Immunization: Overview

Dr Wamalwa D
Types of vaccines
 Harmless agent perceived as an enemy
 Live attenuated:
 virulence reduced by mutation, passage in foreign host .
 e.g.
Sabin (OPV): monkey cells
 Measles, rubella, yellow fever, mumps…

 Killed:
 suspensions of agents: chemical inactivation(formalin)
• pertussis, cholera.
 Toxoids: purified toxins: tetanus, diphtheria.
 Subunits – e.g Hepatitis B
Historical aspects
 Variolation
 inoculate with small
pox material, mortality
2%
 Edward Jenner (1796)
 Cowpox protects
against small pox
 Vacca =cow
 Last case natural
small pox 1977
 Louis Pasteur:
attenuation “weaken”
 Milestones- TB, diphtheria, measles

 TB – chemotherapy
1940s

 Diptheria: toxoid,
penicillin

 Measles: live vaccine

1950/60s
Expanded program
 WHO Global EPI – 1977
 DPT 1- access to immunization: 31%
 DPT 3- complete immunization: 20%

 Kenya Expanded Program on

Immunization (1980)
 Provide immunization for 6 EPI-target dses
 Promote countries’ self reliance

 Programs within MCH rather than immunization

campaigns
WHO ~immunization
 Complete vaccination (WHO)
1 dose BCG,
 3 doses DPT/HepB/HiB,

 1 dose measles

 Target:
 complete immunization by age 12 months
 80% of the children in 80 districts
Schedule of EPI vaccines
Birth 6 10 14 9 months 18
weeks weeks weeks months

BCG 1
0.05 mls id
Polio OPV 0 1st 2nd 3rd
2 drops
orally
DPT/Hib 1st 2nd 3rd 1st
/HepB 0.5ml booster
im
Measles 1
0.5 ml SQ
Yellow fever 1*
0.5 ml im
*specific endemic districts
BCG – at birth /first contact
 Attenuated strain from Myc. Bovis
 Institute Pasteur 1920s
 Efficacy 0 – 80%
 Consistent protection in children
 Poor efficacy against adult TB
 Severe forms of TB in children
BCG – contd.
 Single intradermal dose
 Store 0 – 80 C
 WHO recommends soon after birth
 Adverse effects
 localadenitis, abscess
 Rare: disseminated BCG infection – worse in
immunodeficient
 Avoid in severe immunocompromise
Polio vaccines
 OPV: Sabin 1954
 Live attenuated: wild
polio types 1,2,3
 Cannot infect neurons
 Oral mode: cheaper
and easier
 Store 0 – 80 C
OPV
 Leads to gut infection
 Elicits secretory IgA (mucosal) production
 Spread to household contacts
 Contacts protected (regardless)
 Danger: back-mutation - paralytic polio
 Vacinees and Contacts
Paralytic polio

Wild polio Vaccine-induced

1 in 100 1 in 4 million
IPV
 Salk 1954
 Injectable:
 Can be combined with DPT etc.
 Higher circulating antibodies - IgG

 No risk to contacts
 Now used in the West
DPT - Pertussis
 Pertussis:
 Whole cell
 Acellular –contains only parts of the whole

cell pertussis bacterium

 Fewer local and systemic reactions
Safety of pertussis vaccine
Event Vaccine Pertussis infection
per 100000 per 100000

Febrile convulsions 0.3- 0.9 600-8000

Encephalitis 0.1- 0.3 90-400

Permanent neurological 0.2- 0.6 600-2000

damage
DPT – caution/contraindications

 Inconsolable crying > 3 hours

 Seizure within 3 days
 Evidence of encephalitis within 7 days
 High fever within 3 days*
 Shock-like collapsed state

