Thursday, February 28, 2013

Immunization And A Typical Example Of A National Vaccination Plan, Taking Ukraine As A Case Study




Protection from infectious diseases is referred to immunity. That’s why immune prophylaxis is the most potential method of infectious diseases prevention. World experience shows that potential risk of post immunization reactions and complications is very low. And risk of infectious diseases’ complications and mortality really overweight them. Ambulatory pediatrician plays the main role in immune prophylaxis program. Organization of immune prophylaxis is the main prophylactic work of the ambulatory pediatrician.

The immunoprophylaxis task is management by immunological answer to prevent the disease beside separate persons and groups of the population.

The ways of the immunoprophylaxis:
Active - stimulation of own antibodies production,
Passive - introduction of ready antibodies.

Vaccines preparations characteristic
1.     Vaccines, which include complete killed microorganisms (pertussis, typhoid, cholera) or inactivated viruses (influenza, poliomyelitis Salk vaccine)
2.     Anatoxins, which contains inactivated toxin of the bacteria (diphtheria, tetanus)
3.     The vaccines from alive attenuated viruses (measles, mumps and others.)
4.     Vaccines, which contains crossing alive microorganisms (BCG)
5.     Chemical vaccines from fraction of killed microorganisms (pneumococcal, meningococcal)
6.     Gene-engineering recombinant, chemical synthesized (hepatitis В, influenza)
7.     Associated (in composition of which enters several vaccines)

Composition of vaccines:
1.  Active or immunizing antigens
2.  Fluid base
3.  Preservatives, stabilizers, antibiotics
4.  Auxiliary facilities

Ways of the vaccination
1.  Intramuscular (DTP, DT, DT-M, antirhabic, meningococcal B)
2.  Subcutaneous (measles, mumps, rubella, meningococcal A+C)
3.  Intracutaneous (BCG)
4.  On skin (plague, tularemia, brucellosis)
5.  Peroral (poliomyelitis)
6.  Intranasal (Influenza, inactivated)

Ukrainian Immunization Schedule
The Calendar of preventive vaccinations in Ukraine (hereinafter - Calendar) includes four sections: vaccination by the age, vaccination by the health, vaccination, conducted in endemic and enzootic areas and the epidemic evidences for recommended vaccinations.

Section 1. Vaccination by the Age 

  Age
Vaccination for prevention

Notes
1day

Hepatitis В2





3-7 days
Tuberculosis1






1 mo.

Hepatitis В2





3 mo.


Diphtheria, tetanus, pertussis3
Poliomyelitis4,IPV
Hemophilus influenza infection5

By DTaP vaccine for children with a high risk of postvaccinal complications
4 mo.


Diphtheria, tetanus, pertussis3
Poliomyelitis4,IPV
Hemophilus influenza infection5

By DTaP vaccine for children with a high risk of postvaccinal complications
5 mo.


Diphtheria, tetanus, pertussis3
Poliomyelitis4,OPV
Hemophilus influenza infection5

By DTaP vaccine for children with a high risk of postvaccinal complications
6 mo.

Hepatitis В2





12mo.





Mumps, measles, rubella6

18 mo.


Diphtheria, tetanus, pertussis3 ,
By aDTP vaccine
Poliomyelitis4,OPV
Hemophilus influenza infection5


6 years


Diphtheria, tetanus3
Poliomyelitis4,OPV

Mumps, measles, rubella6

7 years
Tuberculosis1






14 years
Tuberculosis1

Diphtheria, tetanus3
Poliomyelitis4,OPV



15 years





Rubella
(
girls),Mumps
(
boys)6

18 years


Diphtheria, tetanus3




Adults


Diphtheria, tetanus3





1 Vaccines are injected to all newborns, which has no contraindications. Immunization is done by a vaccine to prevent tuberculosis (hereinafter - the BCG). For vaccination of premature infants weighing ≥ 2000 g should be used TB vaccine with reduced antigen content (hereinafter - the BCG-M).

