DPH - National Immunization Manual - Nov-2013

NATIONAL IMMUNIZATION MANUAL
Preface
MINISTRY OF HEALTH - DEPARTMENT OF PUBLIC HEALTH
Ministers Foreword
THE COMMONWEALTH OF THE BAHAMAS
Acknowledgements
Table of Contents
Glossary
Antibody: Most infections leave a person protected for sometime against a second attack of the disease because the micro-organisms causing the infection have stimulated the body to produce antibodies. Antibodies are special proteins in the blood which inhibit the organisms or toxins causing the disease. Those antibodies which inhibit the action of toxins are called anti-toxins. The sites of maximum antibody formation are the lymph nodes and spleen. Maternal Antibodies: Antibodies produced by the mother and transmitted to the fetus through the placenta or colostrums (see passive immunity). Antigen: A substance which when introduced into the body stimulates the production of antibodies. Viruses, bacteria, bacterial toxins, red blood cells, tissue extracts, pollens, dust and many other substances may act as antigens. Eradication of a Disease: This is the situation in which no new cases occur because of activities designed to eliminate the vectors or agents of the disease and to render all cases non-infective. The transmission of the disease is therefore stopped. The term elimination is preferred when the geographical area concerned is limited. Eradication is generally understood to refer to the global level. Small pox is the only disease that has so far been eradicated from the world; concerted international action led to its disappearance by 1977.
Gammaglobulin: This product is a concentrate of antibodies derived from human or animal blood. It can be used to prevent or lessen the effects of measles, hepatitis, yellow fever, tetanus and mumps. Its use is restricted by cost and by its limited protective effect (2-6 months). Incidence: The number of new cases of a health problem in a defined population during a given time period. Incidence is expressed as an absolute number (e.g. 30 cases). Incidence rate: A measure of frequency of new cases of a disease in a defined population during a given time period usually a year. It is expressed as the number of new cases per 1000 as per 100,000 of the population. Prevalence: The number of all cases of disease existing in a defined population at a specific point in time. Prevalence is expressed as an absolute number e.g. 3000 cases. Prevalence rate: A measure of the frequency of all cases of a disease existing in a defined population at a specific point in time. It is expressed as the number of cases existing as per 100,000 of the population.
Extract from Universal Child Immunization by 1990- UNICEF
Commonly Used Abbreviations

AFP AIDS CAREC CRS DT DPT DPT/Hep B/Hib EPI YF GBS Hep B HBIG HBsAg HHE Hib HIV HPV IG IM IMAC IPV IV IVIG M&E MCH MMR OPV PAHO PCR Pentavalent SC SIDS TAG TB Td Tdap TIG TT VAPP VZV VZIG WHO UNICEF Acute Flaccid Paralysis Acquired Immuno-Deficiency Syndrome Caribbean Epidemiology Center Congenital Rubella Syndrome Diphtheria and Tetanus Diphtheria, Pertussis and Tetanus Diphtheria, Pertussis, Tetanus, Hepatitis B, Haemophilus Influenzae Type b Expanded Program on Immunization Yellow Fever Guillain- Barr Syndrome Hepatitis B vaccine Hepatitis B Immune Globulin Hepatitis B Surface Antigen Hypotonic, hypo responsive episode Haemophilus Influenzae Type b Human Immune Deficiency Virus Human Papilloma Virus Immune globulin Intra Muscular Immunization Advisory Centre Inactivated Polio Vaccine Intravenous Intravenous Immune Globulin Monitoring and Evaluation Maternal and child Health Measles, Mumps and Rubella Oral Polio vaccine Pan American Health Organization Polymerase Chain Reaction Five antigens in one injection Subcutaneous Sudden infant Death Syndrome/COT Death Technical Advisory Group Tuberculosis Tetanus and diphtheria Tetanus, diphtheria, acellular pertussis Tetanus Immune globulin Tetanus Toxoid Vaccine associated paralytic poliomyelitis Varicella Zoster Virus Varicella Zoster Immune Globulin World Health Organization United Nation International Children Educational Fund
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CHAPTER 1
EPI MISSION STATEMENT

The Mission of the Expanded Program on Immunization is to eradicate, eliminate or reduce vaccine preventable diseases to the lowest levels possible through sustained immunization of all susceptible persons as an essential component of primary health care.
OBJECTIVES OF EPI MANUAL

1. To Standardize care to vaccine recipients 2. To Train and orientate healthcare providers about EPI functions and protocols 3. To be used as reference material
OBJECTIVES OF THE EXPANDED PROGRAM ON IMMUNIZATION

1. Provide protection for children under one year against Diptheria, Pretussis,Tetanus, Haemophilus Influenza type B, Hepatitis B, Pneumococcus, Polio and Seasonal Influenza 2. Provide protection for children one year of age against Measles, Mumps and Rubella 3. Provide protection for pregnant women and newborns against Tetanus and Diptheria 4. Provide protection to post-natal women against Measles, Mumps, Rubella and prevent Congenital Rubella Syndrome in the newborn 5. Maintain high immunity levels against childhood diseases among children in nurseries, preschools, primary and secondary schools.
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Overview of The Expanded Programme on Immunization
The Expanded Program on Immunization is a joint activity of the nations of the world, the World Health Organization (WHO), United Nation International Children Education Fund (UNICEF) and Pan American Health Organization (PAHO). It was implemented in the late 1970s and initially focused on six infectious diseases. These were diphtheria, pertussis, tetanus tuberculosis and measles. The purpose of the program is to standardize the types of vaccines given by each country and to reduce the number of deaths and cases of diseases that are preventable by immunization. During the decade of the 1980s, two resolutions involving disease elimination through immunization were implemented in the Americas. In May 1985, PAHO/WHO announced the goal of eradication of wild poliovirus from the Americas by 1990. In September 1988, the Ministers responsible for Health in CARICOM resolved to Eliminate Indigenous Measles from their countries by 1995. The last case of wild poliovirus in the CARICOM countries was in 1982 and the Americas in 1991 in South America (Peru); and no case of indigenous measles has been confirmed in the CARICOM countries since 1991. These are good examples of the effectiveness of well-managed immunization programs. The Expanded Program on Immunization is a national programme in the Ministry of Health with a unit in the Department of Public Health. It involves the public and private sectors. The Government of The Bahamas is responsible for the Health Care of the country and diseases preventable by immunization are of high priority. Immunizations were administered in The Bahamas from the 1960s, and a national EPI coordinator was designated to monitor the programme in January 1979.
There are 91 government clinics as well as private physicians offices where immunization services can be accessed for the population. Presently in The Bahamas the following vaccines are a part of the national immunization schedule: Diphtheria, Pertussis, Tetanus, Haemophilus Influenza type b, Hepatitis B, Polio, Pneumococcal Conjugate, Varicella, Seasonal Influenza, Measles, Mumps and Rubella. Yellow Fever is offered to travelers going to countries requiring it. There are other vaccines available in the private sector and include: Rotavirus, meningococcal conjugate, Hepatitis A, Typhoid, and HPV vaccine The governments vaccine procurement is done through PAHO Revolving Fund. This ensures a continuous, high quality, economical, and adequate supply of vaccines in the country. The service is monitored by CAREC in partnership with PAHO/WHO which has an office in Nassau Bahamas. The Measles Mumps and Rubella vaccine was introduced to the program for use instead of the measles vaccine in April, 1985. The Bahamas participated in the Big Bang campaign in 1991 when Caribbean Countries targeted all children ages one to fourteen years and immunized them against measles. While most countries utilized the Measles vaccine in this campaign The Bahamas immunized its target with the MMR vaccine. In May 1997, the Rubella Initiative was instituted on the Maternity Wards at Princess Margaret and Rand Memorial Hospitals. In July 1997 a second MMR campaign was conducted targeting residents 4-40 years. The Bahamas is said to be the first country in the world to embark on a venture such as this.
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Trend of Vaccine Preventable Diseases
The last reported case of: Diphtheria - 1988 Pertussis - 1996 Tetanus - 2007 Neonatal tetanus - 1992 Measles - 1997 Mumps - 2009 Rubella - 1998 Congenital Rubella Syndrome - 1998 * One case of Tetanus (clinically diagnosed) Deborah Fox Senior Nursing Officer 17/1/06
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Overview of The Expanded Programme on Immunization

IMMUNIZATION COVERAGE BAHAMAS 1979 2012
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National Immunization Schedule (Revised)
PROGRAMME BACKGROUND
Although immunizations were given in The Bahamas from the early fifties, the Immunization Program in commenced in 1960s. The first National Immunization Schedule was published with the following vaccines being offered: 1. 1st DPT at 1 month 2. 2nd and 3rd doses at 4 weeks intervals 3. Booster at 18 months 4. Small pox at 12-15 months
3. To maintain immunity levels against childhood diseases in nursery, pre-school, primary and secondary school aged children. 4. To protect pregnant women and newborns against Tetanus. 5. To protect Post-natal women against Measles, Mumps and Rubella and Congenital Rubella Syndrome (CRS) in the newborn. 6. To protect children, pregnant women, elderly, and persons with CNCDs, and the general public against Seasonal Influenza Virus.
Additional vaccines were added to the National Schedule as follows: In 1964, Polio following a polio outbreak. Antenatal tetanus was introduced in 1964. BCG to newborns was introduced in the 1960s but was discontinued in May 1979. Measles Vaccine at 12 months of age was commenced in September 1975. Rubella to 10 year old girls commenced in 1979. Over the years The National Immunization Schedule has been continuously revised to accommodate new and underutilized vaccines. Objectives of the Expanded Program on Immunization (EPI) are as follows:
1. To protect children under one year of age against Diphtheria, Pertussis, Tetanus, Haemophilus Influenza type b (Hib), Hepatitis B, Pneumococcus and Poliomyelitis. 2. To protect children at one year of age against Varicella, Measles, Mumps and Rubella.
This year, The Department of Public Health, Ministry of Health has added to the National Immunization Schedule the following vaccines: Varicella / Chickenpox ( 2-15 months and adults) Pneumococcal Conjugate-13(Prevnar) (child 2-15 months) DTap (adult) Seasonal Influenza (children 6 months and older and adults) It is anticipated that varicella and Prevnar-13 will be offered to a larger target population in the near future. Please find, herewith, revised vaccine administration schedules for all ages and also for antenatal women.
Pearl McMillan (Dr.) Director of Public Health, May 1, 2012
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National Immunization Schedule (Revised) The Bahamas 2012

AGE
Two (2) months Four (4) months Six (6) months Twelve (12) months Fifteen (15) months Four to five (4-5) years Ten to twelve (10-12) years Every 10 years Six (6) months and older
VACCINE(S)
DPT, Hib, Hepatitis B, Polio and Conjugate Pneumococcal DPT, Hib, Hepatitis B, Polio and Conjugate Pneumococcal DPT, Hib, Hepatitis B, Polio and Conjugate Pneumococcal 1st MMR (Measles, Mumps and Rubella) Varicella DPT+ HIB Conjugate Pneumococcal DPT (Paed), Polio & MMR * Varicella Tdap (Adult) Tdap (Adult) Seasonal Influenza Annually
*FOOTNOTE (S): (a) Do not re-start vaccines or administer additional doses if an appointment is missed. (b) Obtain history of prior convulsions before administering vaccines. (c) Haemophilus Influenza type b (Hib) vaccine may be administered to children under age 2 years old in conjunction with DPT, Hepatitis B and Polio for basic coverage. (d) Oral Polio (OPV) vaccine may be administered to HIV asymptomatic children. (e) MMR vaccine should be administered to women with Rubella negative or equivocal results during the postnatal period so as to prevent Congenital Rubella Syndrome of the next child. (f) Two doses of MMR should be administered to children and adults (not previously immunized) so as to eradicate Measles from this region. (g) Mantoux and MMR if needed should be given together or within 24 hours. If MMR is given first the client must wait 4 weeks before Mantoux is placed. If Mantoux is placed first wait until after results are read then give MMR. If Mantoux is positive do not give MMR must be seen at infectious disease clinic. (h) Children of Hepatitis B positive women can receive 4 doses of Hepatitis B vaccine. In place of the 2nd dose of Hepatitis B vaccine at age 1 month they can be given 3 doses of Pentavalent vaccine as scheduled. (i) Children will be administered DPT (pediatric) with second booster. (j) Children over six years of age to be given DTap vaccine. (k) Children 7-11 months will be administered three doses of Prevnar, the first two doses at least four weeks apart and the third dose at 15 months (l) OTHER VACCINES ARE AVAILABLE IN PRIVATE SECTOR 1. To protect children under one year of age against Diphtheria, Pertussis, Tetanus, Haemophilus Influenza type b (Hib), Hepatitis B, Pneumococcus and Poliomyelitis. 2. To protect children at one year of age against Varicella, Measles, Mumps and Rubella.
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Vaccination for Women of Childbearing Age

Vaccine Tdap Hepatitis A Hepatitis B Human Papillomavirus(HPV) Influenza MMR Before Pregnancy Yes Yes, if at risk Yes Yes, if 9 through 26 years of age Yes Yes ,if less than 50 years and healthy: avoid pregnancy for 4 weeks Yes, avoid contraception for 4 weeks If indicated If indicated During Pregnancy Yes Yes, if at risk Yes No, under study Yes No After Pregnancy Yes Yes, if at risk Yes Yes, if 9 through 26 years of age Yes Yes, give immediately postpartum if susceptible Yes, give immediately postpartum if susceptible If indicated If indicated
Varicella Meningococcal Polysaccharide Conjugate Pneumococcal Polysaccharide
No If indicated If indicated
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Recommended Tdap Schedule for Pregnant Women

Immunization Status
No history of Previous DPT/DT Or TT vaccine History of 2 doses of DPT/DT or TT Vaccine History of 3 doses of DPT/DT Or TT vaccine Over 10 years ago
First dose
Any period during gestation
Second dose
Third dose
Booster
Every 10 years
6 8 weeks 12 months following following initial dose 2nd dose
Every 10 years
Any period During gestation
Footnote: Pregnant women with a history of three (3) doses of DPT/DT or TT vaccines with the final dose under 10 years do not require immunization during this pregnancy. Tdap can be given at any stage of the pregnancy.
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Catch-Up Vaccine Schedule for Children Age 4 months through 6 years Vaccine DPT Minimum Age Dose 1 6 weeks Dose 1-2 4 weeks Dose 2-3 4 weeks 4 weeks (if current age is younger than 12 months) 8 weeks (if current age 12 months and dose 1 given 12 months and dose 2 given 15 months) 8 weeks (this dose needed only if age 12-59 months and given 3 doses before 12months) Dose 3-4 6 months Dose 4-5 6 months1
4 weeks HIB 6 weeks 8 weeks2 ( if first dose age 12-14 months)
Polio MMR
6 weeks 12 months
4 weeks 4 weeks
4 weeks
6 months3 (minimum age 4 years for final dose)
Hep B
Birth
4 weeks
8 weeks (at least 16 weeks after dose 1; minimum age for final dose is 24 weeks)
NB. A vaccine series does NOT need to be restarted regardless of the time elapsed between doses
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Catch-Up Vaccine Schedule for Children 7 - 18 Years of age

VACCINE Minimum age Dose 1 Minimum Interval Between Doses Dose 1 - 2 Dose 2-3 4 weeks Dose 3-4 Dose 4-5
Tetanus, Diphtheria, Pertussis
7 years
4 weeks
Polio 2 MMR
6 weeks 12 months
Varicella
12 months
4weeks 2 4 weeks 3 months (if person is younger than 13 years 4 weeks (if person is age 13 years or older)
(If first dose administered at age 6 months younger (if first dose than age 12 adminisEvery ten months ) tered at 12 years months or 6 months (if first dose younger) administered at 12 months or older) 4 weeks 6 months
Hepatitis B
Birth
4 weeks
8 weeks (and at least 16 weeks after the first dose)
Hepatitis A Human Papillomavirus(HPV)
12 months 9 years
6 months Routine dosing intervals are recommended
NB A VACCINE SERIES DOES NOT NEED TO BE RESTARTED REGRADLESS OF THE TIME ELASPED BETWEEN DOSES
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Recommended Immunizations of HealthCare Workers in the Bahamas
CHAPTER 2
Health Care Workers (HCWs) are defined as physicians, nurses, emergency medical personnel, dental professionals, medical and nursing students, laboratory technicians, hospital volunteers, house keeping staff, and other administrative staff who come in direct contact with patients or infective materials from patients. Although, HCWs are at risk of exposure to and possible acquisition and transmission of infectious diseases, preventing work related infections could be difficult in this very important group (1). However, effective vaccines are currently available for prevention of some of these infections. Maintenance of immunity is therefore an essential part of infection control programs for HCWs. Immunizing agents safeguard the health of workers and the benefits of the optimal use are:
1. Reduction of number of susceptible HCWs in hospitals and health departments. 2. Decrease of the risk of transmission of vaccine preventable diseases to patients and other coworkers.
(a) Hepatitis B Hepatitis B virus infection is the major infectious hazard for health care workers (3). The risk of acquiring infection from occupational exposures is dependent upon the frequency of percutaneous and per mucosal exposure to blood and body fluids. The following group of HCWs should be routinely vaccinated:
Physicians, Nurses, Laboratory workers, Emergency Department Technicians, cleaners, mortuary and other attendants. Any other worker who may come in contact with blood and body fluids.
Vaccine: HBV Recombinant Vaccine Frequency: Two doses given IM in the deltoid area, 4 weeks apart and the third dose given 4-6 months after the second dose. Booster doses in persons with normal immune status are not usually necessary. However, the need will be assessed, as additional information becomes available. Contraindications: These are limited to persons with moderate to severe acute illness and serious allergic reaction to a prior dose of hepatitis B Vaccine or a component of the vaccine. Post exposure Prophylaxis: Need to be considered in those who are non immune and are exposed to HBV positive blood and/or body fluids. Hepatitis B Immune Globulin (HBIG) 0.06ml/ kg IM should be given as early as possible and vaccine series initiated.
Ministries of Health are encouraged to formulate immunization policies for all HCWs and take steps to ensure the health of HCWs in the Caribbean. Simultaneously, research and public health action on risk assessment, health system development, surveillance and monitoring and education are necessary for prevention and control of vaccine preventable diseases (2). The following recommendations on immunization of HCWs will be discussed under two headings: 1. Diseases for which Immunization is strongly recommended:
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(b) Tetanus acellular Pertussisand Diphtheria (Tdap) Antitoxin levels decrease with time, but some persons are protected for life after receipt of five (5) properly spaced doses of the vaccine. However, booster is recommended for all persons including health care workers every 10 years. (c) Measles/Mumps/Rubella Although, indigenous measles has been eliminated in the English speaking Caribbean and Suriname, the risk of exposure and acquiring measles while on travel to endemic countries is a possibility (4). Mumps and Rubella are also not uncommon infections acquired in hospital settings. Outbreaks and transmission of rubella in hospitals have been reported in some countries. The Council of Human and Social Development of the Caribbean Community (CARICOM) has resolved in 1998 to eliminate rubella and congenital Rubella Syndrome from the countries by the year 2000. (4) Vaccine: MMR (Measles, Mumps and Rubella) Frequency: One dose SC or IM. Second dose is given a minimum of four weeks later. Contra-indications: Immuno-compromised Health Care Workers. 2. Diseases for which Immunization may be indicated for HCWs: Varicella- Zoster virus Nosocomial transmission of chickenpox virus is well recognized in HCWs. (5,6,7) All categories of staff are indeed at risk of exposure to either patient with Varicella or Zoster infection. Certain patients are at increased risk; pregnant women, premature babies and
and immuno-compromised and immuno-deficient patients of all ages. Vaccine: VZV Frequency: Approximately, 80% of adults will respond to a single dose of VZV but 2 doses 0.5ml SC 4 to 8 Weeks apart are usually given. Indications: No serologic evidence of immunity to VZV Contra-indications: Generally not indicated in immuno-compromised host and pregnant women. Severe allergic reaction to previous dose or vaccine component is also a contraindication. Post Exposure Prophylaxis: VZV immunoglobulin, 125 ugm /kg IM. (c) Typhoid Several cases of laboratory acquired typhoid fever in staff working in microbiology laboratory have been reported. Uniform guidelines for vaccination of HCWs especially laboratory staff against Typhoid fever is not available. However, some countries recommend typhoid immunization for laboratory workers handling specimen containing typhoid organisms. Vaccine: Ty21 S.typhi, oral live attenuated Frequency: One capsule alternate day for 8days (4 capsules) Booster: Every five years for those who are at risk of developing laboratory associated typhoid fever. Contra-indications: Immuno-compromised hosts.
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(d) Tuberculosis BCG vaccination in adult HCWs is not generally recommended. The keys to the prevention of occupational transmission of M. tuberculosis are institution of infection control measures, high index of suspicion and the institution of effective anti-tuberculosis therapy (8). In addition, risk assessment of each facility and the medical surveillance of HCWs at risk of exposure to M. Tuberculosis should be done. Guidelines for Medical Surveillance of Health Care workers: All health care workers at the time of employment should receive a complete medical examination consisting of:
a. Physical Examination b. Routine laboratory tests - CBC, ESR, Blood Sugar, VDRL, and Complete urine examination. c. Chest x-ray d. Tuberculin skin test
Tuberculin skin test One-step Method and two-step Method to detect response to tuberculin are usually done on HCWs regardless Of BCG immunization status. Prior BCG vaccination is not contraindication to PPD testing unless documented history of an accelerated reaction. Tuberculin Converters should be referred to the Chest Physician for evaluation and further clinical management. Procedure for newly recruited staff Any newly recruited staff who has a positive tuberculin skin test should not be allowed to work in the laboratory or manage patients until a medical assessment is completed and approved by the medical institution.
A record of all tests done and the interpretation of the chest X-ray findings, especially old calcified lesions in the lungs, findings suggestive of a past history of exposure to Mycobacterium species, evidence of a BCG scar, and pre-existing conditions such, as Diabetes Mellitus and Systemic Lupus Erythematosus, should be recorded.
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Procedure for Monitoring of staff Tuberculin test-should be performed every six (6) months on skin test negative staff who work in the TB laboratory as well as health care professionals who care known cases of pulmonary tuberculosis. This program should be completed with in one to two weeks so as to detect the cause of any conversions. Management of Outbreaks All health institutions should develop policies and procedures for outbreak control and management of vaccine preventable diseases. In the event of a cluster of tuberculosis cases (two or more cases of conversion) among Hospital /laboratory staff within six to 12 months, the following steps should be undertaken.
a. Initiation of an outbreak investigation by the infection control officer or the Ministry of health. b. Investigation of close contacts of HCWs in the hospital or TB laboratory should be conducted for conversion and active disease. d. Safety audit and review of records (spills, accidents, operation of safety cabinet, isolation precautions, room airflow, and personal protective wear) should be performed to determine the source. e. Implementation of infection control measures.
References
1. MMWR Morb. Mortal Wkly Report. Immunisation of Health Workers. 1997; 46 (RR-18) 1-42. 2. Clever LH and Le Guyader Y. Infectious Risks for Health Care Workers. Annu Rev Public Health 1995; 16:14164 3. Figueroa JP, Carpenter R and Hospedales CJ. A survey of Hepatitis B among health care workers in Jamaica. West Indian Med J 1994; 43 (1): 2-6 4. Irons B, Lewis MJ, Dahl-Regis M et al. Strategies to Eradicate Rubella in the English Speaking Caribbean. Amer J Public Health. 2000; 90 (10): 1545-1549 5. Nathan V and Prabhakar P. Neonatal varicella in Jamaica--A report of two cases. Trop Geogr Med. 1987; 39(4): 380-2 6. Hyams PJ, Stuewe MCS, Heitzer V. Herpes zoster causing varicella in hospital employees: cost of casual attitude. Infect Control 1984; 12: 2-5. 7. Haiduven - Griffiths D, Fecko H. Varicella in Hospital Personnel: A challenge for the infection control practitioner. Am J infect control 1987; 15:207-11 8. Cookson ST and Jarvis WR. Prevention of Nosocomial transmission of Tuberculosis. Infect Dis Clin North Am 1997; 11 (2) 385- 409.
All health institutions need to develop post exposure work restriction policies for HCWs who are not immune to certain vaccine preventable diseases. Similarly periodic advisories are necessary on vaccines that are indicated for health professionals who may conduct research in foreign institutions or seek employment (short term) in countries with endemic vaccine preventable diseases (Rabies, Hepatitis A etc).
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Recommended Immunizations of HealthCare Workers in the Caribbean
CHAPTER 3
Diagram 1 Immunization in Practice, WHO/EPI/ TRAM/98.01-11 6. Use a new syringe and needle for every child. - Inspect the packaging carefully only use those where the package is intact - check expiry date. - Do not touch the needle! Discard any needle that has touched any non sterile surface. 7. Ensure the child is held firmly and anticipate possible movement during or after the injection. - Discard the needle and syringe in a safety box designed for the purpose. - DO NOT RECAP! 9. Giving multiple vaccines at one time. - Do not give more than one dose of the same vaccine to one person in one session. - Do not use the same syringe for more than one vaccine. - Do not use the same site or near it for several vaccines. 10. All vaccines should be given according to schedule. 11. There should be a minimum of four weeks between doses for catch- up defaulters. 13. Multi-dose vials used in a home visiting setting should be discarded at the end of the day. 14. When giving a routine immunization injection it is NOT necessary to aspirate for blood. 15. Be prepared for Anaphylactic Reactions (See Chapter 6). 16. Check with the patient or parent for any previous reaction to immunization (or contra indication) 17. Do not vaccinate infants in the buttocks to prevent sciatic nerve damage. Injections in our immunization schedule are given Intra muscular, or subcutaneously. See Diagram 1.
Administration of Vaccines
1. Prepare injections in a clean designated area where contamination by blood and body fluids is unlikely. 2. Prepare every injection immediately before administration; do not prepare several syringes in advance. 3. Never leave a needle in the top of the vaccine vial. 4. Follow product specific recommendations for the use of vaccines and check expiry date. 5. Follow safe procedures for reconstituting vaccines. -Ensure the correct dilutant is used for each freeze dried vaccine check that both dilutant and vaccine are produced by the same manufacturer. -When reconstituting, the dilutant and vaccine must be at the same temperature (between 2 degrees centigrade and 8 degrees centigrade) -Use a sterile syringe and needle to reconstitute each unit of the vaccine, use all of the dilutant provided in the vial. - All reconstituted vaccine should be discarded at the end of six hours or at the end of each session whichever is sooner. - Open multi-dose vials under strict conditions can be kept four weeks.
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Recommended Tdap Schedule for Pregnant Women
The nurse should support the skin and clean the leg allowing the alcohol to dry before giving the injection. Insert the needle at a 90 degree angle in the upper outer aspect of the thigh. Push in the plunger and administer the liquid. Withdraw the needle and discard with the syringe in the appropriate container. The parent or adult maybe asked to press the spot with an alcohol swab until bleeding stops or a band aid is placed. For subcutaneous injections the needle should point towards the shoulder at a 45 degree angle in the upper outer aspect of the arm. Push in the plunger and administer the liquid. (Diagram 3) Intramuscular injections in the arm should be at a 90 degree angle (Diagram 4) Simple directions Wash hands Select the correct vaccine. Inspect vial Clean rubber top (if necessary) Select the correct size needle and syringe. Select the correct site and get the patient prepared. Administer vaccines Discard syringe and needle in biohazard container Document information
Position the infant sideways on the mothers lap with the whole arm bare (diagram 2). The parent or adult should hold the infants legs possibly by trapping them between their own legs as well as the arm. The skin is cleaned with an alcohol swab and let dry while the nurse gently pinches up the skin and give the injection. Withdraw the needle and discard with the syringe in the appropriate container. The parent or adult maybe asked to press the spot with an alcohol swab till bleeding stops or a band aid is placed.
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Recommended Immunizations of HealthCare Workers in the Caribbean
Diagram3. Immunization in Practice, WHO/EPI/ TRAM/98.01-11
Diagram 4 Source: Immunization Handbook, Ministry of Health
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Recommended Sizes of Needles for Vaccine Administration

