Imunisasi Untuk Jemaah

Haji
Agus Widiyatmoko
 UPAYA PREVENTIF

Imunisasi pre perjalanan

Pertimbangan penting sebelum imunisasi pre perjalanan

• Imunisasi sebelumnya
• Kebutuhan kesehatan
• Lokasi / Eksposur/ Daerah endemis
 • Wajib • Disarankan
Imunisasi Pre • Yellow Fever (jika • Polio
Perjalanan ke daerah endemis) • Tetanus / Difteri /
• Meningokokus Pertusis
• Influenza
• Campak
• Hepatitis A / B
• Penyakit Typhosa
• Rabies
• Japanese
Encephalitis
• Tick-borne
Encephalitis
Vaccine Risk Region
Yellow fever Parts of Africa and South America. (travel.state.gov)
Hepatitis B SE Asia, parts of Africa, Middle East, Pacific Islands,
parts of South America
Hepatitis A All except Japan, Australia, New Zealand, north and
west Europe, North America (except Mexico)
Typhoid Developing countries
Meningococcal Sub Saharan Africa
Japanese Encephalitis Indian Subcontinent, SE Asia
Cholera Outbreak setting
Rabies South and SE Asia, Mexico, parts of South and Central
America and Africa
Plague Outbreak Setting

Destination Specific Vaccines

 Jadwal
Imunisasi
Dewasa
MENINGITIS
 • Neisseria
Meningitidis
• Gram negative
diplococci
• Youngest children =
highest risk
• 0.5-10/100,000 in
non-epidemic areas
• Up to 1,000/100,000
in epidemic areas
Meningococcal
Overview of Meningococcal Disease
Epidemiology

• Meningococcal disease occurs worldwide

• Endemic
• Epidemic
• Annual global total of about 500,000 IMD cases
• CFR 5-20%
• Incidence differs
• Age
• Geographic location
• Time / Seasons
• <1-3/100,000 (Western) & 10-25/100,000 (developing countries)
• Importance of asymptomatic carriers, especially adolescents
• Surveillance issues result in under-reporting in many countries
 • Sub-Saharan Africa
• Greatest risk: dry
season (Dec. - June)
• Risk of travelers
• 0.4/100,000
• Hajj pilgrimage to
Saudia Arabia
associated with
outbreaks

“Meningitis Belt”
Typical Development of Meningococcal
Disease Clinical Features Over Time
PENULARAN

“Droplet infection”- kontak langsung

Penularan sering melalui “carrier”

MASA INKUBASI 2-10 HARI (UMUMNYA 2-3 HARI)

DIAGNOSA: Anamnesa, Gejala dan tanda, Laboratorium

Lesi epitel mukosa nasofaring  penyebaran hematogen

GEJALA DAN TANDA

Panas Mual/
Rash dikulit Ekimosis
mendadak muntah

Kesadaran
Nyeri kepala Kaku kuduk Fisik lemah menurun
koma
Increasing International Travel Presents Opportunities
for Meningococcal Disease Exposure and Spread

• During the Hajj >2 million pilgrims from 140 countries

visit Mecca
• Due to multiple meningococcal outbreaks over the past
decade, the ACWY-PS vaccine is required in order to
obtain Hajj/Umrah visas
• Risk of exposure to meningococcal disease for those
traveling to the African meningitis belt
Serotipe Vaksin Meningitis
Global Neisseria meningitidis Serogroup Distribution Is
Varied and Dynamic, Making Trends Unpredictable
 • Vaccine required
to attend the Hajj
(annual pilgrimage
to Mecca)
• If under age 15,
polio vaccination
needed also

Meningococcal Disease
 MCV4 (Menactra™)
• 2-55 years old
• Preferred in <11 year olds

MPVS4 (Menomune®)
Meningococcal
Vaccine • 2 years and older
• Use for >55 years old