  


Vaccination for tuberculosis prevention could not be done in the same day with other vaccines or other parenteral manipulations.
Children, who were not vaccinated in the maternity hospital for any reason, need to be vaccinated in children's ambulatory departments. For vaccination of children not immunized in the maternity hospital because of medical contraindications BCG-M or half-dose of BCG vaccine must be injected.


If the child is not vaccinated in the maternity hospital because of no medical contraindications, BCG vaccine is used. Children who are under 2 months don’t need Mantoux test before vaccination against TB. Mantoux test before vaccination against TB should be done for babies elder than 2 months. A negative test result allows making vaccination.

 
"Lemon peel" after the injection of tuberculin

 
Positive Mantoux test

Booster (revaccination) by BCG is given to children aged 7 and 14 years with negative Mantoux test.


In the absence of vaccination (BCG) navel children with negative Mantoux test should have additional vaccine 2 years after vaccination.
Mantoux test is done with 2 tuberculin unites (TU). Due to the fact that preventive vaccination may affect the sensitivity to tuberculin, that’s why Mantoux test needs to be planned before preventive vaccination. In the other case Mantoux test should be done no earlier than 1 month after vaccination.

2 Immunization by monovalent hepatitis B vaccine is done to all newborns.
If mother of a newborn is HBsAg "-" (negative), which is documented, the child may begin vaccination during the first months of life, or combined with vaccination against pertussis, diphtheria, tetanus, polio. In the case of immunization with a combination of vaccination against pertussis, diphtheria, tetanus, polio recommended scheme: 3-4-5-18 months, or: 3-4-9 months.


·        Newborns weighing <2000 g born by HBsAg negative mothers, vaccination is done when the child’s weight will be 2000 g or at the age of 1 month.
·        If the newborn child is in critical condition, the child immunization should be done when he will better before hospital discharge.
Vaccination against viral hepatitis B of newborns, whose mothers are carriers of HBsAg, is necessary to do by the accelerated scheme: 0-1-2 and 12 months (0 - date of first vaccination at birth, the minimum interval between the first, second and third vaccine – 1 month, third and fourth vaccine - 10 months). The first dose is entered in the first 12 hours of a child's life regardless of body weight. If there is a specific immunoglobulin against hepatitis B with vaccine in other parts of the body is entered a specific immunoglobulin 40 IU / kg body weight, but not less than 100 IU, in this case vaccination may be used for pattern: 0-1-6 months. If the weight of a newborn child less than 2000 grams, vaccination is required, but this dose is not count as a dose of primary immunization; when the child reaches the age of 1 month a series of three doses of vaccine should be done 0-1-6 (0 - date of first vaccination, the minimum interval between the first and second vaccine - 1 month, second and third vaccine - 5 months). 


If mother’s HBsAg status is unknown, child requires vaccination in the first 12 hours of life, while the HbsAg status of mother is researched. If a result is positive a newborn baby is vaccinated as a newborn of HBsAg "+" mother.
For vaccination of children and adults against hepatitis B outside the vaccinations calendar a scheme 0, 1, 6 months is recommended.
Do not start the vaccination series, if the dose was omitted, no matter how much time has passed. You must enter a doze, for missing the schedule with the minimum spacing (see section 1.2 "Vaccination of children in violation of the calendar”).

3 Vaccinations for the prevention of diphtheria, tetanus and pertussis in the age 3, 4 and 5 months by diphtheria-tetanus-pertussis vaccine (hereinafter - DTP), or vaccine with acellular pertussis component (hereinafter - DTaP). The interval between the first and second, second and third vaccination is 30 days. The interval between the third and fourth vaccination should be not less than 12 months.


The first booster at 18 months is done by DTaP.
DTaP is used for further inoculations for children who have had previous complications after DTP vaccination, and immunization for all children with high risk of complications. For the prevention of diphtheria, tetanus, pertussis, polio, hepatitis B and infections caused by bacteria Haemophilus influenza type b (hereinafter - Hib), you can use the combined vaccine (with variations of antigens combinations) that are registered in Ukraine.