Vaccines given in Childhood and Adolescence DOSE Route Site Thigh DPT, Hib,Hep B 0.5ml IM Anterio lateral muscle Deltoid or Thigh Deltoid or Thigh Needle size 23- 25 g 5/8 length or 1 inch length 23g 1inch 23g 1inch Age 2 mth - 12 mth < 18yrs < 19yrs
HepA Hep B Human Papilloma Virus(HPV) Influenza trivalent inactivated Influenza trivalent inactivated MMR Meningococcal conjugate (MCV) Pneumococcal conjugate(PCV) Pneumococcal polysaccharide(PPSV) Polio, Inactivated (IPV) Polio, Drops Rotavirus Varicella
0.5ml 0.5ml 0.5ml 0.25ml 0.5ml 0.5ml 0.5ml 0.5ml 0.5ml 0.5ml 2 drops ONLY 0.2 ml 0.5ml
IM IM IM IM IM SC IM IM IM/SC IM/SC Oral Oral SC
Deltoid or 23g 1inch >10yrs Thigh Deltoid or 23- 25 g 5/8 6-35 Thigh length months Deltoid or or 1 inch length above 3yrs Thigh 23- 25 g 5/8 12 months+ Deltoid length 23- 25 g 5/8 2yrs + Deltoid length 23- 25 g 5/8 2months+ Thigh length Thigh Mouth Mouth Deltoid 23g-25g 5/8 23- 25 g 5/8 length 25g 5/8 2yrs+ 2months+ 2months+ 2months+
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Safe Immunization Practices
CHAPTER 4
The Health Impact of Giving Unsafe Injections Unsafe Injections can cause infections, injuries, and drug-related problems. The skin and the environment are not sterile and therefore serve as a possible source of contamination. Body fluids may also contain pathogens. The safety of the vaccine is primarily dependent on risk of contamination with pathogenic organism and bacteriostatic or virucidal effect of preservative. Definition of an unsafe injection:
Any injection that can cause harm whether to patient, health care worker or the community. Unsafe infections can spread pathogens more efficiently than breathing (inhaling), swallowing (ingesting), or sexual exposure. Practices that can harm recipients: Keeping freeze-dried vaccines more than six hours after reconstitution. Vaccinating infants in the buttocks. Leaving the needle in the vial to withdraw additional doses.(diagram 5) Mixing vaccines from two or more open vials. Using a diluent that is not manufactured for use with the solvent (e.g. MMR water for Yellow fever injection) Storing vaccines and medications in the same refrigerator. Practices that can harm health care workers: Recapping needles. Placing needles on a surface or carrying them any distance prior to disposal. Practices that can harm the community: Leaving used needles in places where children can play with them. Leaving used needles and syringes in places that are accessible to the public.
Safe Injection Practices:

Record the date when multi-dose vials are opened. Do not open more than one vial at a time. Do not leave needles in the vial to withdraw additional doses Read the Labels on the Vaccine and Diluents Vials Other Tips to keep Vaccines Safe: Discard needles and syringe if expiration date has passed. Use a new syringe and needle to reconstitute each vial of vaccine. Fill the syringe ONLY when the patient is ready to receive an injection. Do not combine partially opened vials of vaccine Do not save opened vials of liquid vaccine for more than 4 weeks.
Keeping vaccines safe and avoiding waste:

Place vaccines in wicker baskets or perforated containers to avoid water damage to labels. Place vaccine with shorter expiry life in front of fridge to use first. Reconstituted vaccines should be kept cool and away from sunlight. Discard reconstituted vaccines after 6 hours. Reminder: When giving an injection it is not necessary to aspirate for blood for routine immunizations. Reconstituting Vaccines: The entire volume of the diluents vial should have been mixed to ensure correct vaccine concentration. Diluents usually do not contain preservatives and should be mixed immediately upon opening.
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Post Exposure Protocol for Bloodborne Pathogens for Staff & Clients
Policy:
An employee (HCW) or client who sustains a needle stick/sharp injury, mucosal exposure or skin exposure to spilled blood or other body fluids should report the incident to the Immediate Nursing Supervisor of the Clinic/Unit immediately and follow the appropriate protocol for assessment and necessary actions and determination of treatment.
Immediate Action Procedure:

1. DECONTAMINATE THE AREA OF THE EXPOSURE. Immediately after exposure by sharps injury or splash: (i) Where appropriate, wash skin thoroughly with soap and water, (ii) DO NOT induce additional bleeding (iii) If mucous membrane is affected flush copiously with running water or sterile saline 2. Notify Area Supervisor or Nurse-in charge of your area. The Area Supervisor or Nurse-in-Charge should initiate the Employee Accident/Incident Form. 3. SOURCE PATIENT: The HCW or the Area Supervisor should ask the source patient (if known) to remain in the clinic area until after the evaluation has been completed. 4. EVALUATION OF EXPOSURE AND FOLLOW-UP a. Complete Employee Accident/Incident Form for Staff Only Employee must complete his/her portion of the Accident/Incident Form relating to his/her sociodemographics and how the accident/incident occurred. It is the employees responsibility to send the completed forms (in triplicate) to office of the Administrator, Department of Public Health within 12-24 hours. Fax No.322-6604.
b. The Area Supervisor/Administrator should notify relevant management supervisor(s): (I) Medical Staff Coordinator @ phone 502-4717/502-4807 or 376-4535 (II) Principal Nursing Officer@ phone 502-4846/502-4832 or 557-9024 (III) Surveillance Unit @ phone 502-4776, 502-4790 or, 3971021(Is this still Surveillance Unit function or HIV/AIDS) (IV) HIV/AIDS Centre during normal business hours @ 323-5968, 328-2668, 323-6373, with name and date of birth of Client (to be checked for known HIV exposure) c. Determine the Risk of the Exposure Determine whether or not incident represents an actual exposure for HIV (see Table 1) Determine whether or not incident represents an actual exposure for Hepatitis B and Hepatitis C (see Table 2)
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5. COUNSEL FOR HIV EXPOSURE RISK AND POSTEXPOSURE PROPHYLAXIS If the HCW may have been exposed to HIV, counsel the HCW about the risk of acquiring HIV from the exposure and the pros and cons of taking HIV Postexposure Prophylaxis (PEP) antiretroviral medications. 6. MEDICAL ASSESSMENT
Have medical examination/assessment done by clinic physician on duty Obtain signature of the Doctor on the form Sign the form after examination/assessment (This is a part of the Accident/Incident Form) If indicated and the HCW consents, start HIV PEP as soon as possible (ideally within 1-2 hours). The sooner PEP is started, the more effective it is thought to be. Antiretroviral PEP can be considered after 24-36 hours after the exposure, but expert consultation is recommended in this situation. If the source patient has known HIV infection, try to obtain pertinent information about their stage of HIV disease: most recent viral load, antiretroviral therapy history, and results from resistance testing (if previously performed through HIV Reference Laboratory/HIV Centre). Obtaining source patient information may help in estimating the exposure risk and in designing an HIV PEP regimen, but gathering this information should not delay timely administration of PEP. Nevirapine is contraindicated for use in PEP due to its potential life-threatening toxicity in this setting. We do not recommend using efavirenz as a preferred postexposure agent for two reasons:
(1) central nervous system adverse effects frequently occur during the initial weeks after starting this medication, a problem that could be particularly problematic HCWs, and (2) efavirenz may be ineffective if the source patients strain of HIV is resistant to nonnucleoside reverse transcriptase inhibitors (NNRTIs). We do not recommend initial use of abacavir because of the risk of hypersensitivity reaction in the HCW (obtaining HLA-B5701 testing for the HCW would delay use of abacavir). When a source patient has known antiretroviralresistant HIV, expert consultation should be obtained to review any known resistance information on the source patient and to determine the optimal PEP regimen. If the HCW is breastfeeding or pregnant, expert consultation is recommended. In addition, review any medications or supplements the HCW may be taking, and investigate potential drug-drug interactions. Provide a minimum of 3-day supply of PEP medications. The total duration of antiretroviral PEP is 28 days. Discuss the dosing and common side effects of the medications prescribed (Table 10: Primary Side Effects and Toxicities) and provide the HCW with contact numbers in the event they have significant side effects. If side effects develop, provide appropriate prescription(s), such as anti-emetics and/or anti-diarrheals. If the side effects are severe, assess whether the medications need to be changed.
7. START HIV ANTIRETROVIRAL PEP
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8. DETERMINE HBV IMMUNE STATUS AND ADMINISTER HBV PEP IF NEEDED

If the HCW may have been exposed to hepatitis B, determine whether the HCW has been immunized against HBV, and if so, whether the HCW is known to have responded to this vaccination (e.g. has documented protective hepatitis antibody titer). Details for HBV PEP are provided in Table 11: Recommended PEP for Exposure to HBV.
9. COUNSEL AFTER EXPOSURE TO HCV
If HIV PEP is initiated, a baseline complete blood count (CBC), U & E, and ALT should also be drawn. Drawing blood for laboratory studies on the HCW should not delay timely administration of PEP. If PEP is indicated, administer the first dose of PEP and then obtain blood for laboratory studies. If the HIV Rapid Test is positive for the staff member or the source client, an additional level of assessment is required; CD4/VL, baseline U&Es, CBC and LIFs are started before ARTs antiretroviral medications. Post counseling must also occur.
In the event the HCW was exposed to hepatitis C, there is no proven effective PEP for HCV and thus PEP for hepatitis C is not recommended. Perform baseline testing for anti-HCV and ALT activity. The recommended baseline and follow-up testing consists of: o Testing for anti-HCV and ALT activity o Testing (at 4-6 months) for anti-HCV and ALT activity
12. TEST THE SOURCE PATIENT
10. DETERMINE TETANUS TOXOID COVERAGE
Assess vaccination status of HCW for Tetanus Toxoid, and administer at this time if needed.
11. OBTAIN BASELINE LABORATORY STUDIES FOR THE HCW

Draw relevant baseline labs on the HCW. These generally include baseline serologic testing for HIV, HCV, hepatitis B, and syphilis (HIV Ab, HCV Ab, HBsAb, VDRL), plus a baseline ALT level. In addition, if PEP is being considered and the HCW is a female of child-bearing age, a stat pregnancy test should be performed. HIV Rapid Test can be performed by trained Clinic staff, after appropriate pre-test counseling
Attempt to obtain permission to perform testing on the source patient for HIV Ab, HCV Ab, and HBsAg. If these tests have previously been performed on the source patient, clinical judgment should be used to determine whether the studies need repeating. The source patient should not be charged for these tests. In certain circumstances where immediate information is needed on the source patient, such as the situation where the exposed HCW is pregnant, use of the rapid HIV test (if available) may be appropriate for testing a source patient with unknown HIV status. If the source patient refuses to give permission to have blood drawn, the exposure will be handled as an unknown source.
13. COUNSEL HCW ABOUT PREVENTING HIV TRANSMISSION

During the follow-up period, especially the first 6-12 weeks, the following precautions are recommended for the HCW to prevent transmission of HIV:
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o Do not donate blood, tissue, semen, or organs. o Do not become pregnant. o Do not engage in sexual intercourse during this time period. If the HCW chooses to have sexual intercourse, they should use a condom consistently and correctly to reduce the risk of HIV transmission. o Women should not breast-feed infants during the follow-up period.
The on-call Nursing Officer for the Department of Public Health should also be notified of the accident/injury at phone numbers 557-9024, 376-4706 or 477-6229. FAMILY ISLAND INCIDENTS All of the above thirteen (13) steps apply. With the availability of HIV Rapid Testing at all major clinics, travel to New Providence will not be necessary for low risk incidents (HIV test non-reactive in source client). However, exposure to body fluids from a client who is HIV/Hepatitis B positive is an Industrial Accident, and Staff must be prepared to travel to New Providence as soon as possible after exposure, Preferably the Same Day. Reasonable cost associated with travel for assessment/ treatment (Air Ticket and Ground Transportation, Accommodation and Per-diem), could be reimbursed from Department of Public Health or National Insurance. In cases where Rapid Test and ARVs are available travel into New Providence is not necessary. In areas where there are regular daily flights staff members should arrange to travel on the scheduled flights. This would still be in the optimum 2 to 24 hours time frame if HIV prophylaxis is necessary. Please note that prior permission must be obtained for CHARTER FLIGHTS, from Nursing Administration responsible for Family Islands or the Acting Administrator of Department of Public Health. Staff will be required to pay for charters that have not been approved. Special arrangements will be made for areas where there are no daily flights - Exuma Cays, Moores Island, Mayaguana, Crooked Island, Acklins, and Inagua on a case-by-case basis.
14. ARRANGE FOLLOW-UP FOR THE HCW
Schedule a follow-up appointment that takes place within 72 hours. Provide the HCW with a post-exposure literature. Provide a contact number for the HCW in the event he or she has further questions, or if problems develop with the PEP regimen. Offer psychological counseling referral for the HCW if indicated. Provide return precautions: instruct the HCW to return immediately for evaluation (e.g., Accident & Emergency Department or Primary Care Clinic) if he or she develops significant adverse effects from the PEP regimen.
New Providence Incidents In case of Accidents ocurring during extended hours and on weekends, HCWs should be assessed at their Clinic by the physician on duty. If personnel on duty are not trained to perform the Rapid HIV Test, the Physician Team Leader and the Nursing Supervisor of that Clinic should be called so that arrangements could be made to call in the required staff to perform the test.
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SEROLOGY SCHEDULE FOR HIGH RISK EXPOSURES:

1. Baseline blood works at time exposure. (HIV, Hepatitis B, Hepatitis C, VDRL) 2. Repeat in 3 months. 3. Follow up at 6 months.
SUPPLIES The Chemotherapy (ARTs) will be in the pharmacy at all poly clinics in New Providence: Family Island clinics have the responsibility for maintaining adequate ARVs using DDA protocol. Emergency Supply is available by calling the oncall phone 557-9024/376-4706. Rapid Test supplies are to be obtained from the Supplies Unit after approval from the Administrators Office. ADDITIONAL RECOMMENDATIONS
1. There is at least one Nursing and Physician staff in New Providence and the Family Island Clinics trained in risk assessment and treatment of exposures to blood pathogens, including PICT and Rapid HIV Testing available for each shift. 2. Please ensure that two to four packs of triple therapy are present in large Family Island clinics, so that treatment can begin within the 2 to 24 hours optimum period, if it is necessary.
HIV PROPHYLAXIS THERAPY ** Please note an assessment of risk, and blood results (ideally) are needed before starting therapy. NB: The optimum time to begin therapy is within 2 to 24 hours post exposure to known HIV positive blood. Prophylaxis is not effective after 72 hours The following Triple therapy regimen is recommended for 28 days:
1. Duovir (AZT & 3TC) 1tablet po BD (AZT= Zidovudine, 3TC = Lamivudine) 2. Kaletra 400 mgs bid
Pre-test counseling is essential, and post-test counseling is imperative. Counseling should be extended to spouse/partner of the affected staff member. HEPATITIS B PROPHYLAXIS NB: If not previously vaccinated give Hepatitis B Vaccine first dose and/or Hepatitis B Immune Globulin (HBIG) as soon as possible WITHIN 24 HRS and not later than 7 days. Persons who did not receive 3 doses of Hepatitis B vaccine should be given the next dose
3. Effective immediately, it is mandatory that all grades of staff at Public Health Clinics receive 3 doses of Hepatitis B vaccine.
** Not all needle stick injuries require anti-retroviral therapy. ** Injured staff and supervisor are responsible for arranging follow-up.
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PAHO/WHO POLICY STATEMENT USE OF OPENED MULTI-DOSE VIALS OF VACCINE IN SUBSEQUENT IMMUNIZATION SESSIONS
REVISED POLICY Vaccine DPT/Hib/Hep B, TT, DT, Tdap, Hep B, Pneumococcal Conjugate, & Hib liquid vaccines Discard
4 weeks providing all conditions cold chain protocols are met
MMR, Varicella, Yellow Fever & Hib combinations
Discard 6 hrs after opening or at the end of the day which ever one comes first
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PREVENTION OF NEEDLES STICK INJURIES Safe Handling and Disposal of Sharps Prevents Needle stick injuries:
Position sharps disposal container for easy access to minimize handling of needle Do not empty or reuse sharps containers. Syringes and needles are destroyed by incineration/ burning Do not fill sharps disposal containers more than full. Close and tape box for disposal when it is full. Sharps boxes will be collected as bio-hazard material and taken to the incinerator.
Do Not fill sharps containers Rapid Test supplies are to be obtained from the Supplies Unit after approval from the Administrators Office.
Do Not Recap Needles Do Not Touch the Needle
Do Not leave needle in the vial
Position the child correctly and securely to prevent needle stick injury
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Classification of Exposures
TABLE 1: CLASSIFICATION OF EXPOSURES VERSUS NON-EXPOSURES TO HIV EXPOSURES

Intravenous, intramuscular or subcutaneous injury with a needle contaminated with a potentially infectious body fluid* whether or not the injury results in visible bleeding Any mucous membrane or break in the skin (e.g., non-healed wound or dermatologic condition that compromises the integrity of the skin) exposed to a potentially infectious body fluid Human bites: o Exposure to the individual doing the biting if the skin was broken resulting in visible bleeding; o Exposure to the bitten individual if the skin was broken and visibly bleeding AND the individual who was doing the biting was bleeding in the mouth at the time of the bite Intact skin or healed wound/skin lesion contaminated with potentially infectious body fluid Intravenous, intramuscular or subcutaneous injury with a needle contaminated with a fluid that is not potentially infectious Mucous membrane or break in the skin exposed to a fluid that is not potentially infectious
TABLE 2: CLASSIFICATION OF EXPOSURES VERSUS NONEXPOSURES TO HBV AND HCV EXPOSURES

Intravenous, intramuscular or subcutaneous injury with a needle contaminated with a potentially infectious body fluid* whether or not the injury results in visible bleeding Any mucous membrane or break in the skin (e.g., non-healed wound or dermatologic condition that compromises the integrity of the skin) exposed to a potentially infectious body fluid Human bites: o Exposure to the individual doing the biting if the skin was broken resulting in visible bleeding; o Exposure to the bitten individual if the skin was broken and visibly bleeding Intact skin or healed wound/skin lesion contaminated with potentially infectious body fluid* Intravenous, intramuscular or subcutaneous injury with a needle contaminated with a fluid that is not potentially infectious Mucous membrane or break in the skin exposed to a fluid that is not potentially infectious.
NON-EXPOSURES
NON-EXPOSURES
*For exposures to HIV, a potentially infectious body fluid includes blood, amniotic fluid, spinal fluid, pleural fluid, pus, semen, vaginal fluid, breast milk, or any fluid that is visibly bloody. Saliva, urine, and feces are not considered to be potentially infectious for HIV unless visibly bloody.
*For exposures to HBV, potentially infectious body fluids include blood, amniotic fluid, spinal fluid, pleural fluid, pus, saliva, semen, vaginal fluid, breast milk, or any fluid that is visibly bloody. Transmission of HBV via saliva exposure has been documented in rare cases involving highly infectious (HBeAg+) source individuals. Urine and feces are not considered to be potentially infectious for HBV unless visibly bloody. For exposures to HCV, the same rules are thought to apply with the exception of saliva, because transmission of HCV via exposure to saliva has not been clearly documented.
Modified from: Panlilio AL, Cardo DM, Grohskopf LA, Heneine W, Ross CS; U.S. Public Health Service. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep. 2005;54(RR-9):1-17.
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TABLE 10: PRIMARY SIDE EFFECTS AND TOXICITIES ASSOCIATED WITH ANTIRETROVIRAL AGENTS USED FOR HIV POSTEXPOSURE PROPHYLAXIS, BY CLASS AND AGENTS Agent Lamivudine (Epivir; 3TC) SIDE EFFECTS AND TOXICITIES Side Effect and Toxicity Minimal toxicity
Zidovudine (Retrovir; ZDV; AZT)
Bone marrow suppression: macrocytic anemia; gastrointestinal intolerance: headache, insomnia, asthenia
Lopinavir/ritonavir (Kaletra; LPV/rTV)
GI intolerance, nausea, vomiting, diarrhea (higher incidence with once daily than twice-daily dosing); asthenia; hyperlipidemia, elevated serum transaminase; hyperglycemia; fat maldistribution
Source: This table is adapted from Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. November 3, 2008;1-139
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TABLE 11: RECOMMENDED PEP FOR EXPOSURE TO HBV Vaccination status of exposed HCW* Source HBsAg Positive Source HBsAg Negative Source Unknown or not available for testing
Initiate HBV vaccine series If known high risk source, treat as if HBsAg positive
Unvaccinated
HBIG x 1 and initiate HBV vaccine series
Initiate HBV vaccine series
Previously Vaccinated Known Responder1 Known non-responder2