MenACWY-CRM (Menveo®)
• 11-55 years old
• Licensed for use in 2010
Quadrivalent Meningitis Vaccine MenACYW-
CRM conjugate
• Menveo® is the first and only quadrivalent conjugate vaccine that has demonstrated robust
immune responses in:
• Infants from the age of 2 months
• Older adults over 55 years
• Demonstrated persistence of bactericidal antibodies out to 36 months compared with other
conjugated vaccines
• Concomitant administration with other routine vaccines did not adversely affect immune
response or tolerability
• Well tolerated in all age groups studied
• Menveo® has demonstrated the characteristics expected from a conjugated polysaccharide
vaccine
• Elicits immune memory
• Repeated doses not associated with hyporesponsiveness
• Elicits robust immune responses in infants
• Clinical data on reduction of carriage (study on going)
 If high-risk (epidemic area or travel)

• If vaccine given at 2-6 years old

• Repeat after 3 years, then every 5 years
Revaccination • If vaccine given >6 years old
• Repeat every 5 years

Indonesia  every 2 years

Kapan harus diberikan ?

• Paling lambat 10-14 hari sebelum berangkat ke daerah

endemis. Khusus untuk haji biasanya diberikan
bersamaan dengan pemeriksaan kesehatan di Dinas
Kesehatan
Cara Pemberian

• Vaksin disuntik di area deltoid

dengan dosis tunggal 0,5 ml ,
intramuskuler (i.m)
• Waktu pemberian : 2 minggu
sebelum tiba di Arab Saudi,
antibodi akan terbentuk
sempurna 2 minggu setelah
penyuntikan
• Kekebalan : 2 - 3 tahun
Bagaimana kalau tidak divaksin tapi dapat
surat keterangan saja?

• Berarti tidak melindungi diri dari penularan MN sehingga berisiko

terinfeksi dan dapat menjadi karier dan membawa kuman tersebut
ke keluarga / kerabat di Indonesia
Adakah efek samping vaksinasi?

• Efek samping pada umumnya ringan

• Reaksi lokal : nyeri tempat suntikan, kemerahan
• Sistemik : demam (jarang)
Siapa yang harus divaksin ?

• Mereka yang bepergian ke daerah endemis MN

• Calon jemaah haji
• Calon jemaah umroh
• Calon tenaga kerja yang akan bekerja di daerah endemis
• Wisatawan / pelajar yang akan bepergian ke daerah endemis
Influenza
Influenza Pandemics in 20th/ 21st
Centuries
 Human Bird Flu, Worldwide

• 10 countries
• 128 deaths of 225
confirmed
• 57% case fatality rate
 Karakteristik virus Influenza

• Influenza virus tipe A, B, C1

• A & B mayor, C tidak penting dalam klinis
• Influenza A virus (spikes):
• haemagglutinins = H1, H2, H3, +
• neuraminidases = N1, N2, +
Nomenklatur Virus Influenza
Aspek Medis dari influenza

• Penyakit yang sangat infeksius/menular

• Infeksi saluran nafas atas akut
• Infeksi dapat berulang (adanya mutasi virus)
• Ditularkan melalui rute udara (airborne):
• batuk/bersin/bicara
• kontaminasi pada saputangan / tangan
• Periode inkubasi 2-3 hari1
Gejala Influenza

• Mendadak: • Disertai dengan:

• demam • batuk
• lemah • meler / mampet
• menggigil • bersin
• sakit kepala
• tdk nafsu makan
• sakit otot
• dizziness
Influenza vs common cold
Diagnosa Influenza

• Selama epidemi/pandemi:
• mudah
• pasien dengan gejala infeksi sama sangat mungkin
terinfeksi

• Musim normal:
• sering spekulasi
• laboratorium diagnosa pasti – tapi jarang dilakukan
Komplikasi Influenza

• Bronchitis – Paling sering

• Pneumonia karena virusnya atau sekunder (bakteri) 
paling serius
• Kematian
Grup resiko tinggi terhadap influenza

• Mempunyai resiko akan komplikasi peny. lain:

• orang > 65 tahun
• rumah perawatan / rumah sakit / panti
• anak dan dewasa dengan kondisi:
• peny paru kronis atau gangguan penyakit kardiovaskular
• peny kronis metabolik, disfungsi renal/ginjal, kelainan darah dan peny imunosupresi
• Peningkatan resiko:
• anak dan orang muda yang diterapi aspirin
• wanita hamil
• travellers
Influenza virus: variasi antigenik – Mutasi
Virus