 

Vaccination of children less than 4 years off the calendar dates should be done with such calculation, that the child will be managed to get DTP or DTaP immunization fourfold up to 3 years 11 months and 29 days.
For children who received primary vaccinal complex (in 3, 4, 5 and 18 months) DTaP or have received three doses DTaP and one DTP, revaccination in 6  and 14 years by diphtheria-tetanus-pertussis acellular vaccine with reduced antigen content (hereinafter - DTaP-M).
For children who received for primary vaccinal complex DTP or received two doses DTP and two doses DTaP the first vaccination against diphtheria and tetanus (6 years) by a diphtheria-tetanus toxoid (hereinafter - DT), second (in 14 years) and third (at 18) - by a diphtheria-tetanus toxoid with reduced antigen content (hereinafter - DT-M ). For children, vaccinated against tetanus because the injury by tetanus toxoid (hereinafter - T) over the past two years, a regular vaccination against diphtheria only with a reduced content of diphtheria antigen in diphtheria toxoid (hereinafter - D-M) should be done.
Children under 5 years 11 months 29 days, which had pertussis, receive DT. Vaccination is triple, interval between the first and second inoculation 30 days between the second and third - 9-12 months.
The first routine adult vaccination by age and epidsituation that were previously vaccinated should be made by DT-M at interval of 5 years after the last vaccination. Further routine vaccinations for adults by DT-M with a minimum 10 years interval from the previous vaccination.
Teenagers and adults who have not previously been vaccinated or do not have data on immunization, vaccination is triple by DT-M (interval between the first and second inoculation should be 30-45 days between the second and third - 6-12 months). Revaccination of those teenagers (who are vaccinated outside the scheme) with a minimum interval of 3 years after the last diphtheria and tetanus vaccination.
For active immunization against tetanus person elder than 60 years, not vaccinated last 10 years, a shortened vaccination scheme is used (single inoculation T-toxoid in double dose - 20 oz / ml, with a booster dose at 12 months - 10 oz / ml) and further every 10 years with no age restrictions.
Do not start the vaccination series, if the dose was omitted, no matter how much time has passed. You must enter a doze, missing the schedule, with a minimum spacing.
Because of possible postvaccinal reactions (after DTP-input), such as increased body temperature, which may lead to convulsions, recommend paracethamol in age doses within 1 day after vaccination.

4 Inactivated vaccine to prevent polio (hereinafter - IPV) is used for the first two immunizations, while the oral polio vaccine (hereafter - OPV) contraindications - for all these immunizations on the calendar.

OPV vaccine is used for 3 - 6th vaccination (third vaccination and age revaccination) with no contraindications to OPV.




After the OPV is proposed to restrict injections, parenteral intervention, routine operations for 40 days, exclude contact with HIV-infected.
Do not start the vaccination series, if the dose was omitted, no matter how much time has passed. Enter dose, which lacks the schedule, with minimum spacing.

5Vaccination to prevent Hib-infection can be done by mono- and combined vaccines containing Hib- components. In the case of Hib-vaccine and DTP-vaccine are from various manufacturers they should be inserted in different parts of the body. It is advisable to use combined Hib-vaccines for primary vaccination.
   

6 Vaccination to prevent measles, mumps and rubella by the combined vaccine (hereafter - MMR) at the age of 12 months. The second vaccine to prevent measles, mumps and rubella - in 6 years.


Kids who were not vaccinated against measles, mumps or rubella by age 12 months and 6 years, vaccination can begin at any age before 18 years. In this case, the child should receive 2 doses in compliance with the minimum spacing between them.
Children age 15 who received 1 or 2 vaccinations against measles, but not vaccinated against rubella and mumps and didn’t ill with these infections, vaccinations against mumps (guys) or rubella (girls) is scheduled.