No treatment No treatment No treatment
HBIG x 1 and initiate revaccination or HBIG x 2
No treatment Consider revaccination
If known high risk source, treat as if HBsAg positive
Antibody Response Unknown
Test exposed HCW for anti-HBs** 1. If adequate,1 no treatment is necessary 2. If inadequate,2 administer HBIG x 1 and vaccine booster
2 A nonresponder has inadequate response to vaccination (i.e., anti-HBs < 10 mlU/mL). The option of giving one dose of HBIG and reinitiating the vaccine series is preferred for nonresponders who have not completed a second 3-dose vaccine series. For persons who previously completed a second vaccine series but failed to respond, two doses of HBIG one month apart are preferred.
Baseline testing of all exposed HCWs should be performed for ALL exposures. HBV PEP should be initiated immediately (within 24 hours) according to the following table from CDC MMWR 2001 Vol 50 No. RR-11, Table 3: Those previously infected with HBV are immune to re-infection and do not require PEP. Hepatitis B immune globulin; dose is 0.06 mL/kg intramuscularly. When indicated, HBIG should be administered as soon as possible (preferably within 24 hours). Its effectiveness >7 days after exposure is unknown.
1 A responder has adequate levels of serum antibody to HBsAg (i.e., anti-HBs 10 mlU/mL).
** Antibody to HbsAg. Revised November 2011 Surveillance Unit, DPH
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Shake Test
The shake test is designed to determine if absorbed vaccines (DPT,DT, TT, Hep B, Hib liquid or any combination) were damaged by freezing When vaccines freeze the bond between the absorbent and the antigen breaks and the absorbent forms particles. After a vaccine has been exposed to freezing temperatures the appearance has granular sediments may settle at the bottom of the vial. The sedimentation occurs faster in a vial that was exposed to freezing. Procedure:
1. Contact the EPI Unit to report the incident 2. Hold all vials suspected of being exposed 3. The Test vial will be one of the vials that is suspected of being damage 4. Use a vial that has not been exposed (control vial) with the same lot number and manufacturer mark it CONTROL 5. Freeze vial until contents are solid or about 10 hours 6. Allow the control vial to thaw-DO NOT HEAT 7. Hold the test sample and the control vial in the same hand together and shake vigorously for 10-15 seconds 8. Place both vials on a flat surface 9. Look at both vials to assess sedimentation rate in vials. 10. If the sedimentation is slower in the test vial than the control vial the vaccine is not damage and can be used. 11. If the sedimentation is similar in both vials or if the sedimentation in the test vial is faster than the control vial the vaccine is damaged and should be discarded. 12. The clinic supervisor and EPI Coordinator should be informed.
ADDITIONAL RECOMMENDATIONS
1. There is at least one Nursing and Physician staff in New Providence and the Family Island Clinics trained in risk assessment and treatment of exposures to blood pathogens, including PICT and Rapid HIV Testing available for each shift. 2. Please ensure that two to four packs of triple therapy are present in large Family Island clinics, so that treatment can begin within the 2 to 24 hours optimum period, if it is necessary. 3. Effective immediately, it is mandatory that all grades of staff at Public Health Clinics receive 3 doses of Hepatitis B vaccine. ** Not all needle stick injuries require anti-retroviral therapy. ** Injured staff and supervisor are responsible for arranging follow-up.
SUPPLIES
The Chemotherapy (ARTs) will be in the pharmacy at all poly clinics in New Providence. Family Island clinics have the responsibility for maintaining adequate ARVs using DDA protocol. Emergency Supply is available by calling the oncall phone 557-9024/376-4706. Rapid Test supplies are to be obtained from the Supplies Unit after approval from the Administrators Office.
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The Tickler File System
The Tickler File System is a system for the identification of immunization defaulters under one year and one year old.
1. Initiate a white immunization control card on each newborn for the clinic area at the time of the birth visit 2. If the birth visit was not done the control card should be initiated at the one month child health visit. 3. Arrange two files in the months of the current year. File one is labeled DPT, Hib, HepB Pneumococcal Conjugate & Polio File two is labeled MMR and Varicella. 4. File control cards alphabetically, (with babys name, date of birth, address ,the parents name, and telephone number) in the month that the child is due to attend clinic for the first dose of DPT, Hib, Hepatitis B, Pneumococcal Conjugate & Polio Vaccines.
Follow steps 1-5 for the second and third dose.

1. After the baby has received the third dose of vaccine, file the card in the childs birth month .An appointment is given as close to the childs birthday for the child to receive MMR and Varicella at one year of age 2. At the one year child health clinic appointment, the control card is pulled, and the vaccines administered are documented as above for the first three doses 3. After the administration of the MMR and Varicella the control card is placed in another file in alphabetical order in the birth year for the first and second boosters. 4. After the second booster (4-5 yrs) the control card is sent to Blue Hill Road Clinic for storage (repository).
DURING CLINIC SESSION

1. Pull the white immunization control card when the baby attends clinic for immunization. 2. After the baby has received the first dose of vaccines 3. Document on control card: date of vaccine administration, lot number #, on yellow card: date of vaccine administration, lot number #, signature of vaccinator, date of next appointment 4. Control cards are collected and tallied at the end of each session to monitor for defaulters, clinic coverage and monthly immunization reports 5. The control card must be filed alphabetically in the month the child is due to return for the second dose of vaccines.
NOTE: At the end of the month check the control cards, all the cards remaining in the files are considered defaulters.
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Immunization Records
Completing appropriate records are important part for monitoring of the Immunization Program. Records are used for:
a. Information on vaccination received by patients b. Validation of services delivered c. Evaluation of services d. Establishment of data banks, e.g. for research and education e. For statistical purposes e.g. budgeting, financing needs and Surveys.
Any contraindications and reactions must be carefully noted. Schools should have a record of each childs immunization status that by policy is a pre-requisite for admission.
There are several records which are used in the immunization program. Perhaps the most important is the immunization card. Every person immunized should be given a permanent and personal immunization record card and should be educated as to its use and care. The card, which should be produced at every visit to a health facility, must be carefully kept and should not be mutilated in anyway. The clinic should have permanent immunization history (control card) of each individual that attends that centre. The immunization information is also entered into the clients medical record. Each immunization card should have the name of the individual, his/her date of birth, sex, address, name of parent or guardian ,medical record number and telephone number(in the case of a child). The name of the vaccine, the date given, the dose given and batch/ lot number and the signature of the persons giving the vaccine must be recorded at each session. In some countries the consent form must be signed by the client or in the case of a minor by the parent or guardian.
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The Cold Chain
CHAPTER 5
The cold chain is a system for storing and transporting vaccines from it is manufactured until it is administered to the client. During the storage and transporting of vaccines the temperature control is vital to ensure potency of the vaccines. The temperature range for vaccines stored in the refrigerator (freeze sensitive) is between 2 and 8 degrees celcus and those in the freezer (heat sensitive) is between -15 to-25 degrees celcus. There are three main components of the cold chain system:
Human Resource-trained persons working in the EPI Program who will ensure delivery of potent safe vaccines to the client Equipment-Well maintained storage and transport system to ensure potency of vaccines Management of the program and control of vaccine distribution(M & E)
Transport Vaccines should be transported in vaccine carriers with appropriately arranged ice packs (See diagram 6). Before placing the ice packs in the carriers, the frozen ice packs should be warmed at room temperature until frost no longer forms on the surface or water is formed in the ice pack. This is known as conditioning of the icepack. Vaccines and diluents should be kept separate from the ice packs (e.g., in a sealed plastic bag) to avoid wetting of labels and freezing of freeze sensitive vaccines. Keep the time for transport to a minimum, and unpack vaccines immediately upon arrival at the health facility or area where vaccination activities will take place. If the ice packs have completely thawed during transport, the vaccines have probably not been kept cool enough. A well packed vaccine carrier can keep the vaccines between +2 to +80 C for 24 hour
Organization Designated person(s) should be responsible for ordering, transporting and storage of vaccines, including recording refrigerators temperatures and adjusting the thermostat accordingly. Stock Management Vaccines are mainly kept at the Central Store and transported to the health centers when they are required for vaccination. Stock levels should be monitored monthly, with the stock balance available from the vaccine log. Ordering should be done prior to the vaccination session or at least monthly and therefore limit the quantity of vaccine in storage. This is very important where there are no standby generating capacities at the health centre level. Vaccine stock in the refrigerator should be arranged for use according to expiry date that is, put new stock at the back so that old stock is used up first.
Diagram 6 The following points should be kept in mind. One or two ice packs are not enough, the vaccine should be surrounded by ice packs; keep the vaccine carrier out of direct sunlight and keep it closed. After a trip, put the ice packs in the freezer so they will be ready for the next use. The vaccine carrier is used for transporting and storing small amounts of vaccine. For larger amounts, a cold box should be used.
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A typical cold chain system for vaccine is shown below.
Monitoring of the Cold Chain System The refrigerator used to store vaccines is an indispensable requirement of the EPI. It must be in good operating condition and well maintained for the success of the EPI Program. The daily temperature should be recorded morning and afternoon in the appropriate column of the Vaccine Refrigerator Temperature Control Chart (See Refrigerator Temperature Chart Annex #?). The central interior, below the freezer, of the refrigerator should be recording between +20C to +80C
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There should be one person in each health centre/ clinic who has the main responsibility for the refrigerator. The responsibilities should include storing vaccines, diluents and ice packs, checking and recording the temperature daily, and maintaining the centres cold-chain equipment. However, all health workers in a health centre/clinic should know how to monitor the cold chain and what action to take if the temperature is too high or too low.
A thermometer in the refrigerator is essential and must be checked twice on every working day and the temperatures recorded. The temperature should be between +2 to +80 C. If the thermometer is taken out of the refrigerator, the temperature should be recorded after it has been in the refrigerator for at least an hour. Only vaccines and diluents are to be stored in the refrigerator. If the door is opened constantly it will cause the temperature to rise and compromise the vaccines. Otherwise the room temperature will affect the reading at the end of the day. The person responsible for recording temperatures should be the only person to alter the thermostat of the refrigerator. Arrangements should be made to move the vaccines to a functional refrigerator, should electrical outage be for a long time. The refrigerator should be kept 4 to 6 inches away from the wall and away from direct sunlight. Ensure a tight seal on the doors conduct paper test. Ensure that the fridge is standing steady and that the electrical cord and plug are out of the way of foot traffic. Read and record fridge temperature morning and evening.
Temperature chart should be placed on the front of the fridge so that it is easily visible. Icepacks in the freezer and water bottles on the bottom shelf of the fridge helps to maintain the temperature in the event of a power outage. The vaccines should be arranged in the refrigerator to allow air to circulate freely. Freeze and store frozen ice packs in the freezer Put vaccines and diluents on the top and middle shelves of the main section. DO NOT place vaccines on door shelves: the temperature is not low enough Keep plastic bottles or ice packs filled with water on the bottom shelf. They help to keep the temperature constant. - OPV and MMR vaccine on the top shelf - BCG, DPT, Td, Hepatitis B and Yellow Fever vaccines on the middle shelves - Diluents next to the vaccines with which they were supplied. Arrange the boxes of vaccine in stacks between which the air can move Keep unopened vials that have been taken out of the refrigerator in a special box in the main section labelled returned. Use these vials first in the next session DO NOT keep expired vaccines in the refrigerator. Discard according to drug policy DO NOT keep any food, drink, or drugs in a vaccine refrigerator. Each refrigerator should be defrosted when 1/4 inch or 5/8 centimeter of ice has formed on the internal sides of the freezer compartment. It is important to open the door only when needed. During power failures the refrigerator should not be opened.
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Review of the Cold Chain System
flamingo gardens clinic graphic
In addition to daily monitoring monthly reviews of the performance of the refrigerator, using the temperature records, should be done by the clinic supervisor. The EPI Manager should be available to advise clinic staff on refrigerator performance and if vaccine damage is suspected. Before clinic staff discards any vaccine, consultation should occur with the EPI Manager/Clinic Supervisor. Vaccines should be discarded in a similar manner as other biohazard wastes. Maintenance of the cold chain requires vaccine and diluent to be:
Collected from an airport as soon it arrives Transported at the correct temperature from the airport and from one storage area to another Stored at the correct temperature in central and in health centres (Table 4) Transported at the correct temperature to outreach sites Kept cold during immunization sessions.
There are three major levels where vaccines are stored, and the cold chain is of paramount importance: The Central level storage in The Bahamas is located at the Flamingo Gardens Clinic; it is equipped for long-term storage of large amounts of vaccine and has a standby generator. Local level storage is usually at the health centers/clinics where vaccines are stored in small amounts for the duration of the immunization clinic. Weak links can occur at any point along the cold chain, and experience indicates that the risk of damage to vaccines is greatest at the local level. The practitioner is a part of this cold chain, and also is responsible for it. The risk of improper handling and storage can result in unexpected outbreaks of some of the EPI diseases due to vaccines that have been rendered ineffective through poor cold chain procedures. The following are the vaccines which are not affected by freezing and those that are damaged by freezing.
The EPI Clinic Coordinator/ Nurse-In-Charge is responsible for maintaining the cold chain while vaccines are stored in the health centre, is being transported to outreach sites, and during immunization sessions. The cold chain must never be broken. Mishandling at any point along the chain can ruin the vaccines and make them useless or ineffective.
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Vaccines: Freezing & Storage

Vaccines Damaged by Freezing:
DPT DT/Td TT Hepatitis B Haemophilius Influenzae Type b (Hib) Hepatitis A Influenza Pneumococcal Meningococcal All combinations of these vaccines Vaccine diluents
Vaccines Not Affected by Freezing:

OPV Mumps MMR Measles Rubella BCG
Storage of Vaccines
Vaccines are biological products that lose their potency if they are not stored and transported correctly. Vaccines should be refrigerated between 2 80 C. Ideally, they should be stored in a dedicated refrigerator, taking up only about half of the storage area in order to allow air movement. Do not store vaccines in the door and bottom shelves. Water bottles in these and other areas will help to reduce temperature fluctuations. A good seal, regular defrosting, and minimizing the number of times the refrigerator door is opened will also help temperature stability. Non self-defrosting refrigerators are good for the storage of vaccines. The power supply of the refrigerator should be secured by taping over the plug and writing a notice against turning off the power or unplugging the refrigerator. During a power failure of one to four hours, vaccines should be left in the refrigerator and the door kept closed. For a failure of four hours or more, vaccines should be transferred to an appropriately packed vaccine and plans made to remove them to a facility with electricity or back up generating capacity.
Recommended Vaccine Storage Temperatures

Type of Vaccine DPT Hep B and Hib Measles/ MMR * TOPV * Td Yellow Fever * Central Level
3 - 7 Years 2oC to +8oC 2 Years 2oC to +8oC 2 Years 2oC to +8oC 6 - 12 Months 2oC to +8oC 4 Years 2oC to +8oC 2 - 3 Years 2oC to +8oC
Transport to Transport to District Local Level

2oC to +8oC 2oC to +8oC 2oC to +8oC 2oC to +8oC
2oC to +8oC
2oC to +8oC
2oC to +8oC
2oC to +8oC
2oC to +8oC
2oC to +8oC
2oC to +8oC
2oC to +8oC
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Guidelines for the Management & Distribution of Vaccines
1. The EPI Manager prepares the appropriate Procurement Forms for Vaccines in July each Year. 2. The prepared Vaccine Procurement Form is submitted to the Ministry of Health (usually the Chief Medical Officer or her designate) for approval and signature. 3. The approved Vaccine Procurement Form is then sent to PAHOs Office-Bahamas/Turks and Caicos Islands where it is submitted to the Immunization Unit of PAHO in Washington. A copy of this form is usually sent to the EPI Advisor at CAREC. 4. The Immunization Unit PAHO Washington verifies the countrys vaccine order prior to forwarding the Vaccine Orders to the Manufacturers. 5. The PAHO Bahamas notifies the Ministry of Health (Permanent Secretary, Chief Medical Officer, Director of Public Health Supervisor of Medical Supplies (PMH) and EPI Manager) of the pending arrival of the vaccines in The Bahamas. 6. The EPI Manager confirms notification with Supervisor of supplies (PMH) .Usually the day before or on the scheduled day of arrival. 7. The driver from Materials Management Department (PMH) goes to the Airport and collects the vaccines and supplies.
8. Vaccines, diluents and supplies are checked for Cold Chain status (by reading the temperature monitors that is included with the vaccines), quantity, date of manufacture, expiry date and are checked against the notification document at Central Storage Site (Flamingo Gardens Clinic). 9. Vaccines and diluents information are recorded as follows: Type of vaccine and diluents are recorded Amount received Vial Size Quantity of Vaccine Manufacturer Date of Manufacture Batch/Lot # Expiry Date for each vaccine and diluent 10. The PAHO Bahamas Office is notified re the arrival of the vaccines/diluents and the condition they were received in. i.e. satisfactory or unsatisfactory. This is usually done within 24 hours (no later than 48 hours) of vaccine arrival. A form is faxed to PAHO office and the office of the Chief Medical Officer is also notified. 11. Documents received with shipment are delivered to the Storekeeper for processing and clearance at Customs.
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Distribution Guidelines
1. All vaccines are stored at the Flamingo Gardens Clinic which is the central stores for vaccines. 2. Vaccines are distributed on a weekly/monthly basis to Health Centers and clinics as needed. 3. Temperature of vaccines refrigerators are read and recorded twice daily at Flamingo Gardens Clinic. The accepted temperature is between +2 to +80C. 4. Central Stores has a Vaccine Record /Log Book where the following information is recorded. Date Type of vaccine requested Batch Number/Lot # Manufacturer Date of Manufacture Expiry Date Balance of vaccines in Central stores Number of Vaccines received by the nurse Balance after deductions Signature of Persons Distributing and Receiving Vaccines.
GUIDELINES FOR EMERGENCY MANAGEMENT OF VACCINE AND DILUENTS

Emergency plans are necessary in the event of or preparation for a Disaster. If there is a hurricane watch an emergency staff meeting should be conducted amongst members of staff at all clinics to review emergency Plan. Once there is a Hurricane Warning staff must review their Disaster plans and ensure that emergency measures are taken to secure vaccines, diluents and other relevant and important records.
How to Manage Vaccines and Diluents:

1. Extra Ice packs are placed in the freezer along with extra water bottles in the fridge to maintain cold chain. Note that the accepted temperature is between +2 to +80C. 2. Maintenance Department should be reminded to arrange to start the standby generator in the event of power outage. 3. In the absence of a Generator, vaccines and diluents are to be labeled and packed for emergency storage at a clinic with generator or other facility in the Family Island with a generator. The disaster committees on the Family Islands also have their pl ans.
5. The EPI Manager routinely checks the Central stores to ensure Cold Chain is maintained and to confirm the level of vaccine stocks.
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Cold Chain Equipment
OTHER RECORDS USED IN EPI PROGRAM: Temperature charts on which are recorded morning and afternoon temperatures in the refrigerators where vaccines are stored. Vaccine Order Forms from clinics-used for vaccine order so that proper accountings of vaccines are done. Monthly reporting form which helps to assess vaccine utilized and actual numbers of persons immunized. Coverage chart which is a graphic representation of the coverage achieved and how this relates to the target population.
Immunization Refrigerator: Store only vaccines in Immunization Refrigerator
Foam in Vaccine Carrier A foam pad is a piece of soft foam that fits on top of the ice packs in a vaccine carrier. When the carrier lid is open, the foam pad keeps the vaccines underneath in a cool state. It also holds and protects vaccine vials during immunization sessions.
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Adverse Events/Treatment Of Anaphylactic Reactions
CHAPTER 6
Table 1- Clinical Criteria for Anaphylaxis
1. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours): a. Involvement of the skin and/or mucosal tissue (e.g., hives/urticaria, pruritus, flushing, swollen lips, tongue, or uvula) b. Respiratory compromise c. Reduced blood pressure or associated symptoms d. Persistent GI symptoms (e.g., cramps, vomiting) 2. Anaphylaxis should be suspected when patients are exposed to a known allergen and develop hypotension
ANAPHYLAXIS Anaphylaxis is a medical emergency that requires immediate diagnosis and treatment. In simple terms, anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. Clinical Features Anaphylaxis is the most severe life-threatening form of a systemic allergic reaction, often involving respiratory or cardiovascular compromise. The clinical signs of systemic allergic reactions include diffuse urticaria and angioedema. At times, these major symptoms are accompanied by any of the following: abdominal pain or cramping, nausea, vomiting, diarrhea, bronchospasm, rhinorrhea, conjunctivitis, dysrhythmias, and/or hypotension. Even mild, localized urticaria can progress to full anaphylaxis, and even to death.
The classic presentation of anaphylaxis begins with pruritus, cutaneous flushing, and urticaria. These symptoms are followed by a sense of fullness in the throat, anxiety, a sensation of chest tightness, a sensation of chest tightness, shortness of breath,
and lightheadedness. As the cascade progresses, decreased level of consciousness, respiratory distress, and circulatory collapse may ensue. In its severest form, loss of consciousness and cardiorespiratory arrest may result. A complaint of a lump in the throat and hoarseness heralds life-threatening laryngeal edema in a patient with symptoms of anaphylaxis. In the vast majority of patients, signs and symptoms begin suddenly, often within 60 minutes of exposure. In general, the faster the onset of symptoms, the more severe the reaction, as evidenced by the fact that 50% of anaphylactic fatalities occur within the first hour. After the initial signs and symptoms have abated, patients are at risk for a recurrence of symptoms. The exact incidence of this biphasic phenomenon is unclear, although it has been reported in 3% to 20% of patients. The effect is caused by a second phase of mediator release, peaking 4 to 8 hours after the initial exposure and exhibiting itself clinically 3 to 4 hours after the initial clinical manifestations have cleared. The late-phase allergic reaction is primarily mediated by the release of newly generated cysteinyl leukotrienes, the former slow-reacting substance of anaphylaxis.
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Diagnosis & Treatment Of Anaphylactic Reactions
Diagnosis The diagnosis of anaphylaxis is clinical. Anaphylaxis should be considered when involvement of any two or more body systems is observed, with or without hypotension or airway compromise (e.g., some combination of cutaneous, respiratory, GI, or cardiovascular systems) (Table 2). The diagnosis is easily made if there is a clear history of exposure, such as a bee sting, shortly followed by the multisystem signs and symptoms described above. Unfortunately, diagnosis is not always easy or clear, because symptom onset may be delayed, symptoms mimic other presentations (e.g., syncope, gastroenteritis, and anxiety), or anaphylaxis may be a component of other diseases (e.g., asthma).
Table 2 - Clinical Manifestations of Anaphylaxis