• Virus2 influenza sering mengalami perubahan2 cepat dan tak

terpredeksi terhadap ciri antigen
• Vaksin2 harus diganti setiap tahun agar cocok dengan virus2 yang
bersirkulasi

• Antigenic drifts – menghasilkan varian2 virus minor karena mutasi (A

dan B) dan menyebabkan epidemik

• Antigenic shifts – menghasilkan strain2 baru mayor yang berbahaya dan

disebabkan karena genetic reassortment (hanya virus tipe A) dan
menyebabkan pandemi
Genetic reassortment hypothesis (influenza
A virus)
Influenza virus: antigenic shifts
Terapi anti virus untuk Influenza

• M2 ion-channel blockers – amantadine dan rimantadine

• Neuraminidase inhibitors – zanamivir and oseltamivir
• Ada kekhawatiran resisten
• Ada benefit potensial saat pandemi
• Vaksin tetap merupakan intervensi pertama (first- line intervention)
Kenapa Vaksinasi melawan Influenza ?

• Terbatasnya pengobatan yang tersedia

• Vaksinasi mewakili ‘ first line intervention’
• Penelitian ‘cost–benefits’ vaksinasi banyak dan menunjang
Mengapa vaksinasi influenza itu penting?

• Angka kejadian tinggi pada semua tingkatan umur

• Pada orang dewasa influenza sangat sering terjadi
• Pada orang tua, vaksinasi influenza dapat mengurangi angka
kejadian dan kematian
• Cakupan vaksinasi influenza yang masih rendah
• Vaksinasi terhadap influenza memberikan keuntungan biaya/
penghematan
• WHO merekomendasikan imunisasi sehubungan dengan ancaman flu
pandemik
Rekomendasi vaksinasi influenza yang telah
‘well-established’

• Dewasa t/u > 65 tahun

• Individu dengan penyakit kronis
• Rumah sakit / perawatan/ panti
• Individu yang beresiko memberikan transmisi pada pasien pasien
dgn resiko tinggi
• Kehamilan pada trimester 2 dan 3
Proses pemilihan strain-strain virus vaksin
How are Flu vaccines formulated?
• Each year choice of vaccines strains are done according to
the following procedure: (1) National influenza Centers
Sentinel Doctors: (110 national laboratories in over 80
Collect samples of the strain countries)
circulating in patients catching Flu Centralize the results from the sentinel
doctors

Collaborating Reference Centers for

Research against influenza
(London, Atlanta, Tokyo and Melbourne)
Vaccine Manufacturers: Centralize the results from the national
Produce the vaccine containing Flu strains centers
recommended by WHO

World Health Organization (WHO - Geneva)

Recommends 2 times a year the flu strains that
should be in the vaccines

(1). Hannoun C. Role of international networks for the surveillance of influenza. Eur Journal of Epidemiol 1994;10:459-61
Adapted from 1
Kapan vaksinasi influenza ?

• Virus Influenza terdapat di seluruh dunia

• Jelas pada daerah dengan 4 musim:
• Oktober s/d April pd belahan kutub Utara
• Northern Hemisphere
• Mei s/d September pd belahan kutub Selatan
• Southern Hemisphere
• Pada dareah tropis / sub tropis  Indonesia
• terdapat sepanjang tahun
• sering terlihat pola 2 kali setahun
Berapa dosis Vaksin Influenza?

• 1 dosis 0,5 ml, diulang setiap tahun

Pengaruh Vaksin Influenza Pada Jama’ah Haji
Indonesia

100%
Risiko seorang yang tidak mendapat
90%
vaksinasi influenza untuk sakit adalah 2,9
80%
kali dibandingkan risiko seorang yang telah
70%
60%
mendapat vaksinasi influenza.
50%
40%
Healthy
30%
Sick
20%
10%
0%
Vaxigrip No Vacc

Kabat. Pengaruh vaksinasi influenza pada jama’ah Haji Indonesia. Medika 2003 Agustus;29(8):493-500
PNEUMONIA
PNEUMONIA