*use antipyretic
Acellular pertussis
 Large cohort US
 Incidence of febrile seizures 6 times more
with whole cell
 Long-term brain damage : similar to whole
cell
 KEPI – whole cell
Hemophilus influenzae type B
 Conjugate vaccine
 > 95% reduction in HiB meningitis US
 Carrier protein: conjugated – tetanus
toxoid
HiB conjugate vaccine
 What is the impact of
immunization against
Hib in Kenya?
Hepatitis B vaccine
 Recombinant DNA vaccine
 Optimal timing: birth vs. deferring
 Kenya - both schedules exist
 Most transmissions 6 months – 3 yrs.
 Combinations: with DPT/HiB
Measles vaccine
 1954:Enders-
Edmonton:
 high immunognicity
 high toxicity/rash
 1963: Schwarz: better
tolerance
 6 months:
malnourished &
hospitalized
 9 months standard
Measles vaccine
 Efficacy debate:
 Maternal antibodies
 Optimal timing (6 mo, 9 mo?)

 Potency of vaccine (heat)

 Booster dose at school entry?

 HIV & measles vaccine

Herd immunity
 "more than 85% coverage is needed to protect
against a measles epidemic. We need to have a
herd immunity effect". In other words, the few
unimmunized people need to be far enough
apart so that transmission cannot continue. “

 For measles, you need to reach > 95% or so —

to get that herd immunity. Has Kenya reached
that level?
KDHS 2003 (12 – 23 mos)

90 88 89
87 84
80 83

70 71 70
60 63

50 49
40
30
20
10 8
0
BCG DPT Polio Meas. All None
KDHS 1998 Data

100
95.9 95.8 95.4
90 90 90.4

80 79.2 80.8 79.2

70
65.4
60
50
40
30
20
10
2.7
0
BCG DPT Polio Meas. All None
Complete immunization by 1year- KDHS

80
70.7
70
58
60
48.7
50
40
30
20
10
0
2003 1998 1993
Vaccination Trends

80 78.7

70 68.3
65.4
60 60.1

50
40 ALL
NONE
30
20
10 6.1 5.3
2.7 3.3
0
Kenya '03 Kenya '98 Kenya '93 Tz '99
Complete vaccination by Province- 2003

80 78.5
70 65.8 65 63.1
60 55.5
50 50
40 37.6
30
20
10 8.8
0
Ce Co Ea Na Ri W Ny N.
nt as st iro f tV est an Ea
r al t ern bi al e z st
le rn a er
y n
Vaccination by birth order -2003

70 65.6
57.4 58.8
60

50
42.1
40

30

20

10

0
1 2&3 4&5 6+
Vaccination and Education- 2003

80
70.6
70
61.8
60 53.8
50
40
33.6
30
20
10
0
Nil Pri. Inc. Pri. Comp. Sec.+
Vacc. trends Urban Vs Rural

90
80.9 78.3
80
70.5
70 64.2
60 58.7 56.4

50
Urban
40
Rural
30
20
10
0
1993 1998 2003
Vaccination and Income Level -2003

70 69.3
63.7 64.5
60
53.3
50
40
40

30

20

10

0
Lowest Second Middle Fourth Highest
Reasons for poor coverage
 Abject poverty
 Unavailability of syringes & cost sharing
 Unavailability of Vaccines due to poor
administration
 Misconceptions and missed opportunities
 Poor recording and reporting
Mumps vaccine
 Live attenuated
 Combined with measles, rubella (MMR)
 96% efficacy
 Adverse (rare –parotitis)
 15 – 18 months
Rubella vaccine
 Live attenuated
 Combine with measles, mumps (MMR)
 15 – 18 months, may repeat at school
entry
 GIRLS – immunity prior to child-bearing
 Caution: severe immunodeficiency
 Adverse: fever, lymphadenitis,
Pneumococcal vaccine
 Previous 23-valent polysaccharide vaccine
poor for < 2 yrs.
 Now 7- and 9-valent conjugated vaccine
 Efficacy 83% South Africa (63% HIV+)
 Plans for inclusion in KEPI
Rotavirus vaccine
 Initial vaccine withdrawn due to link with
intussusception
 Current vaccine candidates appear safe
form this complication
 Prevents severe rotavirus gastroenteritis
 Plans for inclusion in KEPI