System Respiratory Cardiovascular Skin GI Eye GU Signs and Symptoms
Rhinitis, pharyngeal edema, laryngeal edema, cough, bronchospasm, dyspnea
Dysrhythmias, collapse, cardiac arrest Pruritus, urticaria, angioedema, flushing Nausea, emesis, cramps, diarrhea Pruritus, tearing, redness Urgency, cramps
Treatment
EMERGENCY TREATMENT Given the possible development of life-threatening complications, all acute allergic reactions require triage at the highest level of urgency. Anaphylaxis, as defined by airway compromise or hypotension, is obviously a true medical emergency and must be rapidly assessed and treated. With suspected anaphylaxis, the single most important step in treatment is the rapid administration of epinephrine. Moreover, with this rapid administration, many of the secondary measures discussed below may not be necessary.
FIRST-LINE THERAPY Most treatment guidelines derive from expert panels and consensus statements. Emergency management starts with the ABCs (airway, breathing, circulation) of resuscitation. The first-line therapies for anaphylaxis (e.g., epinephrine, IV fluids, and oxygen) have immediate effect during the acute stage of anaphylaxis. Vital signs, IV access, oxygen administration, cardiac monitoring, and pulse oximetry measurements should be initiated immediately. Airway and Oxygenation Securing the airway is the first priority. The airway should be examined for signs and symptoms of
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Diagnosis & Treatment Of Anaphylactic Reactions
angioedema (e.g., uvula edema or hydrops, audible stridor, respiratory distress, hypoxia). If angioedema is producing respiratory distress, intubation should be completed early, as delay may result in complete airway obstruction secondary to progression of angioedema. The patient should be given sufficient oxygen to maintain arterial oxygen saturation >90%.
is warranted in patients taking -blockers, because epinephrine use may result in severe hypertension secondary to unopposed -adrenergic stimulation.
Epinephrine Epinephrine is a mixed 1- and 2-receptor agent. The 1-receptor activation reduces mucosal edema and membrane leakage and treats hypotension, whereas the 2-receptor activation provides bronchodilation and controls mediator release. Most consensus guidelines for the past 30 years agree that epinephrine is the drug of choice and the first drug that should be administered in acute anaphylaxis.
In patients without signs of cardiovascular compromise or collapse, IM epinephrine can be administered. The dose is epinephrine, 0.3 to 0.5 milligram (0.3 to 0.5 mL of the 1:1000 dilution) IM repeated every 5 to 10 minutes according to response or relapse. For convenience, patient safety, and accurate dosing, many EDs have adopted the use of EpiPen (0.3 milligram epinephrine for adults; Dey, L.P., Napa, CA) and EpiPen Junior (0.15 milligram epinephrine for children <30 kg; Dey, L.P., Napa, CA). The most recent United Kingdom guideline recommends a higher starting dose than others, but the evidence for this decision is unclear. Most patients do not need more than a single dose. IM dosing provides higher, more consistent, and more rapid peak blood epinephrine levels than SC administration, and should now be the treatment of choice for adults and children. Injections into the thigh are more effective at achieving peak blood levels than are injections into the deltoid area. Caution
SECOND-LINE THERAPY The second-line anaphylaxis treatments include corticosteroids, antihistamines, asthma medications, and glucagon. These drugs are used to treat anaphylaxis refractory to the first-line treatments or associated with complications, and also to prevent recurrences. Corticosteroids All patients with anaphylaxis should receive corticosteroids. Methylprednisolone 80 to 125 milligrams IV (2 milligrams/kg in children; up to 125 milligrams) or Hydrocortisone 250 to 500 milligrams IV (5 to 10 milligrams/kg in children; up to 500 milligrams) are equally appropriate. Methylprednisolone produces less fluid retention than hydrocortisone and is preferred for elderly patients and for those patients in whom fluid retention would be problematic (e.g., renal and cardiac impairment). Antihistamines All patients with anaphylaxis should receive a histamine-1 blocker, such as diphenhydramine, 25 to 50 milligrams IV. Because the histamine-2 blockers are effective in shock refractory to epinephrine, fluids, steroids, and histamine-1 blockers, it is recommended that histamine-2 blockers, such as ranitidine or cimetidine, be given as well. Cimetidine should not be used for patients who are elderly (side effects), have multiple comorbidities (interference with metabolism of many drugs), have renal or hepatic impairment, or whose anaphylaxis is complicated by -blocker use (prolongs metabolism of -blockers and may prolong anaphylactic state). After the initial IV dose of steroids and antihistamines, the patient may be switched to oral medication (Table 3).
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Table 3 - Drug Treatment of Anaphylaxis and Allergic Reactions

Drug Adult Dose
First-Line Therapy Epinephrine
IM: 0.30.5 milligram (0.30.5 mL of 1:1000 dilution); or EpiPen 0.3 milligram epinephrine (or equivalent preformulated product) IV single dose: 10 micrograms over 510 min; 1:100,000 dilution given as 0.1 milligram in 10 mL at 1 mL/min IV infusion: 14 micrograms/min IV infusion: 0.10.3 microgram/kg/min; maximum, 1.5 micrograms/kg/min Titrate to SaO2 90% 1015 mL/kg bolus IM: 0.01 milligram/kg (0.01 mL/kg of 1:1000 dilution) or EpiPen Junior 0.15 milligram of epinephrine (or equivalent preformulated product)
Pediatric Dose
Oxygen IV fluids: NS or LR
Titrate to SaO2 90% 12 L bolus
Second-Line Therapy H1 Blockers Diphenhydramine

2550 milligrams every 6 h IV, IM, or PO 1 milligram/kg every 6 h IV, IM, or PO
H2 Blockers Ranitidine Cimetidine Corticosteroids Hydrocortisone Methylprednisolone Prednisone

250500 milligrams IV 80125 milligrams IV 4060 milligrams/day PO divided twice a day or daily To be used after initial IV dose (for outpatients: 35 d; tapering not required) 510 milligrams/kg IV (maximum, 500 milligrams) 12 milligrams/kg IV (maximum, 125 milligrams) 12 milligrams/d PO divided twice a day or daily To be used after initial IV dose (for outpatients: 35 d; tapering not required) 50 milligrams IV over 5 min 0.5 milligram/kg IV over 5 min
300 milligrams IV
48 milligrams/kg IV
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Table 3 - Drug Treatment of Anaphylaxis and Allergic Reactions (ctd.)

Drug
Treatment of Bronchospasm, Add: Albuterol
Single treatment: 2.55.0 milligrams nebulized (0.51.0 mL of 0.5% solution) 46 puffs with holding chamber Both repeated every 20 min as needed Continuous nebulization: 510 milligrams/h Single treatment: 1.252.5 milligrams nebulized (0.250.5 mL of 0.5% solution) 46 puffs with holding chamber repeated every 20 min Both repeated every 20 min as needed Continuous nebulization: 35 milligrams/h Single treatment: 125250 micrograms nebulized 46 puffs with holding chamber Both repeated every 20 min as needed 2550 milligrams/kg IV over 20 min
Adult Dose
Pediatric Dose
Ipratropium bromide
Single treatment: 250500 micrograms nebulized 46 puffs with holding chamber Both repeated every 20 min as needed
Magnesium sulfate
2 grams IV over 20 min
Treatment for Patients on -Blockers with Refractory Hypotension, Add: Glucagon

1 milligram IV every 5 min until hypotension resolves, followed by 515 micrograms/min infusion 50 micrograms/kg IV every 5 min
Abbreviations: H1 = histamine-1; H2 = histamine-2; LR = lactated Ringers; NS = normal saline; SaO2 = arterial oxygen saturation.
Agents for Allergic Bronchospasm If wheezing is present, a selective bronchodilator, such as intermittent or continuous nebulized albuterol/salbutamol, should be instituted. As might be expected, asthmatics are often more refractory to the treatment of allergic bronchospasm. For severe bronchospasm refractory to the abovementioned treatments, other treatments, such as anticholinergics and magnesium sulfate, can be added. Anticholinergic agents should be added to the
nebulized albuterol (ipratropium bromide, 250 to 500 micrograms/dose) in severe acute bronchospasm. Magnesium sulfate improves pulmonary function and reduces admissions when administered in severe acute asthma. It is inexpensive and free of major side effects when used in single doses of magnesium sulfate, 2 grams IV over 20 to 30 minutes in adults and 25 to 50 milligrams/kg in children. Bronchodilator and stimulant agents should be used with caution (lower dose and slower rate) in elderly patients.
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Case Definitions Of EPI Vaccine Preventable Diseases
CHAPTER 7
TUBERCULOSIS
ETIOLOGIC AGENT - Mycobacterium tuberculosis SIGNS AND SYMPTOMS -TB usually presents in the lungs (pulmonary TB). However, extrapulmonary disease may present as cervical lymphadenitis, genitourinary disease, osteomyelitis, military dissemination, meningitis, peritonitis or pericarditis. SYMPTOMS OF PULMONARY TB - Chronic cough that lasts > 3 weeks, - Chest pain - Coughing up blood or sputum - Night sweats - Fever - Chills - Weight loss - Fatigue or Weakness - Decreased Appetite Positive skin test: This means the persons body was infected with TB bacteria. Induration of 5 mm is considered positive in: Human immunodeficiency virus (HIV)- positive persons Recent contacts of TB case patients Persons with fibrotic changes on chest radiograph consistent with prior TB Patients with organ transplants and other immunosuppressed patients Induration of 10 mm is considered positive in: Recent immigrants (i.e., within the last 5 years) from high-prevalence countries Injection drug users Residents and employees of the following high-risk congregate settings: prisons and jails, nursing homes and other long-term facilities for the elderly, hospitals and other health care facilities, residential facilities for patients with acquired immunodeficiency syndrome (AIDS), and homeless shelters Mycobacteriology laboratory personnel Persons with the following clinical conditions that place them at high risk: silicosis, diabetes mellitus, chronic renal failure, some hematologic disorders (e.g., leukemias and lymphomas), other specific malignancies (e.g., carcinoma of the head, neck, or lung),weight loss of 10% of ideal body weight, gastrectomy, and jejunoileal bypass Children < 4 years of age, or infants, children and adolescents exposed to adults at high-risk Induration of 15 mm is considered positive in: Persons with no known risk factors for TB
INVESTIGATIONS Mantoux Tuberculin Skin Test: - 0.1ml of tuberculin (1:1000 strength PPD or equivalent to 10 tuberculin units) is injected intrademally using a single-dose disposable tuberculin syringe that has a one-quarter to one-half inch, 27-gauge needle with a short bevel. Placement - The injection should be placed on the palm-side-up surface of the forearm, about 2 to 4 inches below the elbow. - The tuberculin skin test must be read within 48 to 72 hours. - The maximum diameter of the induration, not erythema is measured.
*Redness by itself is not considered part of the reaction.
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Negative skin test: This means the persons body did not react to the test, and that latent TB infection or TB disease is not likely. TB blood tests: TB blood tests (also called interferongamma release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB. DIAGNOSIS A diagnosis of Pulmonary TB is made after the suspected patient has had the following: Medical history clues to possible exposure, risks, symptoms Physical examination, Test for TB infection (TB skin test or TB blood test), Chest X-ray, Appropriate laboratory tests TREATMENT TB disease is treated by taking several drugs as recommended by a health care provider. In latent TB Infection a person does not have TB disease, but has TB bacteria in the body. The decision about treatment for latent TB infection is based on a persons chances of developing TB disease. The first-line anti-TB agents that form the core of treatment regimens include: isoniazid (INH), rifampin (RIF), ethambutol (EMB), pyrazinamide (PZA). References: Center for Disease Control (2012) CDC/Tuberculosis retrieved from www.cdc.gov
GUIDELINES FOR MMR AND MANTOUX ADMINISTRATION

When both of the above need to be administered the following guidelines should be adhered to:
MMR and Mantoux if needed should be given together or within 24hours. If MMR is given first the client must wait 4 weeks before Mantoux is placed. If Mantoux is placed first wait until after results are read then give MMR.
NB: IF MANTOUX IS POSITIVE DO NOT GIVE MMR. HOLD UNTIL AFTER CLIENT IS SEEN BY INFECTIOUS DISEASE UNIT. IF MANTOUX IS PLACED AND NOT READ IT CAN BE REPEATED IN TWO WEEKS.
YELLOW FEVER
DESCRIPTION Yellow fever virus is found in tropical and subtropical areas in South America and Africa and causes an acute febrile illness. SYMPTOMS Fever, headache, chills, malaise, nausea, vomiting, generalized body aches Complications After a brief remission of hours to a day, approximately 15% of cases progress to develop a more severe form of the disease characterized by high fever, jaundice (yellowing of skin and eyes), bleeding, and eventually shock and multiple organ failure.
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TRANSMISSION Yellow fever virus is transmitted through the bite of an infected mosquito. There is no person to person transmission. In persons who develop symptoms, the incubation period (time from infection until illness) is generally 36 days. Treatment is symptomatic. Rest, fluids, and use of pain relievers and medication to reduce fever may relieve symptoms of aching and fever.
Re-immunization every ten- (10) years is recommended for those at risk.
The number and size of doses A single dose of 0.5 ml correctly given confers immunity in nearly 100% of recipients. Immunity persists for at least ten years or, sometimes, for life. Where and how it is given The vaccine should be given by deep subcutaneous injection in the upper arm. Contraindications
Persons with HIV/AIDS should not be given the Yellow Fever vaccine. Persons suffering from acute or febrile illness Patients receiving high dose corticosteroids, or immuno-suppressive treatment, including radiation Patients suffering from malignant conditions, example, lymphoma, leukemia, et cetera. Persons known to be hypersensitive to neomycin or polymyxin.
YELLOW FEVER VACCINE What it is? Yellow fever vaccine is a live attenuated, freeze-dried preparation of 17D-204 strain of yellow fever virus. It is propagated in leucosis-free chick embryos and contains no more than 2 iu of neomycin and 5 iu of polymyxin per dose.
It comes in powder form and must be reconstituted with its dilutent before use. The vaccine, when reconstituted with the cold dilutent, should be used within six hours. How it is stored? Yellow fever vaccine and diluent should be stored at temperature between 20 C and +80 C and protected from light. Reconstituted Yellow Fever vaccine is easily damaged by heat. When it is given? It is administered to travelers requiring an International Certificate of Vaccination for entry into or arriving from an infected country. The vaccine is only given at designated centres and should be given at least ten days prior to travel. Yellow Fever vaccine can be given to children twelve (12) months and over. It should not be given to children aged less than six (6) months.
Adverse Reactions Five to ten percent of recipients have mild headaches, myalgia, low-grade fever or soreness at the injection site 5-10 days after immunization. Immediate allergic-type reactions such as urticaria and rarely anaphylaxis have also been reported.
Severe reaction should be reported promptly to the Ministry of Health through the Medical Officer responsible for the EPI Programme.
DIPHTHERIA
WHAT IS DIPHTHERIA? Diphtheria is caused by the bacteria - Corynebacterium diphtheriae of gravis, mitis or intermedius biotype. Toxin production results when the bacteria are infected by corynebacteriophage containing the diphtheria toxin
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gene tox. The toxin produce can harm or destroy the human body tissue and organs. One type of the disease affects the pharynx and other parts of the throat. It tends to be a disease of the colder months and of temperate climatic zones. Diphtheria affects people of all ages, but mostly non-immunized children less than 15 years of age. HOW IS DIPHTHERIA SPREAD Man is the known reservoir. The type of diphtheria that affects the pharynx and other parts of the throat are spread in droplets and secretions from the nose, throat and eyes when there is close contact between infected and uninfected persons. The other type is spread with contact with skin ulcers. This form of the disease is often spread where clothing and other articles have been contaminated with fluids from the skin ulcers. During outbreaks/epidemics some children may be infected without showing signs or symptoms but can still spread the disease to others. The disease is more easily spread when there is overcrowding and poor living conditions. Infected individuals can usually spread the disease to others for up to 4 weeks and rarely up to 6 months. Effective antibiotic therapy promptly terminates shedding. The rare chronic carrier may shed organisms for 6 months or more. Infants born of immune mothers are relatively immune. Protection is passive and usually lost before the sixth month. Recovery from a clinical attack is not always followed by lasting immunity; immunity is often acquired through inapparent infection. Prolonged active immunity can be induced by injection with the toxoid. Antitoxin immunity protects against systemic disease but not against local infection in the nasopharynx.
WHAT ARE THE SIGNS AND SYMPTOMS?

The incubation period is usually 2 5 days, occasionally longer. Infected persons usually become ill within 2-4 days although the symptoms may appear after 6 days. When diphtheria affects the throat and tonsils, the early symptoms are sore throat, loss of appetite and slight fever. Within two to three days a bluish-white or grey membrane forms in the throat and tonsils. If there is bleeding the membrane may become greyish-green or black. It sticks to the soft palate of the throat, and bleeding may occur if attempts are made to remove it. The patient may recover at this point or may develop severe weakness and die within six to ten days. Patients with severe disease do not show high fever but may develop swelling of the neck and obstruction of the airway. In the type of diphtheria affecting the skin, the lesions may be painful, reddened and swollen. Any chronic skin lesions may become infected with diphtheria organisms.
WHAT ARE THE COMPLICATIONS?

Abnormal heart beats may occur during the early phase of the illness or weeks later, and heart failure may result. There may be inflammation of the heart muscle and valves, leading after many years to chronic heart disease and heart failure. Death occurs in 5-10% of cases.
HOW IS DIPHTHERIA TREATED?

Persons in whom diphtheria is suspected should be given diphtheria antitoxin and antibiotics such as erythromycin or penicillin, and should be isolated to avoid exposing others to the germs. Throat cultures should be obtained in order to secure correct
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diagnosis. Patients become non-infectious about two days after the commencement of antibiotic treatment. Effective antibiotic therapy promptly terminates shredding.
How it is stored? DTP is a liquid vaccine and should never be frozen. If DPT stands for a long time it separates from the liquid and looks like fine sand at the bottom at the vial. Shaking the vial mixes the vaccine. DTP vaccine should be stored at a temperature between +2 degrees Celsius and +8 degrees Celsius. The diphtheria and tetanus toxoid parts of DPT vaccine are destroyed by freezing. Pertussis vaccine is destroyed by heat. To Check if DPT vaccine has been frozen, shake the vial. If granules appear a short time afterwards the vaccine has been spoiled and you must dispose of it.
HOW IS DIPHTHERIA PREVENTED?