• Keradangan parenkim paru  asinus terisi cairan eksudat ±

infiltrasi sel radang ke dinding alveoli / interstitium
• Pneumonia = infeksi kuman patogen (mis : bakteri, virus, fungi,
parasit)
• Pneumonitis = noninfeksi (bahan kimia, radiasi, proses
autoimun)
PATOGENESIS

Inhalasi Aspirasi Hematogenous Langsung

Komorbid :
Predisposisi :
diabetes mellitus
influenzae
gagal ginjal
alkoholisme
menahun ggan
gizi jelek / kurang
imuniti
debiliti Mekanisme PPOK
pneumokoniosis
pertahanan paru

PNEUMONIA
DIAGNOSIS PNEUMONIA SECARA KLINIS

• Infiltrat pada foto torak disertai 2 Gejala berikut :

• Demam > 380C
• Lekosistosis > 10.000 / mm3
• Sputum purulen
• Batuk, sesak, nyeri dada
• Fisik : Tanda konsolidasi
Rawat Inap BPHI Mekkah (Pra ARMINA)

5 Besar Penyakit Rawat Inap

Non Insulin Dependent DM Unspecified dementia Chronic obstructive pulmonary disease
Heart failure Pneumonia

Pneumonia
17%
Non Insulin
Dependent DM
26%

Heart failure
17%

Unspecified
dementia
Chronic
21%
obstructive
pulmonary disease
18%
10 DIAGNOSA TERBANYAK RAWAT INAP BPHI MAKKAH TAHUN 1435
H

3% 19%
5%

8%

8%
15%

9%

15%
14%
 10 DIAGNOSA TERBANYAK RAWAT JALAN BPHI MAKKAH TAHUN 1435 H

5%
6% 19%
6%

7%

16%

9%

9%

10%
14%
What CAUSED severe Pneumonia ?
 S. pneumoniae: Causative Agent of Pneumococcal
Disease
• Gram-positive bacterium1
• Polysaccharide capsule1,2
• Virulence factor
• Defines serotype
• Vaccine target
• More than 90 known serotypes1,2
• 11 serotypes account for 70% to 93% of cases of invasive disease worldwide 3

1. CDC. Epidemiology and prevention of vaccine-preventable diseases. 11th ed. 2009;217-230.

2. WHO. Acute respiratory infections (update September 2009). http://www.who.int/vaccine_research/diseases/ari/en/print.html.
Accessed March 16, 2010.
3. Hausdorff WP et al. Clin Infect Dis. 2000;30(1):100-121.
 Transmisions
• Person to person, by respiratory droplet
contact.
• The infectious period - as long as the organism
is present in respiratory secretions
• The incubation period varies by type of
infection and can be as short as 1 to 3 days
• Viral upper respiratory tract infections,
including influenza, can predispose
to pneumococcal infection and transmission.
CDC - Redbook online 2012
Major clinical forms of pneumococcal disease (PD) 1,2

Invasive pneumococcal
disease (IPD)

PNEUMOCOCCAL
DISEASE

Non-invasive pneumococcal
disease (mucosal)

* Acute otitis media

** including empyema

1. WHO. Acute Respiratory Infections (Update September 2009). 2. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine Preventable Diseases. The Pink Book.
11th Edition. May 2009.
 The risk of IPD and Comorbid
Age Risk Factors for Pneumococcal Disease
1
Underlying Medical Conditions2-
Living
Conditions 4 3-5

• Children <2 years • Congenital or acquired immunodeficiency • Childcare outside of the

• Sickle cell disease, asplenia, HIV
• Adults ≥65 years
• Chronic heart, lung (including asthma),
renal, or liver disease
• Cancer
• Cerebrospinal fluid (CSF) leak
• Diabetes
• Chronic alcoholism or cigarette smoking
• Organ or hematopoietic cell
transplantation
• Cochlear implants
home ≥4 hours per week,
and in the presence of ≥2
other children other than
siblings
• Residence in a nursing
home or other long-term
care facility

1. CDC. MMWR Recomm Rep. 1997;46(RR-8):1-24.

2. WHO. Wkly Epidemiol Rec. 2008;83(42):373-384.
3. CDC. MMWR Recomm Rep. 2000;49(RR-9):1-38.
4. CDC. MMWR Morb Mortal Wkly Rep. 2009;57(53):Q1-Q4.
62
5. Levine OS et al. Pediatrics. 1999;103(3):e28.
Millions of Individuals Worldwide Are at Risk for Pneumococcal
Disease: Selected Risk Factors
Risk factor Global prevalence