18 years or older who have not previously been vaccinated against these infections can be vaccinated with one dose of vaccine at age to 30 years.
Previous diseases as measles, mumps or rubella are not contraindications to vaccination by trivaccine. In a history of these two diseases, vaccination should be done by monovaccine against the infection, which the child was not ill before.
Women of childbearing age that were not sick and have not been vaccinated against rubella may receive vaccination at their own request in accordance with the instruction to vaccines.

1.2. Vaccination of children in violation of the calendar
In deciding on the vaccination of children in violation of the calendar, you should plan with the following minimum intervals.

For children from 4 months to 6 years 11 months 29 days
Vaccines
Minimal interval between doses
1st and 2nd doses
2nd and 3rd doses
 3rdand 4th  doses
DTPDTaP
1 month
1 month
12 months
DT
1 month
9 months

Polio vaccine
1 month
1 month
12 months
Hepatitis B vaccine
1 month
1 month

MMR
1 year


Hib - vaccine
4 weeks: if the first dose is introduced to 12 months.
8 weeks (as the last dose): if first dose is entered at the age of 12-14 months.
Do not put: if the first dose is entered in 15 months or later
4 weeks: if a second dose is introduced to 12 months.
8 weeks (as the last dose): if a child age 12 months or more and a second dose was put under 15 months.
Do not put: if the first dose is entered in 15 months or older


For children from 7 to 18 years
Minimal interval between doses

1st and 2nd doses
2nd and 3rd doses
 3rdand 4th  doses
DT
1 month
6-9 months

MMR
year


Hepatitis B vaccine
1 month
1 month

Polio vaccine
1 month
1 month
12 months
         When planning the application of certain vaccines or toxoids for prevention of various infectious diseases should observe the following features:

Combination of drugs for vaccination
Recommended  intervals
>= 2 inactivated vaccines and / or toxoid
Vaccine could be introduced with time interval as in immunization Calendar
Living vaccines +  inactivated vaccine or toxoids
>= 2 live vaccines for parenteral administration (except BCG)
Vaccines can be introduced simultaneously in different parts of the body or with an interval no less 1 month
BCG vaccine combination with other vaccines
BCG vaccine does not spend the same day with other vaccines.
Other preventive vaccination eligible taken at intervals not less than 2 months before or after vaccination with BCG vaccine (except hepatitis B vaccine)

If necessary, the doctor has the right to enter all vaccines, toxoids, which are shown on the plan (except BCG), per one visit, providing injections in different parts of the body. Otherwise, the doctor plans vaccination with the minimum intervals between vaccines, toxoids and their combination against various infectious diseases.

1.3. HIV / AIDS children Vaccination
Defining the situation
Vaccines
Holding vaccinations

A baby is born HIV-infected mother (Z20.6; R75) - child HIV status is not defined
OPV*, BCG, measles, mumps, rubella
Do not vaccine before HIV status
identifying
Inactivated vaccinestoxoids
By the calendar

Asymptomatic HIV carrier state (Z21) or with weakly expressed clinic (clinical stage I and II **) in the absence of immunosuppression (CD4 +> 25%) or with moderate immunosuppression (CD4 +> 15%)
OPV*, BCG,
Do not vaccine
Other vaccines, toxoids
By the calendar

Child AIDS (clinical stage III, stage II by WHO with severe immunosuppression (CD4 + <15%)
Do not vaccine
OPV Vaccination is replaced with IPV throughout the calendar. OPV is not given to family members of HIV-positive person who cares for him.
** Classification of the World Health Organization (hereinafter - WHO)

1.     When vaccine vitamins that contain vitamin A should be administered.
2.     Vaccinations are carried out in outpatient or inpatient departments.
3.     A child patronage by medical workers on 3-4th and 10th-11th day of postvaccinal period should be done.
4.     Persons with HIV / AIDS passive immunization by immunoglobulin preparations because of epidemic is independent from previously held active immunization.
Persons with HIV / AIDS need to receive additional vaccinations as provided in Calendar section 2, "Vaccinations for health".