The most effective way of preventing diphtheria is to maintain a high level of immunization in the community. A mother can pass protective antibodies to her baby but this protection lasts only about six months. In most countries, diphtheria toxoid vaccine is given together with pertussis vaccine and tetanus toxoid. A combination of tetanus and diphtheria vaccine may be recommended as a booster to maintain protection every ten years.
When it is given
DPT can be given starting at the age of 6-8weeks. The following schedule can be used: 8 weeks 16 weeks 24 weeks
DIPHTHERIA VACCINE
Diphtheria causes disease by making a toxin that is released by the bacteria. Protection against diphtheria depends upon manufacturing antibodies to this toxin. The diphtheria vaccine is made by taking the toxin, purifying it, and inactivating it with chemical preservatives. An inactivated toxin is called a toxoid. Toxoids cause immunity without causing disease. Singe antigen diphtheria toxoid is not available. Diphtheria toxoid is available combined with tetanus toxoid as adult tetanus-diphtheria (Td); and with both tetanus toxoid and acellular pertussis vaccine as DTap and Tdap. Diphtheria toxoid is also available as combined DTaP-HepB-IPV(Pediarix) and DTapIPV/Hib (Pentacel). Pediatric formulations (DT and DTaP) contain a similar amount of tetanus toxoid as adult Td, but contain 3 to 4 times as much diphtheria toxoid.
The interval after the first and second doses must be at least four weeks.Children younger than 7 years of age should receive either DTaP or pediatric DT. DPT should NOT be given to children over 7 years of age (that is the pertussis component) or to children who have suffered a severe reaction to a previous dose of this vaccine. Instead, a combination of diphtheria and tetanus toxoid (Paediatric DT) should be given. Children over 7 years of age should receive the adult formulation (adult Td), even if they have not completed a series of DTaP or pediatric DT. DTaP and Tdap vaccines do not contain thimersol as a preservative. The number and size of doses Three doses are given each of 0.5 ml for primary immunization.
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Where and how it is given DPT is injected into the muscle in the anterior lateral part of the thigh of the infant and the deltoid muscle of the older child. Contraindications DPT immunization should be postponed if there is an acute or febrile illness. A history of a severe local or general reaction to a preceding dose; immunization should be completed with DT vaccine. When pertussis vaccine is genuinely contraindicated, immunization against diphtheria and tetanus should be considered. Adverse Reactions
A child may have fever the evening after receiving DPT vaccine. The fever should disappear with a day. Fever that begins more than 24 hours after a DPT injection is unlikely to be a reaction to the vaccine. Some children have pain, redness or swelling at the injection site. A painless nodule may form at the injection site; this usually disappears and is of no consequence. An abscess may develop a week or more after a DPT injection. This can happen because: an unsterile needle or syringe was used or additionally if the vaccine was not injected into the muscle. Crying, screaming and fever may develop in some children but can usually be controlled by an aspirin-free antipyretic.
Pertussis is a serious communicable disease caused by Bordetella pertussis. The greatest incidence of complications and highest mortality occur in infants. The younger the infant the more serious the complications. These include pneumonia, encephalitis, severe nutritional disturbances and death. Pertussis or Pertussis-like cases are still being reported in some of the Caribbean islands. Bordetella Parapertussis bacteria can cause a similar illness as Bordetalla Pertussis. HOW IS PERTUSSIS SPREAD? Humans are considered to be the only host. Pertussis spreads very easily from person to person in droplets produced by coughing or sneezing. Most persons exposed to the germs become infected. The disease is most readily transmitted from seven days after a person has been exposed to the germs until three weeks after the start of coughing. The incubation period varies between 6 to 21 days. WHAT ARE THE SIGNS AND SYMPTOMS? There are usually three stages of the illness. Initially a child appears to have a common cold, with runny nose, watery eyes, sneezing, fever and a mild cough. The cough gradually worsens and the second stage involves numerous burst of rapid coughing. At the end of these bursts the child takes in air with a highpitched whoop. The child may turn blue because of a lack of oxygen during a long burst of coughing. Vomiting and exhaustion often follow the coughing attacks, which are particularly frequent at night. This stage usually lasts one to six weeks but may go on for up to ten weeks. The attacks become milder with the passage of time. In the third stage, when recovery
PERTUSSIS (Whooping Cough) WHAT IS PERTUSSIS? Pertussis, or whooping cough, is a disease of the respiratory tract caused by a bacteria called Bordetella pertussis which lives in the mouth, nose and throat. Many children with pertussis have coughing spells lasting four to eight weeks. The disease is common in children less than 1 year of age.
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takes place, the coughing gradually becomes less intense and stops in two to three weeks. A high fever during the illness does not usually occur. WHAT ARE THE COMPLICATIONS? Complications are most probable in young infants. The commonest cause of most deaths is bacterial pneumonia. Convulsions and seizures may occur, but these complications may arise because of the reduced oxygen supply to the brain during coughing attacks or because of the toxins released by the pertussis germs. Less serious complications include loss of appetite, inflammation of the middle ear, and dehydration. WHAT IS THE TREATMENT FOR PERTUSSIS? Treatment with an antibiotic, usually erythromycin, may make the illness less severe. The use of antibiotics also reduces the ability of the patient to infect others because the antibiotic kills the bacteria in the nose and throat. Plenty of fluids should be given to prevent dehydration. Sometimes people in the same household as the patient are given antibiotics to reduce the probability of infection. HOW IS PERTUSSIS PREVENTED? Prevention involves immunization with pertussis vaccine, which is usually given in combination with diphtheria and tetanus vaccines. Newborns and infants are not protected against pertussis by maternal antibodies. A person infected with pertussis usually acquires lifelong immunity. PERTUSSIS VACCINE Pertussis is caused by a protein (called a toxin)
released by the bacteria as well as proteins that are part of the bacteria. Protection against pertussis depends in part upon making antibodies to the toxin as well as to these other bacterial proteins. The old pertussis vaccine called whole cell vaccine was made by taking the pertussis bacteria and growing them in broth. The new pertussis vaccine called acellular pertussis or aP, vaccine is made by purifying both the toxin and individual bacterial proteins. The whole bacteria or whole cell is not present. That is why this pertussis vaccine is called acellular. Acellular pertussis vaccines contain purified, inactivated components of B. pertussis cells. The new, purer form of pertussis vaccine is in the formulation called Tdap or DTaP. Acellular pertussis vaccines are available only as combinations with tetanus and diphtheria toxoids.
TETANUS
WHAT IS TETANUS? Tetanus is an acute and often fatal disease caused by Clostridium tetani an organism which produces a very potent meurotoxin. The toxin they produce poisons the nerves that control the muscles which cause stiffness. In tetanus or lockjaw the muscles of the affected person all contract, making the body stiff. The disease is particularly common and serious in newborn babies. When it occurs in newborn babies (neonatal period), it is called neonatal tetanus. The tetanus bacteria, Clostridium tetani, are found throughout the environment. It grows in dead tissue, for instance in a wound or in a babys umbilical cord. The germ is common in the environment, often occurring in soil containing manure. The bacteria form spores that can survive in the environment for years.
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Wounds with devitalised tissue or deep puncture wounds are at greatest risk of becoming infected with the bacteria. People of all ages can have tetanus. Neonatal tetanus kills between 500,000 and 1 million babies worldwide every year. Almost all babies who have the disease die. Tetanus is still a cause of death in adults in the Caribbean islands. HOW IS TETANUS SPREAD? Tetanus is not transmitted from person to person. A person may become infected if soil or dung enters a wound or cut. This may happen, for example, if a wound is made with a dirty tool. Tetanus germs are likely to grow in deep puncture wounds caused by dirty nails, needles, barbed wire, thorns, wood splinters and animal bites. A newborn baby may become infected if the knife, razor or other instrument used to cut the umbilical cord is dirty. Infection may also occur if cow dung or ash is used to dress the cord, or if soil enters the babys navel. If the hands of the person delivering are not clean the baby may become infected. Infants and children may also contract tetanus when dirty instruments are used for circumcision, scarification and skin piercing, and when dirt, charcoal or other unclean substances are rubbed into a wound. WHAT ARE THE SIGNS AND SYMPTOMS? In newborn babies the symptoms usually appear 4-14 days after birth. The incubation period is usually between three and ten days but may be as long as three weeks. The shorter the incubation period, the higher is the risk of death.
Muscular stiffness in the jaw is a common first sign. This is followed by stiffness of the neck, difficulty in swallowing, stiffness of the stomach muscles, muscle spasms, sweating and fever. Newborn babies with tetanus appear normal at birth but stop sucking three to ten days later. At 5-13 days they are still not breast-feeding, the whole body becomes stiff, severe muscle contractions and convulsions occur, and death follows in most cases. WHAT ARE THE COMPLICATIONS? Fractures of the spine or other bones may occur as a result of muscle spasms and convulsions. Abnormal heartbeat, coma, pneumonia and other infections may also occur. Death is particularly likely in the very young and old age groups. WHAT IS THE TREATMENT FOR TETANUS? Wounds should be thoroughly cleaned and dead tissue should be removed. For persons with wounds that are neither clean nor minor and who are not fully protected against tetanus, tetanus immune globulin should be given. Antibiotics may also be used. Persons who recover from tetanus do not have natural immunity. HOW IS TETANUS PREVENTED? The prevention of neonatal tetanus requires women of childbearing age to receive tetanus toxoid containing vaccine. This results in the protection of mothers and tetanus antibodies being transferred from women to their fetuses. Infants are thus protected against the disease at birth. Clean practices during delivery and clean wound care are also very important in preventing tetanus.
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TETANUS NEONATORUM Tetanus neonatorum is a serious health problem in many developing countries where maternity care services are limited and immunization against tetanus is inadequate. In the last 5 years the incidence rates due to tetanus neonatorum declined considerably in many developing countries due to immunization of women of childbearing age with tetanus toxoid. However, in spite of this decline, WHO estimates that more than 500,000 deaths due to tetanus neonatorum still occur annually in the developing world. Most newborn infants with tetanus have been delivered outside a hospital to nonimmunized mothers delivered by a traditional birth attendant. The disease usually occurs through introduction via the umbilical cord of tetanus spores during delivery by cutting the cord with an unclean instrument, or after delivery by dressing the umbilical stump with substances heavily contaminated with tetanus spores, frequently as part of natal rituals. In neonates, inability to nurse is the most common presenting sign. Tetanus neonatorum is typified by a newborn infant who sucks and cries well for the first few days after birth and subsequently develops progressive difficulty and then inability to feed because of trismus, generalized stiffness with spasms or convulsions and opisthotonus. The average incubation period is about 6 days, with a range from 3 to 28 days. Overall, neonatal tetanus case-fatality rates are very high; among cases with short incubation periods, these exceed 80%. Prevention of tetanus neonatorum can be achieved by a combination of two approaches: by improving maternity care with emphasis on increasing the
immunization coverage of women of childbearing age (especially pregnant women) with tetanus toxoid, and on increasing the proportion deliveries attended by trained attendants. Important control measures include licensing of midwives; providing professional supervision and education as to methods, equipment and techniques of asepsis in childbirth; and educating mothers, relatives and attendants in the practice of strict asepsis of the umbilical stump of newborn infants. The latter is especially important in any lesser-developed areas where strips of bamboo are used to sever the umbilical cord and where ashes, cow dung poultices or other contaminated substances are traditionally applied to the umbilicus. In those areas, any woman of childbearing age visiting a health facility should be screened and offered immunization, no matter what the reason for the visit. Non-immunized women, in circumstances where risk of neonatal tetanus exists, should receive at least 2 doses of tetanus toxoid according to the following schedule:
The first at first contact or as early as possible during pregnancy The second 4 weeks after the first and preferably at least 2 weeks before delivery. A third dose could be given 6-12 months after the second, or during her next pregnancy. An additional 2 doses could be given at least at annual intervals when the mother is in contact with the health service or during her subsequent pregnancies.
This total of 5 doses would protect her through her entire childbearing period.
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Shake Test
TETANUS VACCINE Like diphtheria, tetanus causes disease by making a toxin that is released by the bacteria. Protection against tetanus depends upon producing antibodies to this toxin. This immunogen is made by taking the toxin, purifying it, and inactivating it with chemical preservatives. Tetanus toxoid is available as a single-antigen preparation, combined with diphtheria toxoid as pediatric diphtheriatetanus toxoid (DT) or adult tetanus-diphtheria (Td), and with both diphtheria toxoid and acellular pertussis vaccine as DTaP or Tdap.A combination of DPT/Hib/ Hepatitis B is also available. Tetanus toxoid (TT) is given to women of childbearing age to prevent neonatal tetanus. It is the same tetanus toxoid as that given to children in DPT vaccine. However, TT is now being replaced by DT Adult vaccine (TT/Td) plus low dose Diphtheria Toxoid. How it is stored Tetanus toxoid should be stored at a temperature between +2 degrees and +8 degrees Celsius. It should never be frozen. When it is given To reduce the risk of neonatal tetanus, tetanus containing vaccine is recommended for all women of childbearing age. Td has replaced TT. Recommended schedule for Pregnant Women
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The number and size of doses For primary immunization, the course consists of three doses of 0.5 ml of absorbed tetanus containing vaccine (TT or DT) by intramuscular or deep subcutaneous injection into the deltoid muscle of the upper arm. If there is no record of diphtheria immunization either, then three doses of Td vaccine should be given. A reinforcing dose (TT or DT Adult) ten years after the primary course. Contraindications Acute or febrile illness. Adverse Reactions
After an injection a women may have mild pain, redness, warmth and swelling for one to three days at the injection site. Persistent nodules at the injection site may arise if the injection is not given deep enough. This reaction may be more common after later doses than earlier ones. General reactions, which are uncommon, include headache, lethargy, malaise, myalgia and pyrexia. Acute anaphylactic reactions and urticaria may occasionally occur and, rarely, peripheral neuropathy.
Hepatitis B Virus is one of several viruses that cause hepatitis. HbsAg has been found in virtually all body secretions and excretions; however, only blood (and serum-derived fluids), saliva, semen and vaginal fluids have been shown to be infectious. The presence of e antigen or viral DNA indicates high virus titer and higher infectivity of these fluids. The virus is present in the blood of persons suffering from the disease and in chronic carriers. Infection is usually associated with exposure to body fluids, blood and blood products. The disease occurs all over the world and can affect all age groups. Most chronic carriers are in China, SouthEast Asia, and Africa. HOW IS HEPATITIS B SPREAD? The incubation period averages six weeks but may be as long as six months. The variation is related in part to the amount of virus in the inoculum, the mode of transmission and host factors. Transmission occurs by percutaneous (IV, IM, SC or intradermal) and permucosal exposure to infective body fluids. Percutaneous exposures that have resulted in HBV transmission include transfusion of blood or blood products, sharing needles during injecting drug use, hemodialysis, acupuncture, tattooing and needlesticks or other injuries from sharp instruments sustained by hospital personnel. IG, heat-treated plasma protein fraction, albumin and fibrinolysin are considered safe. Sexual and perinatal HBV transmission usually results from mucous membrane exposures to infectious blood and body fluids. Because HBV is stable on environmental surfaces for more than 7 days, indirect inoculation of HBV can also occur via inanimate objects.
VIRAL HEPATITIS B
WHAT IS HEPATITIS B?
The disease, caused by the hepatitis B virus, affects the liver. People usually recover, but some continue to carry the virus for many years and can spread the infection to others throughout the time that they are chronic carriers. It is estimated that there are about 350 million carriers worldwide of hepatitis B virus.
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Perinatal transmission is common in hyperendemic areas of Southeast Asia and the Far East, especially when HbsAg carrier mothers are also HbeAg e antigen positive. Infection may also be transmitted between household contacts and between sexual partners, either homosexual or heterosexual, and in toddleraged children in groups with high HbsAg carrier rates. Communally used razors and toothbrushes have been implicated as occasional vehicles of HBV transmission causing percutaneous and mucosal inoculation. Fecal-oral or vectorborne transmission has not been demonstrated. In about 35% of cases, no transmission source can be identified. The hepatitis B virus is carried in the blood, saliva, semen, vaginal fluids and most other body fluids. However, it is usually spread by contact with blood in the following ways:
Injection with unsterilized needles or syringes containing hepatitis B virus from an infected person, for instance another patient or a needle-user. Transmission of hepatitis B virus by mothers to their babies during the birth process, when contact with blood always occurs. Transmission between children during social contact through cuts, scrapes and scratches. Transmission during sexual intercourse through contact with blood or other body fluids.
volunteers has been shown to be infective many weeks before the onset of first symptoms and to remain infective through the acute clinical course of the disease. Following acute HBV infection, the risk of developing chronic infection varies inversely with age; chronic HBV infection occurs among about 90% of infants infected at birth, 25%-50% of children infected at 1-5 years of age and about 1%10% of persons infected as older children and adults. Chronic HBV infection is also common in persons with immunodeficiency. The infectivity of chronically infected individuals varies from highly infectious (HbeAg positive) to sparingly infectious (anti-Hbe positive). WHAT ARE THE SIGNS AND SYMPTOMS? Usually, the disease is milder and often anicteric in children, and in infants it is usually asymptomatic. Protective immunity follows infection if antibody to HbsAg (anti-HBs) develops and HbsAg is negative. Persons with Down syndrome, lymphoproliferative disease, HIV infection and those on hemodialysis appear to be more likely to develop chronic infection. The younger a person is when infected, the more likely it is that he or she will not show signs or symptoms. A person with no symptoms may remain infected for many years and can spread the infection to others. Such a person is more likely than one showing symptom, to suffer complications caused by liver damage in the long term. Infected persons may feel weak and may experience stomach upsets and other influenza-like symptoms. They may also have very dark urine or very pale stools.
The virus does not occur in the stool of an infected person, unless the stool contains blood. It does occur in the milk of infected mothers but in such small amounts that nursing can proceed. All persons who are HbsAg positive are potentially infectious. Blood from experimentally inoculated
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Jaundice may appear as yellow skin or a yellow colour in the whites of the eyes. The symptoms may last several weeks. General weakness and fatigue may continue for months. A laboratory blood test is required to determine with certainty whether a person has hepatitis B virus or disease. Most acute infections in adults are followed by completed recovery, and the affected persons rarely become chronic carriers. However, many children, even though they are not acutely ill, as a rule, do become chronic carriers, and many develop severe complications. WHAT ARE THE COMPLICATIONS? Infected persons who recover and do not become carriers possess antibodies and are protected throughout their lives. The consequences of acute infection can be severe. Death occurs in a small percentage of adults. Most serious complications, including chronic hepatitis, cirrhosis, liver failure and liver cancer, occur in persons with chronic infection. WHAT IS THE TREATMENT FOR HEPATITIS B? There is no treatment for the acute condition. In chronic infection the disease process can sometimes be stopped by certain medications. HOW IS HEPATITIS B PREVENTED? Safe and effective hepatitis B vaccine is available. It is recommended that children receive three doses during the first year of life. The first dose should
be administered either at birth or at about six to eight weeks of age on the occasion of the first clinic visit, and the third at 24 weeks. If possible all pregnant women should be tested to determine whether they carry the virus in their blood. Babies of mothers who are carriers should then receive an injection of hepatitis B antibodies (hepatitis B immune globulin) together with the first dose of vaccine at birth. In some countries the hepatitis B vaccine is offered to or recommended for adolescents and young adults, since the virus is sexually transmitted and is also easily spread through needle-sharing. Persons with hepatitis B virus should not donate blood and should not allow other persons to come into contact with their blood or other body fluids. They should use barrier methods when having sexual intercourse and should not share eating utensils, toothbrushes, needles or razors with other people. Health care workers should be vaccinated against the disease and use all necessary precautions with all patients because patients who are carriers of the virus can spread the infection to them quite easily through blood contact.
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HEPATITIS B VACCINE Hepatitis B vaccine is available in two types a recombinant inactivated viral antigen vaccine and also plasma-derived Hepatitis B vaccine. Therefore the HepB vaccine which contains only one antigen, is called a monovalent vaccine. Recombinant HepB vaccine is available in combination DTP_HepB and DTP-HepB+Hib vaccines.
How it is stored Hepatitis B vaccine is a cloudy liquid that comes in single or multi dose vial or a prefilled auto-disable syringe. If Hep B vaccine stands for a long time is separates from the liquid and looks like fine sand at the bottom of the vial. It must be mixed by shaking. It should be stored at +2 degrees Celsius to +8 degrees Celsius but not frozen. Freezing and heat destroys the potency of the vaccine. Use the shake test to find if it has been frozen. When it is given Only monovalent HepB vaccines should be used as a birth dose, the dose given within the first week of life. Combination vaccines should not be used at birth, but may be used in subsequent doses. Preterm infants born to HBsAg-positive women and women with unknown HBsAg status must receive immunoprophylaxis with hepatitis B vaccine 0.5mi and hepatitis B immunoglobin 0.5ml (HBIG) within 12 hours if birth. Subsequently doses of the vaccine should be given as recommended. For infants <2kgs at birth, the initial dose of vaccine should be counted as part if the 3 dose schedule. Infants should be retested for HBs antibodies and HBs antigen 1-3 months after completion of the vaccination series. Infants who do not produce adequate antibodies and are HBs antigennegative should receive an additional dose of vaccine.
The common schedule is:

1st dose at 8weeks 2nd dose at 16 weeks 3rd dose at 24 weeks
Routine vaccination is recommended for those at high risk of infection such as health workers and hospital staff. The number and size of doses Three doses are given each of 0.5 ml for children birth to 10 years of age and 1.0 ml in adults. In adults and children, the first two doses are given 1 month apart and the 3rd dose six months after the first dose (0,1,6 months). Where and how is it given Hepatitis should be given intramuscularly in the antero-lateral thigh for infants and in the deltoid region for older children and adults. The buttock MUST not be used because vaccine efficacy may be reduced (erratic absorption in subcutaneous tissue) and so protection cannot be guaranteed. If DPT vaccine is given at the same time as hepatitis B vaccine and it is not a combination vaccine, do not inject both in the same thigh. Contraindications
Immunization should be postponed in individuals suffering from severe febrile infections. Hypersensitivity to yeast is a contraindication since Hepatitis B vaccine is developed in bakers yeast. Anaphylactic reaction to a previous dose contraindicates further immunization with that vaccine.
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Adverse Reactions
A child may develop a mild fever for one or two days after an injection of hepatitis B vaccine. Adverse reactions are generally well tolerated and the most common adverse reactions are soreness and redness at the injection site. Other reactions that have been reported include fever, rash and malaise. An influenza-like syndrome, arthritis/arthralgia, myalgia and abnormal liver function tests may occur.
Complications Complications are rare and include death(3-6 persons per 1000 ), chronic liver disease, fulminant hepatitis and liver failure. Diagnosis Check IgG and IgM antibody titers to hepatitis A. However commercial assay may not readily available for testing. Treatment Treatment is symptomatic with extra fluids, and analgesics. For post exposure treatment ,hepatitis A immune globulin can be given within two weeks of exposure especially to persons with weakened immune system, with chronic liver problems like cirrhosis or children under the age of 1 year old. Primary Prevention
Always wash hands with soap and water frequently especially after using the toilet or after handling body fluids or waste products such such as feaces or after handling raw foods and vegetables and fruits. Sewage and other waste products must be properly and strictly eliminated. Under cooked and raw foods especially seafood and shellfish should not be eaten. Vegetables and fruits should be wash with safe water, peeled or cooked before eaten. Textile furnitures and counter tops, toys etc should be washed with household bleach water. Food and water should be cooked to at least 185 degrees farenheit. Do not drink or use untreated water or use untreated ice If there is uncertainty about water then boil water to 185 degrees farenheit before use.
HEPATITIS A
This is a viral infection that causes inflammation of the liver. Is a single stranded RNA virus from the picornovirus family. Most of the time it is a self limiting infection but rarely can cause chronic disease. About eighty five percent of persons will recover in three months. Transmission This virus is transmitted by fecal-oral route , through sexual contact or transfusion of blood products. The transmission is mainly person to person. Symptoms The incubation period is two to seven weeks. An individual may remain contagious for months. Persons may experience nausea, vomiting weight loss,abdominal pain , fatigue, fever, sore muscles, jaundice ( yellow eyes and skin ),& dark urine and pale stools.
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Secondary Prevention There are several types of hepatitis A vaccine including monovalent and combined valent vaccines. Below is a list of monovalent vaccines. Havrix, Avaxim, Vaqta
Two doses of the vaccine is to be given . The second dose is given six to twelve months after the first. It is given intramuscularly. The vaccine can be given at the same time as other vaccines but at different sites. This vaccine should be stored between t2 degrees celsius and t8 degrees. Never freeze. It can be given to children over the age of one years. It should be given to persons working in research laboratory where hepatitis A is housed. It can be given to persons working with sewage. It can be given to persons traveling to endemic areas such as Asia, Central and South America, Africa and Eastern Europe. If the vaccine is given to a person a few days post exposure it can still elicit an adequate immune response. The vaccine begin to protect two to four weeks after receiving the first dose and immunity may last for twenty years, at which time a booster is required.
HEPATITIS A VACCINE
What it is Two inactivated whole virus Hepatitis A vaccines are available. Both vaccines are available in both paediatric and adult formulations. The vaccine is currently not given to children less than 2 years of age. The inactivated Hepatitis A vaccines induce HAV antibodies (anti-HAV) at titres many fold greater than that provided by the recommended dose of normal human immunoglobulin. Although the vaccines are highly immunogenic, the titres are usually below the detection limits of the routinely available commercial tests for anti-HAV. Therefore, testing to assess immunity following vaccination against Hepatitis A is neither necessary nor appropriate. The inactivated Hepatitis A vaccines are also highly immunogenic in children; >95% of children and adolescents have protective levels of anti-HAV one month after the administration of either the 720 ELISA U HM175 strain or the 25 U CR326F strain. A clinical trial in the United States in the early 1990s determined that the 25 U CR326F strain vaccine, administered to seronegative children 2-16 years of age, had a protective efficacy of 100% after a single dose. A very large clinical trial conducted in Thailand, again in the early 1990s determined that three doses of the 360 ELISA U HM175 strain vaccine, administered to children 1-16 years of age in a 0, 1 and 12 months schedule, had a protective efficacy of 95%. The protective efficacy after the first two doses (0, 1 month) was 94%; following the third dose 12 months later the efficacy was 100%.
Contraindications Any anaphylactic reaction or severe allergic reaction to this vaccine or its components. Not to be given to persons under one years of age. Adverse Effects This is not a live vaccine and there are only minor side effects. There may be transient reddnes and soreness at the site. Others include fever ,nausea and vomiting and headache. Please report any adverse event to EPI department at the Ministry of Health.
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How it is stored Hepatitis A vaccine should be stored in the refrigerator at 20 C to +80C but not frozen. Do not freeze or store the vaccine in direct contact with ice packs. The vaccine should be transported in an insulated container and the temperature monitored. When it is given / Number and size of doses Two inactivated types of Hepatitis A vaccines are available - the Havrix and the VAQTA . These two vaccines are available in two formulations, paediatric and adult. Havrix Vaccine Children and Adolescents For children 2-18 years of age, the 360 ELISA units (EL.U.) per dose vaccine is used and, the schedule is 2 doses separated by one month, followed by a booster dose 6-12 months after the second dose. For the 720 EL.U. vaccine, a single primary dose is recommended, followed by a booster dose 6-12 months later. Adults For adults greater than 18 years of age, the 1440 EL.U. per dose vaccine is used. Adults receive one dose followed by a booster 6-12 months later. The vaccine should be administered intramuscularly into the deltoid muscle. A needle length appropriate for the vaccinees age and size should be used.
Recommended doses of Havrix Hepatitis A vaccine

Group
Children and Adolescents Adults VAQTA Vaccine Children and Adolescents Children 2-17 years of age should receive one dose of paediatric formulation (25 U per dose) with a booster dose 6-12 months later. Adults Adults greater than 17 years of age, should receive one dose (50 U per dose) followed by a booster dose 6-12 months later. The vaccine should be administered intramuscularly into the deltoid muscle. A needle length appropriate for the vaccinees age and size should be used.
Age
2-18 yrs >18 yrs
Dose (U)
720 1,440
Volume
0.5 mL 1.0 mL
No. doses
2 2
Schedule
0, 6-12 0, 6-12
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Recommended doses of VAQTA Hepatitis A vaccine

Group
Children and Adolescents Adults
Age
2-17 yrs >17 yrs 25 50
Dose (U)
Volume
0.5 mL 1.0 mL
No. doses
2 2
Schedule
0, 6-12 0, 6-12
It is not yet known whether the vaccines from different manufacturers can be interchanged. Completion of the vaccination schedule with the same product is preferable. Where and how it is given The vaccine should not be diluted or mixed with other vaccines. Shake the vial vigorously before withdrawing dose and inject vaccine as soon as possible. The vaccine assumes a slightly opaque appearance once in suspension. The dose is 1 mL for adults and 0.5 mL for children from 2 years up to either 15 or 17-18 years given by deep intramuscular injection. Hepatitis A vaccine should be given intramuscularly in the deltoid region. Contraindications
Immunization should be postponed in individuals suffering from severe febrile infections. Anaphylactic reaction to a previous dose contraindicates further immunization with that vaccine Hypersensitivity to the vaccine components.
No special precautions are needed when vaccinating immuno-compromised individuals because it is an inactivated vaccine. Post-Exposure Prophylaxis Hepatitis A vaccine is not recommended for postexposure prophylaxis. Because Hepatitis A has a relatively long incubation period, the vaccine may not prevent the disease in individuals who have an unrecognized Hepatitis A infection at the time of vaccination. Immunoglobulin is used for passive temporary protection against Hepatitis A. When administered within 2 weeks following exposure to Hepatitis A, immunoglobulin (IG) is >85% effective in preventing Hepatitis A. Adverse Reactions
Adverse reactions are generally well tolerated and the most common adverse reactions are soreness and redness at the injection site. Mild systemic signs/symptoms may develop such as fever, malaise, fatigue after an injection of Hepatitis A vaccine. These may occur in 10% of vaccinees. Headache and malaise is more frequently reported by adults than children.
The safety of Hepatitis A vaccination during pregnancy has not been determined. However, it is an inactivated vaccine, therefore the theoretical risk to the foetus is extremely low.
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Serious reactions following Hepatitis A immunization should be reported promptly to the Ministry of Health through the Medical Officer in charge of the EPI Programme.
Contact with discharges from the conjunctivae or upper respiratory tracts of infected people, from contaminated fingers, clothing and other articles may spread the organism. WHAT ARE THE SIGNS AND SYMPTOMS? The incubation period may be as short as 27 to 72 hours. Children less than 5 years of age are most often affected and the incidence decreases with age. Clinical categories of disease caused by Hib include meningitis, epiglottitis, and a range of other infections such as septic arthritis, cellulitis, and pneumonia. The classical sign of meningitis neck stiffness, is often not detected in infants, who present with drowsiness, poor feeding, and high fever. Epiglottitis (inflammation of the epiglottis) presents with respiratory obstruction, associated with stridor and often drooling in an anxious child who remains upright to maximise his or her airway. Meningitis and epiglottitis are almost invariably fatal without appropriate treatment. Septic arthritis and cellulitis present with local signs related to the involved joints or skin. Pneumonia due to Hib may present with respiratory distress and pleural effusion. There are no specific clinical features of any of these infections due to Hib which enable them to be differentiated from those due to other organisms. WHAT ARE THE COMPLICATIONS? The complications of Hib disease are the complications of the specific invasive disease it causes. Before the introduction of the vaccine, Hib was the leading cause of bacterial meningitis and other invasive bacterial disease among children less than 5 years old. The case-fatality rate for invasive Hib disease is 2% to 5%.
HAEMOPHILUS INFLUENZAE TYPE B