Smoking 1 billion1
Age ≥65 years 518 million2

Asthma 300 million3

Diabetes 230 million4

COPD 210 million5
Alcohol use disorders 125 million6

HIV 33 million7

1. WHO. Tobacco key facts. http://www.who.int/topics/tobacco/facts/en/index.html. Accessed June 23, 2009.

2. US Census Bureau. Table 094. Midyear population by age and sSex. 2009.
http://www.census.gov/ipc/www/idb/worldpopinfo.html. Accessed June 23, 2009.
3. WHO. Asthma. Fact sheet. http://www.who.int/mediacentre/factsheets/fs307/en/index.html. Accessed June 18, 2009.
4. World Diabetes Foundation. Diabetes facts. http://www.worlddiabetesfoundation.org/composite-35.htm. Accessed
June 18, 2009.
5. WHO. Chronic obstructive pulmonary disease (COPD). Fact sheet.
http://www.who.int/mediacentre/factsheets/fs315/en/index.html. Accessed June 18, 2009.
6. WHO. The global burden of disease: 2004 update.
http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf. Accessed May 5, 2009.
63
7. WHO. World health statistics 2009. http://www.who.int/whosis/whostat/EN_WHS09_Full.pdf. Accessed June 23, 2009.
Strategy to give good immune response among elderly
Pneumococcal Vaccination

• Approximately half of deaths from pneumococcal disease could be

prevented by vaccinations.
Pneumoccocal Vaccines

• Pneumococcal Polysaccharide Vaccine (PPSV)

• 1977: 14 Valent PPSV14
• 1983: 23 Valent PPSV23

• Pneumococcal Conjugate Vaccine (PCV)

• 2000: 7 Valent PCV7
• 2010: 13 Valent PCV13
PPSV23 Vaccine

Pneumococcal disease has more than 90 serotypes.

The 10 most common serotypes cause 62% of

invasive disease worldwide.

PPSV23 protects against 23 serotypes, including

those most likely to cause serious disease.
Pneumococcal Vaccines – PPSV 23

• PPSV 23: Pneumococcal Purified Polysaccharide Vaccine

• Stimulation of B Cells which release IgM without help from T Cells.

• Not Lifetime immunity

• Can prevent 60%-70% of IPD coming from included pneumococcal serotypes

• No consensus on ability to prevent non-bacteremic pneumonia – not really a “PNEUMONIA”

vaccine
Pneumococcal Vaccines – PCV 13

• PCV: Pneumococcal Conjugate Vaccine

• More robust immune response using both T Cells and B Cells

• Results in mucosal immunity

• 12 of the 13 serotypes are also included in PPSV 23

PPSV 23 Recommendations

• One time vaccination for healthy adults >65

• Vaccinate age 19-64 with chronic disease conditions

• Vaccinate age 2-18 with asplenia, CSF leak, cochlear implants,

immunocompromising conditions
PPSV 23 Revaccination

• Only revaccinate if received first dose before age 65

• Once in 5 years for those with asplenia and immunocompromising conditions.

• For all other indications – Revaccinate at age 65; but needs to be given at least 5
years after first dose

• Concern for multiple PPSV 23 dosing

• Lack of known benefit

• Increased reactions/side effects

PCV 13 Recommendations

• All adults age >65

• Will be looked at in 2018 to see if revisions to recommendations are needed

• Will assess burden of IPD and community acquired pneumonia (CAP) in adults

• Adults age 19-64 with high risk and immunocompromising conditions

Who is immunocompromised ?

