppression. It may
predispose individuals to severe bacterial infection,
particularly bronchopneumonia, a major cause of
measles-related mortality among younger children.
Clinical presentation

The incubation period 9 - 17 (21!) days.

• Prodromal period - 3 - 5 days.
– Temperature is usually high at first day.
– The classic three “C’s” (cough, coryza,
conjunctivitis).
– the enanthema or Koplik’s spots. They usually
disappear by the second day of the exanthema.
Measles conjunctivitis
Koplik’s spots
Measles enanthema
Exanthema period: 3-4 days
• Second increase of temperature.
• Initial lesions on the forehead and face.
• During 3-4 days they spread downward
• The rash is red maculopapular, initially discrete then
confluent.
• Ctarrhal signs progress
• Koplick’s spots and enanthema remain for 1-2 days
Pigmentation period (1-1.5 weeks)
• Pigmentation progresses in the same fashion as the
rash, than desquamation (microscalling)
• Normalisation of the temperature
• Ctarrhal signs resolves
Measles, typical rashes, 1 day
st
Measles, typical rashes, 2 day
nd
Measles, hemorrhagic rashes
Measles, pigmentation period
Complications: primary (viral)

• laryngotracheitis (croup),
• bronchitis,
• encephalitis,
• Giant-cell pneumonia
• diarrhea
• keratoconjunctivitis
• Rare complications include
– hepatitis, encephalitis.
Complications: secondary bacterial

• otitis media,
• pneumonia,
• gingivostomatitis,
• pyelonephritis,
• diarrhea,
• dermatitis.
Differential diagnosis

• scarlet fever.
• Epstain-Barr viral infection.
• meningococcal sepsis.
• Stevens-Johnson syndrome.
• adenovirus.
• enterovirus infection.
Laboratory work-up

• common laboratory tests are non-specific.

– leukopenia, lymphocytosis, eosynophylia, and
thrombocytopenia (may be)
• virus isolation (nasopharyngeal smears) is
technically difficult
• Cytoscopic examination presence of typical
multinuclear giant cells
Measles: Treatment
• Supportive Care
– Rest, hydration, nutrition.
– Look for and treat bacterial super-infections
– Rinse eyes daily (saline or sterile water)
• Vitamin A
– May decrease mortality by 40%
– Benefit may be independent of deficiency
– WHO recs for both hospitalized and less ill
• Ribavirin
– Inhibits viral replication in cell culture
– Limited benefit in immune compromised patients
– High cost makes = impractical in developing world
Rubella (German measles)

• It is caused by RNA rubella virus, which

belongs to the Togaviridae family, Rubivirus
genus.
Transmission

• the source of infection is a patient or carrier

• the mechanism of transmission is air-droplet,
transplacental
• receptivity is common, especially high in
children 2-9 years
Pathophysiology:

• Acquired Rubella:
– The primary cite of infection (atrium) - mucus
membranes of nasopharynx, replication.
– hematogenous distribution (viremia).
– Damage of organs and systems.
– Immunological response, recovery.
• Congenital Rubella:
– Transplacental infection of the fetus.
– destruction of the cells by the virus (cytotoxic
defect), violation of the organs’ development.
– Forming of the congenital defects.
 Diagnostic criteria of
congenital Rubella

Classical Triad:
• Cataract
• CHD:
(PDA
AO co arctation,
VSD, PS,ASD, TGA)
• Deafness
 Treatment
• Basic therapy:
– Hygienic regime, often room ventilation
– Control of fever – as in measles
– Cardiac and ophthalmic consultation
Whooping cough
Bordetella pertussis

• Aerobic, Gram negative coccobacillus

• Specific to Humans
• Colonizes the respiratory tract
– Whooping Cough (Pertussis)

http://microvet.arizona.edu/Courses/MIC420/lecture_notes/bordetella_pertussis/
gram_pertussis.html
 Transmission
• Very Contagious
• Transmission occurs via respiratory droplets

http://www.ratbags.com/rsoles/history/2000/12december.htm
http://www.universityscience.ie/imgs/scientists/whoopingcough.gif
Pertussis Clinical Features

• Incubation period 5-10 days (up to 21 days)

• Insidious onset, similar to minor upper

respiratory infection with nonspecific cough

• Fever usually minimal throughout course

Pertussis Clinical Features

• Catarrhal stage 1-2 weeks

• Paroxysmal
cough stage 1-6 weeks

• Convalescence Weeks to
months
 Clinical Symptoms in Infants
• Most severe in infants <6
months
• Atypical presentation
• Apnea most common
symptom
• Whoop is absent
• Hospitalization often
needed
• Lymphocyte
predominant, increased
white count can match
severity of the cough
Infant Complications
 Seizures (3%)
 Pneumonia (22%)
 Encephalopathy (1%)
 Death
 Case fatality rate:
1.3% in infants <1
month
0.3% in infants 2-11
months
Diagnosis of Pertussis: time sequence

PCR and
culture and PCR serologic serologic tests
tests

Cough 3 weeks 4 weeks

Pertussis notification rate 1/100 in the States and UK

Either tests are not available or
Physicians choose the wrong test
 Supportive Care

• Hospitalized patients need to be on Droplet Isolation for 5 days

after therapy
• Monitor exposed children for respiratory symptoms for 20 days
• Laboratory confirmation is difficult, so diagnosis often based on
characteristic clinical manifestations
• Children may return to school after 5 days of appropriate antibiotic
therapy
Treatment

• Aim is to eradicate nasopharyngeal carriage

• Treatment duration usually 14 days with erythromycin sulfate
(EES), newer Macrolides 5-7 days
• Macrolides-erythromycin, azithromycin, and clarithromycin
• Azithromycin eradicates naso-pharyngeal carriage the fastest
• Hypertrophic pyloric stenosis has been reported with oral EES in
infants younger than 6 weeks
• Trimethoprim-sulfamethoxazole is an alternative to
erythromycin-resistant strain, or for intolerance to macrolides
• Penicillins, first and second generation cephalosporins are not
effective
TETANUS IN NEONATES
EPIDEMIOLOGY

• C. tetani is a part of the normal flora in human

and animal intestines and is disseminated through
excreta
• In spore form they are hard and long lasting in
soil and dust
• The contamination of wound, unhygienic and
improper handling of the umbilical cord in
newborns, lack of hygienic habits and aseptic care
during and after delivery are the main risk
factors for infection
Tetanus Pathogenesis

• Anaerobic condition helps to germinate

spores and production of toxins.
• Toxins binds to the central nervous system
• Interferes with the neurotransmitter release
to block inhibitory impulses.
• Leads to unopposed muscle contraction and
spasm.
Clinical Features

• Incubation period: 8 days (3-21

days).
•Descending symptoms of trismus,
difficulty swallowing, muscle
rigidity and spasm.
•Spasm continues ( consciousness
retained)
Neonatal tetanus

A conscious spasm
Tetanus: complications

• Laryngospasm
• Hypoglycemia
• Nosocomial infections
• Myoglobinuria
• Aspiration
• Iatrogenic apnoea
• Death
Management:

• IV line.
• Nasogastric tube feeding.
• Minimal handling.
• A separate room.
Management: Principles

• Eradication of C. tetani.
– Penicillin G 100,000 U / kg / 24 hrs.
• Neutralizing the toxin
– Human tetanus immunoglobulin: 500 IU IM
• Prevent spasm:
– Diazepam: 0.1 – 0.2 mg every 3 – 6 hourly
intravenously.
– Dantrolene; chlorpromazine; baclofen
– Mechanical ventilation (best survival rate)