WHAT IS HAEMOPHILUS INFLUENZAE TYPE B? Haemophilus influenzae is a gram-negative coccobacillus, which is generally aerobic, but grows as a facultative anaerobe. Although six capsular types (a to f) have been described, before the introduction of Haemophilus Influenzae Type B (Hib) vaccine almost all Haemophilus Influenzae isolates from sterile sites were usually of one capsular type - type b. Type b organisms account for almost all strains that cause invasive disease. Risk factors for Hib disease include host factors that increase the likelihood of exposure to Hib organisms. Exposure factors include household crowding, large household size, daycare attendance, low socioeconomic status, low parental education levels and school-aged siblings. Some protective factors (effect limited to less than 6 months of age) include breastfeeding and passively acquired maternal antibodies. HOW IS HAEMOPHILUS INFLUENZAE TYPE B SPREAD? The organism enters the body through the nasopharynx, colonizes it and may remain only transiently or for several months in the absence of symptoms. The exact mode of invasion of the blood stream is unknown. Primary spread is presumably by respiratory droplet. Humans are the only reservoir.
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WHAT IS THE TREATMENT FOR HAEMOPHILUS INFLUENZAE TYPE B? Antimicrobial therapy with chloramphenicol or an effective third generation cephalosporin should be given immediately. The type of antimicrobial that is given is dependent on the antibiotic sensitivity pattern of the organism in your country. HOW IS HAEMOPHILUS TYPE B PREVENTED? Haemophilus influenzae type b disease and the rate of carriage of Hib among vaccinated children are prevented by vaccination with Hib vaccine. This also reduces the chance of unvaccinated children will be exposed. HAEMOPHILUS INFLUENZAE TYPE B Hib is a conjugated capsular polysaccharide vaccine. It is not live and contains non-replicating bacterial capsular antigens. Vaccine efficacy exceeds 95% in infants immunized from 2 months of age. How it is stored Hib vaccine should be stored between +2 degrees Celsius and +8 degrees Celsius but NOT frozen. If the vaccine is frozen; it should not be used. When it is given The first dose of Hib vaccine can be given as early as 6 weeks of age. The minimal interval between doses is 4 weeks (1 month). The national schedule is:
8 weeks 16 weeks 24 weeks
The vaccine can be given at the same time with DPT. If the primary course is interrupted, it should be resumed, allowing one month between remaining doses. The number and size of doses The dose of Hib vaccine is 0.5 ml The primary course consists of three (3) doses of Hib vaccine followed with Booster dose at 15 months. Where and how it is given Hib vaccine is given by deep subcutaneous or intramuscular injection in the antero-lateral thigh. In older children or adults, the vaccine can be given in the deltoid. The site of injection should be recorded. Contraindications
Immunization should not proceed in children who have had a severe local reaction or a general reaction that can be confidently related to a preceding Hib immunization. When Hib vaccine has been given with DPT, generalized reactions are far more likely to have been caused by DPT vaccine. Acute or febrile illness; immunization should be postponed.
Adverse Reactions
Swelling and redness at the injection site have been reported. These effects usually appear within three to four hours and resolve completely within 24 hours. The incidence of these reactions declines with subsequent doses, supporting the recommendation that courses of immunization should be completed despite the occurrence of such reactions.
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POLIOMYELITIS
WHAT IS POLIOMYELITIS Poliovirus (genus Enterovirus) types 1, 2 and 3 can cause paralytic poliomyelitis. Type 1 is usually isolated from paralytic cases most often, type 3 less so, and type 2 least commonly. Type 1 most frequently causes epidemics. Most vaccine-associated cases are due to type 2 or 3. The last poliomyelitis cases in the English-speaking Caribbean and Suriname were in Jamaica in 1982, and that in Trinidad and Tobago was in 1972. Humans are usually the reservoir, most frequently people with inapparent infections, especially children. Long-term carriers have not been found. HOW IS POLIO SPREAD? The disease is primarily person-to-person spread, principally through the fecal-oral route. The virus is more easily detectable, and for a longer period, in feces than in throat secretions. However, where sanitation is good, pharyngeal spread may be relatively more important. No reliable evidence of spread by insects exists; water and sewage are rarely implicated. The virus enters the body through the mouth when people eat food or drink water contaminated by faeces with the virus. Consequently, the disease is most likely to spread in areas of poor sanitation. The virus enters the bloodstream and may invade certain types of nerve cell, which it can damage or destroy.
The viruses also occur in throat secretions, and are sometimes spread in airborne droplets through close contact with persons carrying the infection (who are sneezing or coughing), or through exposure to throat and nose secretions in other ways. The disease is very easily spread. Nearly all children living in households where someone is infected, themselves become infected. Persons are most likely to spread the virus seven to ten days before and seven to ten days after they first experience symptoms of the disease. Infected persons who do not have symptoms can also spread the disease. WHAT ARE THE SIGNS AND SYMPTOMS? The incubation period is commonly 7 14 days for paralytic cases but may range from 3 to 35 days. People infected with the virus may not feel ill. Some may have influenza-like symptoms such as fever, loose stools, sore throat, stomach upset, headache or stomachache. Sometimes there may be pain or stiffness in the neck, back and legs. The most serious form of the disease is paralytic polio. It begins with the milder forms but usually causes severe muscle pain as well as the other symptoms. Paralysis usually develops during the first week of illness. The use of one or both legs or arms may be lost, and breathing may be impossible without the help of a respirator. The degree of recovery varies from person to person. In childhood polio there is initially a slight fever. Within three to five days the child develops a headache, stiff neck, and muscle pain, and the fever then increases. After a further period of one to three days the child becomes paralyzed in the legs, arms, face or chest.
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Period of communicability is not precisely defined, but transmission possible as long as the virus is excreted. Poliovirus is demonstrable in throat secretions as early as 36 hours and in the feces 72 hours after exposure to infection in both clinical and inapparent cases. Virus typically persists in the throat for approximately 1 week and in the feces for 3 6 weeks or longer. Cases are most infectious during the first few days before and after onset of symptoms. Laboratory testing of the stools or throat secretions is used to confirm cases of polio. SUSCEPTIBILITY AND RESISTANCE Susceptibility to infection is common, but paralysis rarely occurs. The rate of paralysis among infected, non-immune adults is higher than that among nonimmunized infants and young children. Type-specific immunity, apparently of lifelong duration, follows both clinically recognizable and inapparent infections. Second attacks are rare and result from infection with a poliovirus of a different type. Infants born of immune mothers have transient passive immunity. Intramuscular injections administered during the incubation period or prodromal illness may provoke paralysis. Tonsillectomy increases the risk of bulbar involvement. Excessive muscular activity in the prodromal period may likewise predispose to paralysis. An increased rate of paralysis is found among pregnant women. Poliomyelitis in pregnancy is associated with an increased risk of abortion, prematurity and stillbirth.
WHAT ARE THE COMPLICATIONS? About 1% of infected children may progress to paralysis, and a larger percentage of these children will have some permanent paralysis. Death may occur if the respiratory muscles (muscles used for breathing) are paralysed and no respirator is available. HOW IS POLIO TREATED? There is no treatment but the symptoms can be somewhat relieved. Sometimes the patient has to use a respirator in order for breathing to be sustained. HOW IS POLIO PREVENTED? Polio prevention involves immunization with oral polio vaccine (OPV). Antibodies from the mother provide protection to the infant for two to three months after birth. Infected people who recover can develop natural immunity that protects them against future infection. Adverse Reactions
Minor local reactions such as pain and redness at site of injection may occur. No serious adverse reactions have been documented. Allergic reactions to the vaccine are very rare.
Severe complications should be reported promptly to the Ministry of Health through the medical officer of health responsible for the EPI Programme.
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WHAT IS TRIVALENT ORAL POLIO VACCINE? TOPV contains live attenuated strains of poliovirus types 1, 2 and 3. Oral polio vaccine (OPV) gives protection against three types of viruses that cause polio. It is a liquid that comes in two types of containers: small plastic bottles that work like droppers, and glass vials with droppers in a separate plastic bag. How it is stored OPV should be stored at a temperature between +2 degrees and +8 degrees Celsius. It is easily harmed by heat but is not harmed by freezing. When it is given 1st dose is given from 6-8weeks of age 2nd dose between 10-16 weeks of age 3rd dose between 20-24 weeks of age The interval after the second and third doses must be at a minimum of at least four weeks. Booster doses can be given to children at 18 months and 4-5 years of age (school entry). The number and size of doses Three doses are given in the primary schedule, each of two drops. Where and how it is given OPV is dropped in the mouth with the dropper that comes with the vaccine. Contraindications
Acute or febrile illness; immunization should be postponed. Moderate or severe vomiting or diarrhea; immunization should be postponed. Treatment involving high dose of corticosteroids or immune-suppression including general radiation.
The inactivated polio vaccine (IPV) should be used for HIV Positive symptomatic individuals and persons in households with immune-compromised individuals. Oral Polio vaccines may be administered to HIV asymptomatic children.
Adverse Reactions
OPV has minimal side effects. Cases of vaccine associated poliomyelitis have been reported in recipients of TOPV and in the contacts of recipients. The need for strict personal hygiene for contacts of recent vaccines must be stressed. In rare instances paralytic polio has been associated with oral poliovirus vaccine. No serious side effects are seen with IPV.
WHAT IS INACTIVATED POLIOMYELITIS VACCINE? Inactivated Poliomyelitis Vaccine (IPV) contains polioviruses of all three, inactivated by a preservative in addition to traces of neomycin, streptomycin and polymyxin B may also be present in the vaccine. It is highly effective in producing immunity to poliovirus; 90% immune after 2 doses and 99% immune after 3 doses. The most important advantage of IPV is that it is inactivated so that if cannot replicate and cannot be shed in the stool of a vaccinated person. IPV does not cause vaccine associated paralysis and is safe to use in immuno-deficient persons if in household contacts of immune-deficient persons. IPV produces less local gastrointestional immunity than does OPV, so persons who receive IPV are more readily infected with wild polio virus than OPV recipients. A person who receives IPV could become infected with wild polio virus in an endemic area.
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The infected person would be protected from paralytic polio but the wild virus being shed in the stool could spread and result in transmission to a contact. How it is stored IPV should be stored at a temperature between +2 degrees and +8 degrees Celsius. It is easily damaged by heat and should not be frozen. When it is given 1st dose of IPV is given T 8 week of age. 2nd dose is given at 16 weeks of age 3rd dose between 6-18 months of age The preferred interval between the second and third doses of IPV is 2-8 months. However, if accelerated protection is needed, the minimum interval between doses of IPV is four weeks. Children who receive three doses of IPV before the 4th birthday should receive a 4th dose before or at school entry. The 4th dose is not needed of the 3rd dose is given on or after the 4th birthday. The number and size of doses Three doses are given in the primary schedule, each of 0.5 ml Where and how it is given IPV is given subcutaneously in the anterior lateral thigh in infants and in older children in the deltoid area. Contraindications
Immunization should be postponed if there is a history of acute or febrile illness. Anaphylactic reaction to a previous dose contraindicates further immunization with that vaccine. Persons with a history of anaphylactic reaction to
neomycin, polymyxin B or streptomycin should not receive IPV. Pregnancy is considered a precaution on theoretical grounds. However, there is no convincing evidence of adverse effects on the fetus.
Adverse Reactions
Minor local reactions such as pain and redness at the site of injection may occur. No serious adverse reactions have been documented. Allergic reactions to the vaccine are very rare.
CONGENITAL RUBELLA SYNDROME
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KOPLICKS SPOTS
MEASLES
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MUMPS
VARICELLA (CHICKENPOX) Etiologic Agent Human herpesvirus Type 3 - Varicella-zoster virus Transmission
Chickenpox is highly contagious.
- Inhalation of infective droplets Exposure is usually 14 -21 days before onset of symptoms. - Contact with the fluid within the lesions
Signs and Symptoms of Primary Infection Persons usually experience fever and malaise just prior to or with the eruption of lesions. The progression of lesions Papules become vesicular and quickly rupture forming small ulcers. Pustular lesions are also present and all of these eventually form crusts.
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Characteristics - The rash is very pruritic and centripetal. It is most prominent on the face, scalp, trunk, but also involves the extremities. New lesions erupt for 1-5 days and all stages of eruption are present simultaneously. The crusts slough off in 7 -14 days. Persons are infectious 1 to 2 days before the rash appears and remain contagious until all lesions have crusted over. Diagnosis Diagnosis is usually made on clinical findings. However, Tzanck smears of scrapings of the vesicle bases can also be done. Treatment Persons should be isolated, especially away from immunoincompetent individuals. Treatment is usually supportive. Acetaminophen is recommended for fever. Aspirin is avoided because of its association with causing Reyess syndrome. The skin needs to be kept clean. Oral antihistamines, calamine lotion and oatmeal baths help to relieve pruritis. Antiviral medications are recommended for people with chickenpox who are more likely to develop serious disease. Acyclovir, the mainstay of treatment reduces the severity and shortens the duration of the disease. Complications
- The most common late complication of Varicella is Herpes zoster( shingles). This painful rash is caused by reactivation of the varicella zoster virus decades after the initial episode of chickenpox. Lesions follow a nerve root distribution and in most cases involve a single dermatome.
- Secondary bacterial skin infections - Congenital malformations if contracted in pregnancy during the first or second trimesters.
Prevention Varicella vaccines contain live, attenuated varicellazoster virus derived from the Oka strain. Two doses are recommended for children over 12months, adolescents and adults who have not had chickenpox.
VARICELLA VACCINE
What it is Varicella or Chicken Pox vaccine is a live attenuated vaccine, and is part of the infant immunization schedule in some countries. Multiple studies have demonstrated that this vaccine provides excellent seroconversion and protection. Duration of the vaccine-induced immunity is unknown. Studies are being conducted to determine the need for booster doses. There are two live attenuated Varicella vaccines Varilix (made by GlaxoSmithKlline) and Varivax (made by Merck Sharp and Dohme). How it is stored The Varicella vaccines (Varilix, Varivax), should be stored between +2 and 80 C or colder until reconstituted for injection. The manufacturer recommends administration immediately after reconstitution to minimize loss of potency. When it is given Varicella vaccine is given to children between twelve (12) to eighteen (18) months of age. It is not recommended for use in children less than one (1) year of age.
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Adolescents, older than 13 years, and adults should receive two doses at least one month apart. The number and size of doses One dose of 0.5 ml is given. Where and how it is given Varicella vaccine is given deep subcutaneous in the deltoid muscle. Contraindications
Moderate or severe illness, with or without a fever. Varicella vaccine contains Neomycin and Gelatin, therefore anaphylactic reaction to Neomycin or Gelatin contraindicates the immunization. Hypersensitivity to any of the vaccine component.
MENINGOCOCCAL DISEASE
Description and Etiologic Agent Meningococcal meningitis and septicemia are systemic infections caused by Neisseria meningitidis, a gram negative diplocloccus with multiple serogroups A, B, C, Y, W-135 and L. Serogroup D is very rare. An association has been demonstrated between the seasonal onset of influenza activity and meningococcal disease. The incidence of the disease is highest in infants, followed by 1-5 year old children, but an increase of Group C disease has been associated with an increased incidence in school age children and young adults in the United Kingdom. Transmission The disease occurs worldwide but is most common in poor overcrowded areas. Meningococci are transmitted by droplet spread or direct contact from carriers or from individuals in the early stage of the illness. The probable route of invasion is via the nasopharynx. The usual reservoir is humans. The person is infectious as long as the meningococci are present in discharges from nose and mouth. Carrier prevalence of >25% may exist without cases of meningitis. Most carriers do not develop the illness but they may transmit the disease for about six months. Signs and Symptoms The incubation period varies from 2 to 10 days, but is usually 2-3 days. The onset of disease varies from fulminant to insidious with mild prodromal symptoms. Early symptoms and signs are usually malaise, fever, and vomiting.
Adverse Reactions These are reported to be mild.
Redness, induration, swelling and transient pain at the injection site Fever Varicella-like rash localized rash tend to occur within two (2) days of vaccination and generalized rash about two to three weeks after vaccination Herpes zoster following varicella vaccination in health children is a rare occurrence (18 per 100,000 person years of follow-up) and has been mild and without complication.
Severe complications should be reported to the Ministry of Health through the medical officer of health responsible for the EPI Programme.
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Headache, photophobia, drowsiness or confusion, joint paints, and atypical hemorrhagic rash of meningococcal septicemia may develop. Initially, the rash may be non-specific. The rash, which may be petechial or purpuric, does not blanche and this can be confirmed readily by gentle pressure with a glass when the rash may seem to persist. Patients may present in coma. In young infants, the onset may be insidious and the classical signs are absent. The diagnosis should be suspected in the presence of vomiting, fever, irritability, and if still patent, raised anterior fontanelle tension. High index of suspicion is required for all cases of meningitis. Complications Susceptibility to the clinical disease is low and decreases with age. A high ratio of carriers to cases prevails. Those who are deficient in certain complement components are especially prone to recurrent disease. Splenectomized persons and those with Sickle Cell Disease are especially susceptible to meningococcal bacteremic illness. Overall mortality from meningococcal infection is around 10-15%. Of patients who recover, 11%-19% have permanent hearing loss, mental retardation, loss of limbs, or other serious sequelae. This has changed little for 20 years. Meningitis is the common presentation, but in about 15-20% of cases, features of septicemia predominate. Treatment Benzylpenicillin is one of the antibiotics of choice and therapy should start immediately. Benzylpenicillin should not be withheld if there is no history of anaphylaxis following previous penicillin administration.
Meningococci usually disappear from the nasopharynx within 24 hours after institution of treatment with antimicrobial agents to which the organisms are sensitive and which attain substantial concentrations in oropharyngeal secretions. Penicillin will temporarily suppress the organisms, but it does not usually eradicate them from the oronasopharynx. Prevention Vaccines against sero-groups A, C, Y, and W-135 are available but there are no vaccines against serogroup B. Close contacts of cases of meningococcal meningitis have a considerable risk of developing the disease in the subsequent months despite appropriate chemoprophylaxis. The recommended prophylaxis is rifampicin. The alternate drugs are ciprofloxacin and ceftriaxone for pregnant contacts. Immunization has been shown to be effective in controlling epidemics and reducing infection rates but not carriage rates.
MENINGOCOCCAL POLYSACCHARIDE VACCINE

Description Meningococcal vaccines are currently available against serogroups A, C, Y and W 135, but, a vaccine against serogroup B is not yet available. The vaccines are polysaccharide, inactivated-bacteria vaccine. Serogroup A is the predominant cause of vaccine-preventable meningococcal disease in areas of risk to travelers. Risk to travelers is generally low and cases are rare, but risk becomes greater as the length of stay in risk areas and the level of contact with local populations increase.
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A serological response is detected in more than 90% of recipients and occurs 5 to 7 days after a single injection. The response is strictly group specific and confers no protection against Group B organism. Young infants respond less well than adults. Due to limited efficacy in young children, use of polysaccharide meningococcal vaccine should be restricted to those 2 years and older. Storage Meningococcal vaccines should be reconstituted immediately before use with the diluent supplied by the manufacturer. It should be stored at 20 C to +80C but not frozen. Freezing and heat destroys the potency of the vaccine. When it is given? The vaccine is not routinely given to adults and children, except in areas where the overall risk of meningococcal disease is very high. A single dose is given to children over two (2) years of age. For children who are at continued risk of exposure and receive their vaccination younger than 4 years of age, a booster dose should be considered after 2-3 years. However, for children who receive their first dose when four years of age or older, a booster should be considered after three to five years. In adults, when the vaccination is indicated for international travel, the vaccine should be administered 1-2 weeks before departure to allow maximum antibody response (estimated efficacy 85-90%). Routine vaccination is recommended for those at high risk of infection such as health workers. Asplenic children and adults, irrespective of age and interval from splenectomy, should receive a single dose of meningococcal vaccine before travelling to areas, where there is an increased risk of Group A infection.
The Number and Size of Doses A single dose of 0.5ml is given as the primary schedule to persons over two (2) years of age. Administration of vaccine Meningococcal vaccine should be given by deep subcutaneous or intramuscular injection to adults and children from two (2) years of age in the deltoid area. Contraindications
Immunization should be postponed in individuals suffering from severe infections with or without fever. Anaphylactic reaction to a previous dose contraindicates further immunization with that vaccine. Anaphylactic reaction to a vaccine constituent contraindicates the use of vaccines containing that substance. Meningococcal vaccine should not be used in pregnancy, unless there is a substantial risk of meningococcal infection. Safety of the vaccine in pregnancy has not yet been established.
Adverse Reactions
Adverse reactions are infrequent and mild, consisting principally of pain and localized erythema lasting 1-2 days. Up to 2% of young children may develop transient fever after immunization.
Serious reactions following Meningococcal vaccination should be reported promptly to the Ministry of Health through the EPI Programme.
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MENINGOCOCCAL CONJUGATE VACCINE

Description There are two types of meningococcal conjugate vaccines that are presently in use namely, meningococcal C vaccine used in infants and meningococcal A.C.Y. and W135 vaccines which are used in persons 2 to 55 years of age. Storage These vaccines are stored at 2 to 80 C. When it is given? Meningococcal conjugate C vaccine the number of doses depends on the age when immunization is started and the type of vaccine used. Children two to four months of age require two or three doses, two months apart. Children from four to 11 months require two doses, two months apart and children 12 months and older and adults require a single dose. The Number and Size of Doses The dose of the vaccine is 0.5 ml and it is given IM. In the United Kingdom, the schedule is as follows: 3 and 4 months of age with a booster dose at 12 months of age. In Alberta, Canada it is given to babies at the following ages: 2 months, 4 months and 12months. The vaccine is given at the same time as the other childhood immunizations for those ages. It is also given to children of other ages considered to be at increased risk, (medical conditions with no spleen, a spleen that may not be working properly due to illness such as sickle cell disease, lupus, celiac disease, inflammatory bowel disease or low platelet counts of unknown cause), for meningococcal infection.
Contraindications
Severe allergic reaction to vaccine component or a previous dose of the vaccine. As with other vaccines, acute febrile illness, postpone vaccination until the person is clinically well
Adverse Reactions The meningococcal vaccines are safe. The following minor side effects are common and usually last for one to two days:
Local reactions - redness, swelling and tenderness at the injection site; Other reactions are headache; fever higher than 38C, drowsiness, fussiness, diarrhea and vomiting in young children. Rarely, severe allergic (anaphylactic) reactions can occur
MENINGOCOCCAL CONJUGATE A,C,Y, AND W135 VACCINE

The vaccine was licensed in the USA in 2005. The vaccine contains N. meningiditis serogroups A, C, Y, and W135 capsular polysaccharide antigens individually conjugated to diphtheria toxoid protein. The vaccine is recommended for children at 11-12 years of age and children 13-18 years of age who have not been previously vaccinated. Persons 2-55 years of age who are at increased risk of meningococcal disease should be vaccinated. The Number and Size of Doses A single dose of 0.5 ml of meningococcal conjugate A, C, Y, and W135 vaccine, administered IM is needed for vaccination. The vaccine can be given at the same time with other vaccines.
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Contraindications
Severe allergic reaction to vaccine component or a previous dose of the vaccine. As with other vaccines, acute febrile illness, postpone vaccination until the person is clinically well.
Adverse Reactions The meningococcal vaccines are safe. The following minor side effects are common and usually last for one to two days:
Local reactions - redness, swelling and tenderness at the injection site; Other reactions are headache, fever higher than 38C, drowsiness, fussiness. Rarely, severe allergic (anaphylactic) reactions can occur
The pneumococcal serotypes most often responsible for causing infection are those most frequently found in carriers. The spread of pneumococcal disease is usually associated with increased carriage rates. S. pneumoniae is the most common cause of pneumonia acquired in nursing homes. Pneumococcal disease is more often reported in adults older than age 40 and children younger than age 2 years. Recent reports indicate that pneumococci cause 36% of all adult communityacquired pneumonia and up to half of all hospitalized pneumonia cases, with incidence greatest in patients older than 40 years of age. Because the incidence of H. influenzae type b (Hib), meningitis in children rapidly decreased following the introduction of Hib conjugate vaccines, S. pneumoniae has become one of the most common causes of bacterial meningitis. Penicillin-resistant Streptococcus pneumoniae is an increasing concern in many countries. Signs and Symptoms The major clinical syndromes of invasive pneumococcal disease include pneumonia, bacteremia, and meningitis. Pneumococcal pneumonia is the most common clinical presentation of invasive pneumococcal disease. The incubation period of pneumococcal pneumonia is short, about 1 to 3 days. Symptoms generally include an abrupt onset of fever. Typically there is a single rigor, and repeated shaking chills are uncommon.
Serious reactions following Meningococcal vaccination should be reported promptly to the Ministry of Health through the EPI Programme.
PNEUMOCOCCAL DISEASE Description and Etiologic Agent