• Extremes of age
• Patients on immunosuppressant drugs
• Transplant. High dose steroid etc
• Cytotoxic chemotherapy
• Infection: HIV
• Marrow replacement by leukaemia
• Splenectomy
• Rare hereditary disorders
 Immunization

Prevention of Infections Chemoprophylaxis

in the
Immunocompromised
Personal Hygiene

Transmission prevention
Immunization

Inactivated ,toxoid , subunit vaccines

• used when appropriate
• No increased risk of complications
• immune responses maybe inadequate
• Response depends on presence of immunosuppression during or within 2
weeks of immunization
Red Book, 2006
Immunization
Live vaccines : NOT recommended
Vaccines which may be given:
• Pneumococcal
• Meningococcal
• annual Influenza
• MMR / Varicella

Red Book, 2006

Immunization

Consider unimmunized :
• vaccinated while on immunosuppressive therapy
• 2 weeks before starting therapy

Revaccinate 3 months after discontinuation of therapy.

CDC, Epidemiology and Prevention of Vaccine-

Preventable Diseases, 4th Edition, September 1997.
Immunization in patients receiving high dose
steroids

• wait at least 1 month after discontinuation of high dose systemically

absorbed corticosteroid therapy before administering a live-virus vaccine.
Immunization in persons with Malignant
Neoplasms

• delaying the administration of influenza vaccine for 3 months risky for

patient
• wait 3 to 4 weeks after immunosuppressive therapy before administering
influenza immunization.
• Reasonable response if peripheral granulocytes and lymphocytes exceed
1,000 cells/μL
AAP,2006
Immunization in immunosuppressed oncology
patients

• Live vaccines generally avoided

• leukemia patients in remission may receive livevirus vaccines 3 months
after their last round of chemotherapy
• VZV indicated for children with ALL in remission for at least 1 year must
have lymphocyte counts > 700 cells/mL platelet counts > 100,000 cells/mL
24 hours before the immunization

J Am Pharm Assoc 41(6):839-849, 2001

Immunization in Transplant recipients

• Vaccinate at least 2 weeks before transplantation

• Live vaccines deferred once transplant has been performed
• all inactivated vaccines recommended plus those vaccines recommended for
patients with chronic diseases
• household contacts should also be immunized.
• Post renal transplantation, immunization may not be effective for 6 to 8 months
• Prophylactic antibiotics and antivirals can serve as valuable adjuncts

J Am Pharm Assoc 41(6):839-849, 2001

Immunization in Chronic renal disease undergoing
dialysis

• Bacterial and viral infection

• All standard immunization required
• Ensure optimal protection : varicella, hepatitis B, influenza ,
pneumococcal disease
• Yearly influenza immunization
• Household contact
• Hepatitis B: double dose, booster for antiHBsAg < 10 IU/L
• Varicella

Canadian Immunization Guide 7th edition, 2006

Immunization in Asplenic Patients

• NO contraindication for any vaccines

• Receive all routine immunization
• Optimal protection :
S. pneumonia, H. influenzae, N. meningitidis
• Yearly influenza vaccination

Canadian Immunization Guide 7th edition, 2006

Immunization in Asplenic patients

• Pneumococcal vaccine :
• Children :
reimmunized within 4 to 5 years
• Adults and adolescents :
2nd dose > 6 years have elapsed
• Meningococcal vaccine :booster q 2-5 yrs

Canadian Immunization Guide 7th edition, 2006

Vaccination Intervals

• Can not give together

• Best to give PCV 13 first, then PPSV 23

• Give PPSV 23 at minimum interval of 8 weeks after PCV 13

• In adults, studies showed:
• Shorter intervals between PCV 13 and PPSV 23 may lead to greater local reactions
• Longer intervals ( >1 year) may lead to better immune response to the common
serotypes of the 2 vaccines
Vaccination Intervals

• Immunocompetent adults age >65

• If given PCV 13 first then PPSV 23: 1 year (was 6-12 months)

• If given PPSV 23 first then PCV 13: 1 year

Vaccination Intervals

• PCV 13: PPSV 23 Sequence

• Age 2–64 years: 8 week minimum, for all PPSV 23 indications

• PPSV 23: PCV 13 Sequence

• Age 2–18 years: 8 week minimum

• Age 19–64 years: 1 year minimum

• These intervals for all PCV 13 indications
Side Effects

• PPSV 23
• Swelling/erythema/tenderness at injection site - common

• Myalgia/headache/fatigue – 5-15%

• Severe local reactions/fever - rare

• PCV 13
• For adults, similar to PPSV 23
ALHAMDULILLAH