Pneumococcal Disease is caused by the bacterium, Streptococcus pneumoniae, a gram-positive diplococcus. Predisposing conditions such as season, crowding, presence of upper respiratory infection, pneumococcal disease such as pneumonia or otitis media or other underlying medical conditions have a significant impact on disease occurrence. Transmission Transmission of Streptococcus pneumoniae occurs as the result of direct person-to person contact via droplets, and by autoinoculation in persons carrying the bacteria in their upper respiratory tract.
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Other common symptoms include pleuritic chest pain, cough productive of mucopurulent, rusty sputum, dyspnea (shortness of breath), tachypnea (rapid breathing), hypoxia (poor oxygenation), tachycardia (rapid heart rate), malaise, and weakness. Nausea, vomiting, and headaches occur less frequently. Pneumococci account for up to 36% of adult community-acquired pneumonia and 50% of hospital-acquired pneumonia. It is a common bacterial complication of influenza and measles. The case-fatality rate is 5%-7%, and may be much higher in elderly persons. Complications Complications of pneumococcal pneumonia include empyema (i.e., infection of the pleural space), pericarditis, or inflammation of the sac surrounding the heart, and endobronchial obstruction, with atelectasis and lung abscess formation. Bacteremia occurs in about 25-30% of patients with pneumococcal pneumonia. The overall mortality rate for bacteremia is about 20%, but may be as high as 60% in elderly patients. Patients with asplenia who develop bacteremia may experience a fulminant clinical course. One-quarter of patients with pneumococcal meningitis also have pneumonia. The clinical symptoms, spinal fluid profile and neurologic complications are similar to other forms of purulent bacterial meningitis. Symptoms may include headache, lethargy, vomiting, irritability, fever, nuchal rigidity, cranial nerve signs, seizures and coma. The mortality rate of pneumococcal meningitis is about 30%, but may be as high as 80% in elderly persons. Neurologic sequelae are common among survivors.
Pneumococci cause 30-60% of episodes of acute otitis media in infants and children. Complications of pneumococcal otitis media may include mastoiditis and meningitis. Treatment Penicillin is the drug of choice for treatment of pneumococcal disease. However, patients who are allergic to penicillin may be given cephalosporins (depending on the severity of the penicillin allergy) or erythromycin for pneumonia, and chloramphenicol for meningitis. The route, dosage, schedule, and duration of therapy depend on the severity of the illness. Resistance to penicillin and other antibiotics is rising, and studies indicate that 5% to 15% of pneumococci are resistant. IM or IV immunoglobulin administration may be useful for preventing pneumococcal infection in children with congenital or acquired immunodeficiency diseases including those with HIV infection who have recurrent, serious bacterial infections. There are no specific recommendations regarding isolation of patients with pneumococcal disease, although respiratory secretions may be infective for 24 hours after the start of effective antimicrobial therapy. Prevention Penicillin prophylaxis is another method of preventing pneumococcal infection.
Oral penicillin V, when administered to infants and young children with sickle cell disease has reduced the incidence of severe bacterial infections. Oral penicillin G or V is recommended for prevention of pneumococcal disease in children with functional or anatomic asplenia, regardless of whether or not they have been immunized.
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THE PNEUMOCOCCAL VACCINES

Pneumococcal vaccines are designed to cover the serotypes most frequently associated with severe pneumococcal disease. Currently, a 13-valent polysaccharide-protein conjugate vaccine (PCV13) and a polysaccharide vaccine covering 23 serotypes (PPV23) are marketed internationally. Both vaccines are injectable and considered very safe. The vaccines:
1) Pneumococcal Conjugate Vaccine (PCV) or PCV 13 can be used in young children less than two (2) years of age. The similar vaccine PCV-7 was licensed in 2000 for use in the prevention of pneumococcal disease in infants and children up to five (5) years of age. However the vaccine can be given to all age groups.
The average duration of protection following 3 doses of primary immunization in infancy is yet to be established, but expected to be long-lasting. One booster dose between 12 24 months of life is recommended. Because most serious pneumococcal infections happen during the first 2 years of life, the vaccine protects children when they are at greatest risk. Storage The vaccine is provided as a single injectable dose and in a syringe. The pneumococcal conjugate vaccine (PCV13) should be stored at a temperature between +20 C to +80 C in the refrigerator. It MUST NOT BE FROZEN. When it is given? All children younger than 2 years can receive the vaccine. In the routine schedule, the first dose of the vaccine can be administered at 2 months of age together with the first dose of polio, DPT/Hep B/ Hib (Pentavalent) and rotavirus vaccines. 3 doses of pneumococcal conjugate vaccine should be given:
1st dose: 2 months of age 2nd dose: 4 months of age 3rd dose: 6 months of age
2) Pneumococcal Polysaccharide Vaccine (PPV 23) or (PPV) must be used for children over 2 years of age and adults. This vaccine was licensed in 1997.
Pneumococcus bacteria are spread from person to person through close contact. Pneumococcal infections can be hard to treat because the disease has become resistant to some of the medicines that have been used to treat it. This makes preventing the disease even more important. Pneumococcal Conjugate Vaccine (PCV13) Description Pneumococcal conjugate vaccine is an injectable vaccine. This vaccine contains thirteen (13) pneumococcal serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F. It prevents pneumococcal disease caused by these serotypes and it also helps stop the disease from spreading from person to person.
Immunize all infants if no contraindications are present. The minimum age of first dose is 6 weeks. Pneumococcal conjugate vaccine (PCV13) is also recommended for children with the following conditions:
Sickle cell disease Damaged spleen or no spleen HIV/AIDS Other diseases that affect the immune system, such as diabetes or cancer
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The Number and Size of Doses PCV13 comes as a single dose vaccine - pre filled liquid in a syringe. Each dose is 0.5 ml and contains serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F. No mixing is required for this vaccine. No thiomersal preservative is used. Three doses are given at ages 2, 4 and 6 months of age. Administration of Vaccine PCV13 should be given intramuscular in the anterior lateral muscle of the thigh, as is done for other vaccines that are given intramuscular. This vaccine can be given at the same time with other vaccines, but CANNOT be mixed with others in the same syringe and MUST be given at another site. Contraindications to PCV13 PCV13 should not be administered to the following infants:
Severe (life-threatening) allergic reaction to a previous dose of the vaccine. Children who are moderately or severely ill at the time the vaccine is scheduled should wait until they recover before getting the vaccine. Children with minor illnesses, such as a cold, may be vaccinated.
Other serious reactions that could also occur include the following below, which are signs and symptoms of anaphylaxis:
Difficulty breathing Hoarseness or wheezing Hives Paleness Weakness A fast heartbeat Dizziness Swelling of the throat
It is uncommon to have the serious side effects, such as fever, myalgia, or severe or local or systemic reactions. There is no evidence that the severity of side effects increases following revaccination. Serious reactions following PCV13 VACCINATION MUST be reported promptly to the Ministry of Health through the EPI Programme.
Adverse Reaction In clinical trials, pneumococcal conjugate vaccine was associated with only mild reactions. The mild reactions are:
Redness, tenderness or swelling where the shot was given. Mild fever. Some fussiness, poor appetite. Vomiting in one in every 50 cases.
PNEUMOCOCCAL POLYSACCHARIDE VACCINE Description This is an inactivated-bacteria vaccine. The vaccine is effective for diseases caused by Streptococcus pneumoniae, including pneumonia and meningitis. The first 14-valent vaccine was licensed in the USA in 1977; it was replaced by a 23-valent polysaccharide vaccine in 1983.
Storage Pneumococcal polysaccharide vaccine should be stored at a temperature between 20 C to 80 C and MUST NOT BE FROZEN.
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When it is given? Pneumococcal polysaccharide vaccine may be administered routinely to all adults 65 years of age and older, if the epidemiology of the disease warrants this action. The vaccine is also indicated for adults with normal immune systems who have chronic illnesses, including cardiovascular disease, pulmonary disease, diabetes, alcoholism, cirrhosis, or cerebrospinal fluid leaks. Immuno-compromised adults who are at increased risk of pneumococcal disease or its complications should also be vaccinated. This group includes persons with splenic dysfunction or absence (either from disease or surgical removal), Hodgkins disease, lymphoma, multiple myeloma, chronic renal failure, nephrotic syndrome (transplantation associated with immuno-suppresssion. Adults with asymptomatic or symptomatic HIV infection should be vaccinated. As the immunization is not effective in children younger than age 2, do not administer it to them even though they are at risk for pneumococcal diseases. Children 2 years old and older with long-term illnesses that are associated with a high risk of serious pneumococcal infections or its complications should be vaccinated. These include children whose spleens have been surgically removed, as well as those who have sickle cell disease, nephrotic syndrome, or CSF leaks. Children with immuno-suppression, including those with asymptomatic or symptomatic HIV, should be vaccinated. Providers should not withhold vaccination in the absence of an immunization record or complete record. The patients verbal history may be used to determine vaccination status.
Persons with uncertain or unknown vaccination status should be vaccinated. Administration of Vaccine Pneumococcal polysaccharide vaccine (0.5 ml) is administered intramuscularly or subcutaneously. Contraindications
Consider postponing vaccination in persons with moderate or severe illness, with or without fever, until recovery to minimize potential adverse effect. Anaphylactic reaction to a previous dose contraindicates further immunization of that particular vaccine. Anaphylactic reaction to a vaccine constituent contraindicates the use of vaccines containing that substance. A serious allergic reaction to a dose of pneumococcal vaccine or a vaccine component is a contraindication to further doses of vaccine. Such allergic reactions are rare. Persons with moderate or severe acute illness should not be vaccinated until their condition improves. The safety of pneumococcal vaccine for pregnant women has not been studied. It should generally not be given to healthy pregnant women. Women who are at high risk of pneumococcal disease and who are candidates for pneumococcal vaccine should be vaccinated before pregnancy.
Adverse Reactions
Mild side effects such as pain, swelling and redness at the injection site, commonly occur. It is uncommon to have more serious side effects, such as fever, myalgia, or severe or local or systemic reactions. There is no evidence that the severity of side effects increases following revaccination
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Severe complications should be reported to the Ministry of Health through the EPI Program.
HEPATITIS A Etiologic Agent Hepatitis A is a single stranded RNA virus from the Picornovirus family. Infection with this causes inflammation of the liver. Most of the time it is a self- limiting infection, but rarely can cause chronic disease. About 85% of infected persons recover in three months.
Transmission Hepatitis A virus is transmitted by the fecal-oral route, sexual contact or by transfusion of blood products. The transmission is mainly person to person. Symptoms The incubation period is 2 to 7 weeks. An individual may remain contagious for months. Persons may experience nausea, vomiting, weight loss, abdominal pain , fatigue, fever, sore muscles, jaundice ( yellow eyes and skin ), dark urine and pale stools. Complications Complications are rare and include death (3-6 persons per 1000 ), chronic liver disease, fulminant hepatitis and liver failure. Diagnosis Lab Tests - IgG and IgM antibody titers to hepatitis A. However commercial assay may not readily available for testing. Treatment Treatment is supportive and geared toward symptomatic relief with extra fluids, and analgesics.
For post exposure treatment, hepatitis A immune globulin can be given within two weeks of exposure especially to persons with weakened immune system, with chronic liver problems like cirrhosis or children under the age of 1 year old. Primary Prevention
- Always wash hands with soap and water frequently especially after using the toilet or after handling body fluids or waste products such as feces or after handling raw foods and vegetables and fruits. - Sewage and other waste products must be properly and strictly eliminated. - Under cooked and raw foods especially seafood and shellfish should not be eaten. - Vegetables and fruits should be washed with safe water, peeled or cooked before eaten. - Textile furniture and counter tops, toys etc. should be washed with household bleach and water. - Food and water should be cooked to at least 185 oF - Do not drink or use untreated water or untreated ice. If there is uncertainty about water then boil water to 185 oF before use.
Secondary Prevention There are several types of hepatitis A vaccines including monovalent and combined valent vaccines. Havrix, Avaxim, and Vaqta are monovalent vaccines.
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Recommended and Minimum Ages and Intervals between Doses

Vaccine and Dose number Hepatitis A (HepA)-1 Hep A-2 Vaccine Facts Recommended age for this dose
12-23 months >18 months
Minimum age for this dose

12 months 18 months
Recommended interval to next dose

6 18 months 5 -
Minimum interval to next dose

6 months5 -
- Two doses of the vaccine should be given. The second dose is given six to twelve months after the first. - It is given intramuscularly. - The vaccine can be given at the same time as other vaccines but at different sites. - This vaccine should be stored between 2oC and 8 oC. Never freeze. - It can be given to children over the age of one year. - It should be given to persons working in research laboratory where hepatitis A is housed. - It can be given to persons working with sewage. - It can be given to persons traveling to endemic areas such as Asia, Central and South America, Africa and Eastern Europe. - If the vaccine is given to a person a few days post exposure it can still elicit an adequate immune response. - The vaccine provides protection 2 to 4 weeks after receiving the first dose and immunity may last for twenty years, at which time a booster is required.
Adverse Effects This is not a live vaccine and there are only minor side effects. There may be transient redness and soreness at the site. Others include fever, nausea, vomiting and headache. Adverse events and severe complications should be reported to the Ministry of Health through the EPI Program
HUMAN PAPILLOMA VIRUS (HPV) Etiologic Agent There are over 100 types of HPV and more than 40 types can infect the genital areas of males and females. These HPV types can also infect the mouth and throat. However, there are 4 types which lead to most of the complications associated with HPV infection. These are the oncogenic, or high-risk types 16 and 18 and the nononcogenic, or low-risk HPV types 6 and 11.
Transmission Direct skin-to-skin contact during sexual activity with someone who has HPV. Intercourse is not necessary.
Contraindications
- Any anaphylactic reaction or severe allergic reaction to this vaccine or its components. - Hep A vaccines should not to be given to persons under 1 year of age.
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Recommended and Minimum Ages and Intervals between Doses

Vaccine and Dose number HPV - 1 HPV - 2 HPV- 3 Signs and Symptoms Recommended age for this dose
11-12 years 11-12 years (+ 2 months) 11-12 years (+ 6 months)
Minimum age for this dose

9 years 9 years (+ 4 weeks) 9 years (+24 weeks)
Recommended interval to next dose

2 months 4 months -
Minimum interval to next dose

4 weeks 12 weeks -
- Genital warts in females and males -HPV Types 6 and 11 cause about 90% of these cases. - Warts in the throat - recurrent respiratory papillomatosis - Cervical cancer - HPV Types 16 and 18 cause about 75% of these cases. - Vaginal and Vulvar cancer - HPV Types 16 and 18 cause about 70% and up to 50% of cases in females, respectively. - Less common, but serious cancers- cancers of the penis, anus, and oropharynx (back of throat including base of tongue and tonsils). - All HPV types that affect the genital area can cause abnormal Pap tests in females.
Treatment Subclinical genital HPV infection typically clears spontaneously, and therefore specific antiviral therapy is not recommended to eradicate HPV infection. Treatment is directed to the macroscopic (i.e., genital warts) or pathologic (i.e, precancerous) lesions caused by infection. Prevention Two vaccines are available to prevent the human papillomavirus (HPV) types that cause most cervical cancers. These vaccines are bivalent vaccine (Cervarix) and quadrivalent vaccine (Gardasil). There are two different HPV vaccines (Cervarix or Gardasil) that can be given to girls and young women. Only one HPV vaccineGardasilcan be given to boys and young men. Both vaccines are given in 3 shots over 6 months. The second shot is given 1 or 2 months after the first, and the third shot is given 6 months after the first shot. Preteens and teens should ideally get all 3 doses of an HPV vaccine long before their first sexual contact, so they have time to develop protection from the vaccine. This is also the age they will have the best immune response from the vaccine.
Diagnosis
- Physical examination: A diagnosis of genital warts can be made by visual inspection. - Pap smears - HPV Testing - The HPV tests are used to help screen women at certain ages and with certain abnormal Pap smear findings. HPV tests are available for women aged >30 years undergoing cervical cancer screening. These tests should not be used for men, for women <20 years of age, or as a general test for STDs. These HPV tests detect viral nucleic acid (i.e., DNA or RNA) or capsid protein.
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The minimum age for HPV-3 is based on the baseline minimum age for the first dose (108 months) and the minimum interval of 24 weeks between the first and third doses. Dose 3 need not be repeated if it is given at least 16 weeks after the first dose (and if the intervals between doses 1 and 2 and doses 2 and 3 are maintained at 4 weeks and 12 weeks, respectively). Severe complications should be reported to the Ministry of Health through the EPI Program.
At that time interval, antibody titers against HPV types 6, 11, 16, and 18 were higher than those that developed after natural HPV infection. HPV vaccine has been found to have high efficacy for prevention of HPV vaccine typerelated persistent infection, vaccine typerelated CIN, CIN2/3, and external genital lesions in women 1626 years of age. Clinical efficacy against cervical disease was determined in two double-blind, placebo-controlled trials, using various endpoints. Vaccine efficacy was 100% for prevention of HPV 16 or 18related CIN 2/3 or adenocarcinoma in-situ (AIS). Efficacy against any CIN due to HPV 6, 11, 16, or 18 was 95%. Efficacy against HPV 6, 11, 16 or 18related genital warts was 99%. Although high efficacy among females without evidence of infection with vaccine HPV types was demonstrated in clinical trials, there was no evidence of efficacy against disease caused by vaccine types with which participants were infected at the time of vaccination. Participants infected with one or more vaccine HPV types prior to vaccination were protected against disease caused by the other vaccine types. However, prior infection with one HPV type did not diminish efficacy of the vaccine against other vaccine HPV types. There is no evidence that the vaccine protects against disease due to non-vaccine HPV types or provides a therapeutic effect against cervical disease or genital warts present at the time of vaccination.
HUMAN PAPILLOMAVIRUS (HPV) VACCINE

The currently licensed vaccine in the USA, is a quadrivalent HPV vaccine (Gardasil, Merck). The vaccine antigen is the L1 major capsid protein of HPV, produced by using recombinant DNA technology. The L1 protein is expressed in Saccharomyces cerevisiae (yeast) cells, and the protein self-assembles into noninfectious, nononcogenic viruslike-particles (VLP). Each 0.5-mL dose contains 20 g HPV 6 L1 protein, 40 g HPV 11 L1 protein, 40 g HPV 16 L1 protein, and 20 g HPV 18 L1 protein. The quadrivalent HPV vaccine contains no thimerosal or antibiotics. The vaccine is supplied in single-dose vials and syringes. Immunogenicity and Vaccine Efficacy The immunogenicity of the quadrivalent HPV vaccine has been measured by detection of IgG antibody to the HPV L1 by a type-specific immunoassay developed by the manufacturer. In all studies conducted to date, more than 99.5% of participants developed an antibody response to all four HPV types in the vaccine 1 month after completing the three-dose series.
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A subset of participants in the phase II HPV vaccine study has been followed for 60 months post-dose 1 with no evidence of waning protection. Study populations will continue to be followed for any evidence of waning immunity. HPV vaccine has been shown to be immunogenic and safe in males. However, no clinical efficacy data are available for males. These studies are in progress. Vaccination Schedule and Use As of January 2007, ACIP recommendations for use of HPV vaccine have not been published. Recommendations included here are provisional until published in the Morbidity and Mortality Weekly Report. Quadrivalent HPV vaccine is licensed by the Food and Drug Administration for use among females 926 years of age. The recommended age for routine vaccination in the United States is 1112 years. The vaccine can be given as young as 9 years of age at the discretion of the clinician. The vaccine should be given at the same visit as other vaccines recommended for persons of this age (e.g., Tdap, meningococcal conjugate, hepatitis B). At the beginning of a vaccination program, there will be females older than 12 years of age who did not have the opportunity to receive vaccine at age 1112 years. Catch-up vaccination is recommended for females 13 through 26 years of age who have not been previously vaccinated or who have not completed the full series.
Ideally, vaccine should be administered before potential exposure to HPV through sexual contact; however, females who may have already been exposed to HPV should be vaccinated. Sexually active females who have not been infected with any of the HPV vaccine types will receive full benefit from vaccination. Vaccination will provide less benefit to females if they have already been infected with one or more of the four HPV vaccine types. However, it is not possible for a clinician to assess the extent to which sexually active females would benefit from vaccination, and the risk of HPV infection may continue as long as persons are sexually active. Pap testing or screening for HPV DNA or HPV antibody is not recommended prior to vaccination at any age. Dosage
HPV vaccine is administered in a three-dose series administered by intramuscular injection. The vaccine dose is 0.5 ml. The second and third doses should be administered 2 and 6 months after the first dose. The minimum interval between the first and second doses is 4 weeks. The minimum interval between the second and third dose of vaccine is 12 weeks. Doses administered at an interval shorter than the minimum interval should not be counted as valid and should be repeated.
If the HPV vaccine schedule is interrupted, the vaccine series does not need to be restarted. If the series is interrupted after the first dose, the second dose should be given as soon as possible, and the second and third doses should be separated by an interval of at least 12 weeks. If only the third dose is delayed, it should be administered as soon as possible.
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Although no data are available yet on administration of quadrivalent HPV vaccine with vaccines other than hepatitis B vaccine, the vaccine contains only HPV capsid protein and has no components that have been found to adversely affect safety or efficacy of other vaccinations. The vaccine can be administered at the same visit as other age-appropriate vaccines, such as Tdap and quadrivalent meningococcal conjugate (MCV4) vaccines. Administering all indicated vaccines at a single visit increases the likelihood that adolescents and young adults will receive each of the vaccines on schedule. Each vaccine should be administered using a separate syringe at a different anatomic site. HPV vaccine is not approved for use among females younger than 9 years or older than 26 years of age. Use of the vaccine in females younger than 9 years or older than 26 years is not recommended. Studies with females older than 26 years of age are ongoing. There are no current studies among children younger than 9 years of age. Quadrivalent HPV vaccine is not licensed for use among males, and off-label use among males is not recommended. While data on immunogenicity and safety are available for 915-year-old males, there are no data on efficacy in males at any age. Efficacy studies among males are under way. Females who have an equivocal or abnormal Pap test could be infected with any of more than 40 high-risk or low-risk genital HPV types. It is unlikely that such females would be infected with all four HPV vaccine types, and they may not be infected with any HPV vaccine type.
Women younger than 27 years with a previously abnormal Pap test may be vaccinated. Women should be advised that data do not indicate the vaccine will have any therapeutic effect on existing HPV infection or cervical lesions. Females who have a positive HPV DNA test (Hybrid Capture 2)done in conjunction with a Pap test could be infected with any of 13 high-risk types. This assay does not identify specific HPV types, and testing for specific HPV types is not done routinely in clinical practice. Women younger than 27 years with a positive HPV DNA test may be vaccinated. HPV DNA testing is not a prerequisite for vaccination. Women should be advised that the vaccine will not have a therapeutic effect on existing HPV infection or cervical lesions. A history of genital warts or clinically evident genital warts indicates infection with HPV, most often type 6 or 11. However, these females may be infected with HPV types other than the vaccine types, and therefore they may receive HPV vaccine if they are in the recommended age group. Women with a history of genital warts should be advised that data do not indicate the vaccine will have any therapeutic effect on existing HPV infection or genital warts. Because quadrivalent HPV vaccine is a subunit vaccine, it can be administered to females who are immunosuppressed because of disease or medications. However, the immune response and vaccine efficacy might be less than that in persons who are immunocompetent. Women who are breastfeeding may receive HPV vaccine.
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Adverse Reactions Following Vaccination The most common adverse reactions reported during clinical trials of HPV vaccine were:
Local reactions at the site of injection. These were most commonly pain (84%), swelling (25%), and erythema (25%). The majority of injection-site adverse experiences reported by recipients of quadrivalent HPV vaccine were mild to moderate in intensity. Fever was reported within 15 days of vaccination by 10% of vaccine recipients and 9% of placebo recipients. No serious adverse reactions have been reported. A variety of systemic adverse reactions were reported by vaccine recipients, including nausea, dizziness, myalgia and malaise. However, these symptoms occurred with equal frequency among both vaccine and placebo recipients.
If a woman is found to be pregnant after initiating the vaccination series, the remainder of the three dose regimen should be delayed until after completion of the pregnancy. If a vaccine dose has been administered during pregnancy, no intervention is indicated. A vaccine in pregnancy registry has been established; patients and healthcare providers are urged to report any exposure to quadrivalent HPV vaccine during pregnancy by calling (800) 986-8999.
Vaccine Storage and Handling HPV vaccine should be stored continuously at 3546F (28C) and should be protected from light. The vaccine should be removed from refrigeration immediately before administration. The vaccine must not be exposed to freezing temperature. Vaccine exposed to freezing temperature should never be administered. Serious reactions following HPV vaccination should be reported promptly to the Ministry of Health through the Medical Officer in charge of the EPI Programme.
Contraindications and Precautions to Vaccination
A severe allergic reaction (acute respiratory distress or collapse) to a vaccine component or following a prior dose of HPV vaccine is a contraindication to receipt of HPV vaccine. A moderate or severe acute illness is a precaution to vaccination, and vaccination should be deferred until symptoms of the acute illness improve. A minor acute illness (e.g., diarrhea or mild upper respiratory tract infection, with or without fever) is not a reason to defer vaccination. HPV vaccine is not recommended for use during pregnancy. The vaccine has not been associated with adverse outcomes of pregnancy or with adverse effects on the developing fetus. However, data on vaccination during pregnancy are limited. Until further information is available, initiation of the vaccine series should be delayed until after completion of the pregnancy.
ROTAVIRUS Description and Etiologic Agent Rotavirus is a virus that causes acute gastroenteritis (inflammation of the stomach and intestines). It is a segmented dsRNA virus with at least 7 distinct antigenic groups A through C.
Transmission Transmission is by the fecal-oral route. Rotavirus can be found on hard surfaces and so fomites can also serve as a mode of transmission. There have been rare reports of transmission via contaminated food and water. The incubation period ranges from 1-3 days.
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Symptoms Acute onset of fever and vomiting followed in 24-48 hours by severe watery diarrhea. These symptoms usually last 3-8 days. Complications Moderate to severe cases can result in dehydration and electrolyte abnormalities. Diagnosis Specific enzyme immunoassays are used to detect rotavirus antigen in the stool Treatment Treatment is symptomatic. Fluids and electrolytes are given to treat or prevent dehydration. Prevention Rotavirus is best prevented by the rotavirus vaccine. It is given by mouth and works to prevent infection from the serotypes which cause severe illness. There are two brands of rotavirus vaccine which are both effective. RotaTeq (pentavalent), which does NOT require reconstitution and Rotarix (monovalent) which comes with a prefilled oral applicator of diluent. Both vaccine components should be stored at 2-8 o C; the diluent may be stored at room temperature. The doses are given at 2, 4 and 6 months depending on the brand of vaccine given. The first dose can be given as early as 6 weeks but should be given before 15 weeks of age. The last dose should be given by 8 months of age. Adverse events and severe complications should be reported to the Ministry of Health through the EPI Program.
THE ROTAVIRUS VACCINES There are two (2) rotavirus vaccines that are available. Both vaccines are oral, that is can be given by mouth. One of the vaccines is made by a manufacturer GlaxoSmithKline (GSK) and the other by Merck. These vaccines are being used in other countries of the Americas. The vaccine manufactured by GSK is Rotarix and that by Merck is Rotateq. Both vaccines are live attenuated vaccines of which the origin of Rotarix is a monovalent human strain and Rotateq is pentavalent human bovine strain. Rotateq Vaccine and Rotarix Vaccine The Rotateq Vaccine protects against rotavirus gastroenteritis or diarrhea in infants and children caused by the serotypes (G1, G2, G3, G4 and P1) in the vaccine. The Rotarix Vaccine protects against rotavirus gastroenteritis or diarrhea in infants and children caused by the serotypes (G1, P8) in the vaccine Rotateq is a live oral vaccine (weakened live strain) consisting of five (5) different strains of rotavirus. It is packed as single doses and contains no preservatives. Rotateq is a pale yellow clear liquid that may have a pink tint. A single dose comes in a small squeezable plastic bottle. The bottle has a twist-off cap that allows for it to work as a dropper directly dropping the liquid in the mouth. Rotarix is packed as single doses and contains no preservatives. It is a lyophilized vaccine reconstituted with a CaCO3 buffer and administered orally.
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How it is stored The vaccine is provided as a single 2-mL oral dose in a buffered stabilizer solution Rotateq and Rotarix vaccines should be stored at a temperature between +20 C and + 8 0C in the refrigerator. Do not freeze. The shelf life of properly stored vaccine is 24 months. When it is given The rotavirus vaccines Rotateq and Rotarix can be given at the same time with other vaccines such as OPV, DPT/Hep B/Hib (pentavalent) and pneumococcal (PCV7). The vaccine should be given as follows: The Rotateq vaccine should be given as follows:
1st dose: 2 months of age 2nd dose: 4 months of age 3rd dose: 6 months of age
Vaccinate infants who have recovered from documented rotavirus infection. Do not repeat dose if infant spits out or regurgitates vaccine and administer the rest of doses on schedule. The number and size of doses Rotateq vaccine - Three doses are given. Each dose is administered as a single 2-mL oral dose in a buffered stabilizer solution. Rotarix vaccine - Two doses are given orally. It is a lyophilized vaccine reconstituted with a CaCO3 buffer and administered orally through an applicator. Where and how it is given Rotateq vaccine is dropped in the mouth from the squeezable plastic tube that contains the vaccine. Administer as soon as possible after it is removed from refrigeration. Rotarix vaccine - Two doses are given orally via an applicator. Special precaution Special precaution (guidance from supervisor/doctor/ MCH director) should be requested prior to administering Rotateq vaccine to infants with the following:
Altered immunocompetence Recent receipt of blood product Acute, moderate to severe gastroenteritis Acute illness Pre-existing chronic GI disease Infants with history of intussusception
Immunize all infants if no contraindications are present. The minimum age of first dose is 6 weeks. The first dose of Rotateq should be administered between 6 and 12 weeks of age (until age 13 weeks). Do not start series after 12 weeks of age. The minimum interval between doses is 4 weeks and the maximum age for ANY dose is 32 weeks. Do not administer on or after age 32 weeks, even if fewer than three doses have been administered. The Rotateq vaccine can be administered simultaneously with all other indicated vaccines. The Rotarix vaccine should be given as follows: 1st dose: 2 months of age, 2nd dose: 4 months of age. Breastfeeding infants should be vaccinated on usual schedule.
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When not to give the vaccines Rotateq vaccine should not be administered to the following infants:
History of hypersensitivity (allergy) to any component of the vaccine Development of symptoms suggestive of hypersensitivity after receiving a dose of the vaccine
Adverse Reaction No serious adverse reactions reported. Other reactions noted:

Fever Diarrhea Vomiting Nasopharyngitis
HOW TO PREVENT ROTAVIRUS Rotavirus is best prevented by the rotavirus vaccine. It is given by mouth and works to prevent infection from the serotypes which cause severe illness. There are two brands of rotavirus vaccine which are both effective. The doses are given at 2, 4 and 6 months depending on the brand of vaccine given. The first dose can be given as early as 6 weeks but should be given before 15 weeks of age. The last dose should be given by 8 months of age. WHO SHOULD NOT GET ROTAVIRUS VACCINE A baby who has had a severe life threatening reaction to a previous dose of rotavirus vaccine should not receive any further doses. A baby with SCID (severe combined immunodeficiency) should not receive rotavirus vaccine WHAT ARE THE RISKS FROM RECEIVING THE ROTAVIRUS VACCINE Mild problems: Irritability, mild vomiting and diarrhea Severe problems: Some studies have shown a small increase in cases of intussusception within a week after the first dose of rotavirus vaccine. Intussusception is a type of bowel blockage that is treated in a hospital. In some cases surgery might be required. The estimated risk is 1 intussusception case per 100,000 infants. Adapted from CDC Vaccine Information Statement: Yellow Fever Vaccine
Immuno-compromised household member is afforded protection by vaccination of young children in the household. This outweighs the small risk for transmitting vaccine virus to the immuno-compromised household member. Household members should employ hygienic measures such as good hand washing after contact with the faeces of the vaccinated infant. Serious reactions following rotavirus Rotateq vaccine must be reported promptly to the Ministry of Health through the Medical Officer in charge of EPI.
ROTAVIRUS VACCINE FACT SHEET What you should know WHAT IS ROTAVIRUS Rotavirus is a virus that causes diarrhea in babies and young children. It can sometimes be very severe and lead to dehydration and eventually death. It is often accompanied by fever and vomiting. It is one of the most common causes of serious vomiting and diarrhea in infancy.
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INFLUENZA WHAT IS INFLUENZA? Influenza is an acute viral disease of the respiratory tract affecting all ages. Three types of influenza virus are recognized: A, B and C. Virus type is determined by the antigenic properties of the two relatively stable structural proteins, the nucleoprotein and the matrix protein.
Influenza A subtypes are classified by the antigenic properties of the surface glycoproteins, the hemagglutinin (H) and the neuraminidase. Emergence of completely new subtypes (antigenic shift) occurs at irregular intervals and only with type A viruses. They are responsible for pandemics and result from the unpredictable recombination of human and swine or avian (usually duck) antigens. The relatively minor antigenic changes (antigenic drift) of A and B viruses that are responsible for frequent epidemics and regional outbreaks occur constantly, necessitating periodic (almost annual) reformulation of influenza vaccine. In pandemics, epidemics and localized outbreaks, clinical attack rates range from 10% to 20% in the general community to greater than 50% in closed populations such as boarding schools or nursing homes. In temperate zones, epidemics tend to occur in winter; in the tropics, they often occur in the rainy season, but outbreaks or sporadic cases may occur in any month. HOW IS INFLUENZA SPREAD? Humans are the primary reservoir for human infections. However, mammalian reservoirs such as swine and avian reservoirs such as ducks, are likely
sources of new human subtypes and are thought to emerge through genetic re-assortment. New subtypes of a virulent virus strain with new surface antigens cause pandemic influenza by spreading through an essentially non-immune population. Airborne spread predominates among crowded populations in enclosed spaces, such as school buses. Transmission may also occur by direct contact, since the influenza virus may persist for hours, particularly in the cold and in low humidity. The period of communicability is probably 3-5 days from clinical onset in adults and up to 7 days in young children. WHAT ARE THE SIGNS AND SYMPTOMS? The incubation period is short, usually 1-3 days. Fever, headache, myalgia, prostration, coryza, sore throat and cough characterize influenza. Cough is often severe and protracted, but other manifestations are usually self-limited with recovery in 2-7 days. Recognition is commonly by epidemiological characteristic and sporadic cases can be identified only by laboratory testing. Influenza in children may be indistinguishable from disease caused by other respiratory viruses. Influenza virus may cause the clinical picture of the common cold, croup, bronchiolitis, viral pneumonia and undifferentiated acute respiratory disease. Gastrointestinal tract manifestations (nausea, vomiting, and diarrhea) may accompany the respiratory phase, particularly in children, and have been reported in up to 25% of children in school outbreaks of influenza B and A.
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WHAT ARE THE COMPLICATIONS? Influenza derives its importance from the rapidity with which epidemics evolve the widespread morbidity and the seriousness of complications, notably viral and bacterial pneumonia. During major epidemics, severe illness and death occur primarily among the elderly and those debilitated by chronic cardiac, pulmonary, renal or metabolic disease, anemia or immuno-suppression. The proportion of total deaths associated with pneumonia and influenza in excess of the proportion expected for the time of year (excess mortality) varies from epidemic to epidemic depending on the prevalent virus type. In the USA, more than 10,000 excess deaths were reported during each of 7 of the 11 influenza seasons between 1977 and 1988, and more than 40,000 total excess deaths were reported during each of two seasons. In all 11 years, 80%-90% of deaths occurred in persons > 65 years of age. However, in the 1918 pandemic, the highest mortality rates were among young adults. The Reye syndrome, involving the CNS and liver, is a rare complication in children who have ingested salicylates. It occurred mainly in children with influenza B disease and less frequently with influenza A. During the early febrile stage of disease, laboratory confirmation is made by isolation of influenza viruses from pharyngeal or nasal secretions or washings in cell culture or embryonated eggs, and/or by direct identification of viral antigens in nasopharyngeal cells by FA test or ELISA. Infection may also be confirmed by demonstration of a specific serologic response between acute and convalescent sera.
WHAT IS THE TREATMENT FOR INFLUENZA? Specific treatment - Amantadine or rimantadine started within 48 hours of onset of influenza A illness and given for approximately 3-5 days reduces symptoms and virus titers in the respiratory secretions. Doses should be reduced for those > 65 years of age or those with decreased hepatic and renal function. Amantadine is associated with CNS side effects in 5%-10% of recipients. These may be more severe in the elderly or those with impaired kidney function. For this reason, persons with underlying renal disease should have reductions in dosage reflecting the degree of renal impairment. Rimantadine is reported to cause fewer CNS side effects. The use of these drugs should be considered in non-immunized persons or groups at high risk of complications, such as institutions or nursing homes for the elderly, when an appropriate vaccine is not available, or as a supplement to vaccine when immediate maximal protection is desired against influenza A infection. The drug should be continued throughout the epidemic. It will not interfere with the response to influenza vaccine. During treatment with either drug, drug-resistant viruses may emerge late in the course of treatment and may be transmitted to others. Therefore, cohorts of people on antiviral therapy should be considered, especially in closed populations with many highrisk individuals. Patients should be watched for development of bacterial complications, and only then should antibiotics be administered. Because of the association with the Reye syndrome, salicylates should be avoided in children.
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HOW IS INFLUENZA PREVENTED? When a new subtype appears all children and adults are equally susceptible, except those who have lived through earlier epidemics caused by the same subtype. Infection produces immunity to the specific infecting virus, but the duration and breadth of immunity depend on the degree of antigenic drift and the number of previous infections. Vaccines produce serologic responses specific for the included viruses and elicit booster responses to related strains with which the individual has had prior experience. Age-specific attack rates during an epidemic reflect persisting immunity from past experience with strains related to the epidemic subtype, so that incidence of infection is often highest in school-aged children. Thus, with the H1N1 epidemics occurring after 1977, the incidence of disease has been greatest among those born after 1957; most people born before this time had partial immunity from infection with antigenically related H1N1 viruses that circulated between 1918 and 1957. Preventive measures
1) Educate the public and healthcare personnel in basic personal hygiene, especially the danger of unprotected coughs and sneezes, and hand-tomucous membrane transmission. 2) Immunization with available killed-virus vaccines may provide 70%-80% protection against infection in healthy young adults when the vaccine antigen closely matches the circulating strains of virus. However, in the elderly, immunization may be less effective in preventing illness but may reduce the severity of disease and the incidence of complications by 50%-60% and death by approximately 80%. Influenza immunization should be coupled with immunization against pneumococcal pneumonia.
A single dose suffices for those with prior exposure to influenza A and B viruses (i.e. person > 9 years old); 2 doses of vaccine 1 month apart are required for younger persons who have no pervious immunization history. Routine immunization programs should be directed primarily at those at the greatest risk of serious complications or death and those who might spread infection to them (healthcare personnel and household contacts of high-risk people). Immunization of children on long-term aspirin therapy is also recommended to prevent the development of the Reye syndrome after influenza infection. Immunization should also be considered for those engaged in essential community services and is recommended for military personnel. However, any individual may benefit from immunization. The vaccine should be given each year before influenza is expected in the community (November to March in the USA). For those travelling, timing of immunization should be based on the different seasonal patterns of influenza in different parts of the world (April to September in the Southern Hemisphere and tropics). Yearly recommendations for vaccine components are based on the viral strains currently circulating, as determined by international surveillance. C. Epidemic measures:
1) The severe and often disrupting effects of epidemic influenza on community activities may be reduced in part by effective health planning and education, particularly locally organized immunization programs for high-risk patients and their care providers. Surveillance by health authorities of the extent and progress of outbreaks and the reporting of findings to the community are important.
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2) Closing of individual schools has not proven to be an effective control measure; it has generally been applied too late and occurs because of high absenteeism of students and staff. 3) Hospital administrators should anticipate the increased demand for medical care during epidemic periods. There may also be excessive absenteeism of healthcare personnel as a result of influenza. To prevent this, healthcare personnel can be immunized annually.
When it is given/Number and size of doses The vaccine is preferably administered before the onset of the influenza season. It is usually recommended for person 65 years of age or older, persons who are in long term care facilities, persons older than 6 months of age with chronic illnesses, persons 6 months to 18 years receiving chronic aspirin therapy. It is usually given in 1 or 2 doses dependent on whether the person has been vaccinated during a previous influenza season. 1 dose of vaccine is usually administered annually for persons 9 years of age or older. Children 6 months to 9 years, receiving vaccines for the first time should receive two doses administered at least 1 month apart. Where and how it is given The vaccine is given intramuscularly (IM). Children less than 3 years usually receive 0.25 ml and children older than 3 years, receive 0.5 mls. (Please read manufacturers instructions). Contraindications Allergic hypersensitivity to egg protein or other vaccine components is a contraindication. During the swine influenza vaccine program in 1976, an increased risk of developing Guillain-Barre syndrome (GBS) within 6 weeks following receipt of the vaccine was reported in the USA. Subsequent vaccines produced from other virus strains have not been clearly associated with an increased risk of GBS. Moderate to severe acute contraindications to vaccination. illnesses are
INFLUENZA VACCINE What it is Influenza vaccine is prepared each year using virus strains similar to those considered most likely to be circulating in the forthcoming winter. The highly purified viruses are grown in embryonated hens eggs, chemically inactivated and then further treated and purified. Current vaccines are trivalent containing two type A and one type B sub-types and in recent years have given a good match with subsequently circulating viruses.
Two types of vaccine are available, the split virus vaccines (containing virus components prepared by treating whole viruses with organic solvents or detergents and then centrifuging), and surface antigen vaccines (containing highly purified haemagglutinin and neuraminidase antigens prepared from disrupted virus particles). The vaccines are equivalent in efficacy and adverse reactions. How it is stored Influenza vaccines should be stored at 20 C to +80C but not frozen. Freezing and heat destroys the potency of the vaccine. The vaccine should be protected from light.
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Adverse Reactions
Local reactions are usually soreness, redness and induration at the site of injection. These are usually transient, lasting 1-2 days. Local reactions have been reported in about 15% of recipients of the vaccine. Fever, chills, malaise and myalgia have been reported in less than 1% of recipients of the vaccine. This tends to occur within 6-12 hours of vaccination and lasts 1-2 days. It has been said that systemic symptoms are no more common than in persons given a placebo injection. Anaphylactic reactions are very rare.
Serious reactions following Influenza immunization should be reported promptly to the Ministry of Health through the EPI Manager.
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APPENDICES
DOCUMENTATION
INSIDE OF IMMUNIZATION CARD FRONT SIDE OF CONTROL CARD REFRIGERATOR TEMPERATURE RECORD REMARKS:
Monitoring the Refrigerator Temperature Record the temperature twice daily Record the morning reading on left side in date space and the evening on the right by making a dot in the appropriate space Connect all dots Put your initial Temperature between 2C and 8C no action necessary Abnormal Temperature < 2C or > 8C If temperature is below 2C Adjust refrigerator thermostat Remove extra water bottles Inspect freeze- sensitive vaccines Conduct shake test Recheck temperature Alert clinic supervisor Record all actions taken Inform National Immunization Coordinator
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If Temperature is above 8C Check door seal Remove vaccines to a working refrigerator Alert clinic supervisor Record all actions taken Inform National Immunization Coordinator Action Plan for Abnormal Refrigerator Temperature Adjust temperature gauge Ensure H2O bottles in refrigerator Check refrigerator door seal Alert clinic supervisor
Record all actions taken Clinic supervisor inform the National EPI Coordinator immediately National EPI Coordinator will document information and inform Administrator of Public Health in order to have the fridge repaired
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ANNEX 4 MONTHLY MONITORING OF IMMUNIZATION COVERAGE CHART COUNTRY: Bahamas (EPI DISTRICT) : ___________ FULL IMMUNIZATION OF CHILDREN AGED UNDER ONE YEAR TYPE OF IMMUNIZATION DPT/Hib/Hep B/ (FULL IMMUNIZATION = 3 DOSES) Estimated Live Births: Estimated Infant Deaths: 8 (b) Estimated Target Population: 240 (a)-(b) (Annual Target Population = Live Births - Infant Deaths) YEAR:2013
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(a)
1. Enter in boxes A the preliminary data of the number of children fully immunized during that month for the clinic area 2. Enter in box B the total cumulative number of doses (add box [A] and [C]). 3. Enter in box C the total doses received from other clinics during the month for the clinic 4. Enter in box D the cumulative doses from other clinics 5. Plot monthly progress on the graph by marking X for the cumulative total at the end of each month and join with a solid line.
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DPH - National Immunization Manual - Nov-2013

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NATIONAL IMMUNIZATION MANUAL

MINISTRY OF HEALTH - DEPARTMENT OF PUBLIC HEALTH

THE COMMONWEALTH OF THE BAHAMAS

NATIONAL IMMUNIZATION MANUAL

MINISTRY OF HEALTH - DEPARTMENT OF PUBLIC HEALTH

THE COMMONWEALTH OF THE BAHAMAS

NATIONAL IMMUNIZATION MANUAL

MINISTRY OF HEALTH - DEPARTMENT OF PUBLIC HEALTH

THE COMMONWEALTH OF THE BAHAMAS

NATIONAL IMMUNIZATION MANUAL

Extract from Universal Child Immunization by 1990- UNICEF

MINISTRY OF HEALTH - DEPARTMENT OF PUBLIC HEALTH

Commonly Used Abbreviations

THE COMMONWEALTH OF THE BAHAMAS

NATIONAL IMMUNIZATION MANUAL

EPI MISSION STATEMENT

OBJECTIVES OF EPI MANUAL

OBJECTIVES OF THE EXPANDED PROGRAM ON IMMUNIZATION

MINISTRY OF HEALTH - DEPARTMENT OF PUBLIC HEALTH

Overview of The Expanded Programme on Immunization

THE COMMONWEALTH OF THE BAHAMAS

NATIONAL IMMUNIZATION MANUAL

Trend of Vaccine Preventable Diseases

MINISTRY OF HEALTH - DEPARTMENT OF PUBLIC HEALTH

Overview of The Expanded Programme on Immunization

THE COMMONWEALTH OF THE BAHAMAS

NATIONAL IMMUNIZATION MANUAL

National Immunization Schedule (Revised)

Pearl McMillan (Dr.) Director of Public Health, May 1, 2012

MINISTRY OF HEALTH - DEPARTMENT OF PUBLIC HEALTH

National Immunization Schedule (Revised) The Bahamas 2012

THE COMMONWEALTH OF THE BAHAMAS

NATIONAL IMMUNIZATION MANUAL

Vaccination for Women of Childbearing Age

Varicella Meningococcal Polysaccharide Conjugate Pneumococcal Polysaccharide

MINISTRY OF HEALTH - DEPARTMENT OF PUBLIC HEALTH

Recommended Tdap Schedule for Pregnant Women

6 8 weeks 12 months following following initial dose 2nd dose

Any period During gestation

THE COMMONWEALTH OF THE BAHAMAS

NATIONAL IMMUNIZATION MANUAL

4 weeks HIB 6 weeks 8 weeks2 ( if first dose age 12-14 months)

6 months3 (minimum age 4 years for final dose)

MINISTRY OF HEALTH - DEPARTMENT OF PUBLIC HEALTH

Catch-Up Vaccine Schedule for Children 7 - 18 Years of age

Tetanus, Diphtheria, Pertussis

8 weeks (and at least 16 weeks after the first dose)

Hepatitis A Human Papillomavirus(HPV)

6 months Routine dosing intervals are recommended

THE COMMONWEALTH OF THE BAHAMAS

NATIONAL IMMUNIZATION MANUAL

Recommended Immunizations of HealthCare Workers in the Bahamas

MINISTRY OF HEALTH - DEPARTMENT OF PUBLIC HEALTH

THE COMMONWEALTH OF THE BAHAMAS

NATIONAL IMMUNIZATION MANUAL

MINISTRY OF HEALTH - DEPARTMENT OF PUBLIC HEALTH

THE COMMONWEALTH OF THE BAHAMAS

NATIONAL IMMUNIZATION MANUAL

Recommended Immunizations of HealthCare Workers in the Caribbean

MINISTRY OF HEALTH - DEPARTMENT OF PUBLIC HEALTH

Recommended Tdap Schedule for Pregnant Women

THE COMMONWEALTH OF THE BAHAMAS

NATIONAL IMMUNIZATION MANUAL

Recommended Immunizations of HealthCare Workers in the Caribbean