Section 2. Vaccinations for health
Vaccinations for health are required in the medical support of patients with high risk of infection and its possible severe course, against which vaccination by age is not provided in terms of vaccinations.

2.1. Vaccination scheme for children by health
Vaccination against
Vaccination scheme
Indications
Note
Flu

Annually. Permission for vaccination of children 6 - month old. The optimal time for vaccination is October-November.  

Children under the age of 9 years that had not received vaccination against influenza, vaccination is carried out with minimum 2 doses at intervals of 1 month.
 HIV infection
See Calendar subsection 1.3
“Immunization of HIV-infected Children and AIDS patients”


Primary immunodeficiency (select IgA deficit , IgG subclasses deficiency, transient hypogammaglobulinemia, phagocytosis deficits, complement system deficits)


Chronic liver disease (including cirrhosis and fibrosis)

Bronchial asthma

Renal (chronic renal failure or nephrotic syndrome)

Chronic lung disease (birth abnormalities, acquired disease, cystic fibrosis)

Chronic lesions of the cardiovascular system (birth and acquired heart defects, cardiomyopathy)

Functional or Anatomic asplenia (including - sickle-cell anemia)

Transplantation of bone marrow
Vaccination is not earlier than 6 months after transplantation

Patients continued hold acetylsalicylic acid

Lymphoma
Multiple Myeloma
Leukemia
Vaccination is made not earlier than 3-4 weeks after
immunosuppressive therapy (chemotherapy) and the increase granulocytes and lymphocytes in peripheral blood  > 1000 cells / mcl (> 1.0 *10/ l)

Staphylococcus pneumonia infection
Vaccination by unconjugated Polysaccharide vaccine patients 2 years or older, once (except for recipients of bone marrow) with the need to revaccination no earlier than 5 years
HIV infection
See Calendar subsection 1.3
"Immunization of HIV-infected Children and AIDS patients


Renal (chronic renal failure or nephrotic syndrome)

Primary immune deficiency - deficiency of complement system (early proteins - C1, C4, C2, C3), selective IgA deficiency

Bronchial asthma
Vaccine is carried out at PSV OFV1 or 80% of the required parameters, variability in performance or PSV OFV1 <20-30% with stable severe disease
Functional or anatomic asplenia (including sickle-cell anemia)
Vaccination 2 weeks before planned splenectomy. Otherwise the most earlier after it
Chronic liver disease (including cirrhosis and fibrosis)

Nasal liquorrea (chronic, remittent)

Diabetes type 1

Chronic lung disease (birth abnormalities, acquired disease, cystic fibrosis)

Tuberculosis (infected ILO)

Chronic lesions of the cardiovascular system (birth and acquired heart defects, cardiomyopathy)

Lymphoma
Multiple Myeloma
Leukemia
Hodgkin's disease


Vaccines are held 2 weeks prior to the immunosuppressive
therapy. Otherwise - 3 months after cessation of immunosuppressive therapy
Immunosuppressive hormone therapy (as defined. "List of Medical Contraindications to preventive vaccination" this order)
Vaccination is made 2 weeks before the beginning of immunosuppressive therapy or after its termination
Bone marrow transplantation

The optimal vaccination is at 12 and 24 months after transplant
Internal organs transplantation
Optimal vaccination 6 months after transplantation
Meningococcal infection
Persons older than 18 months are vaccinated only once 
Functional or anatomic asplenia (including sickle-cell anemia)

Deficiency of complement system (early proteins - C1, C4, C2, C3, С5-С9 ), properdyn, В factor

Varicella zoster vaccine
Is made to persons over 12 months are vaccinated only once   


While vaccination persons older than 13 years - double with 4-weeks intervals
Chronic renal failure


HIV infection /AIDS

Vaccines are held at the level of CD4 + > 25% of the age range, CDC class N1 or A1, two doses with3 - month intervals


Transplantation of bone marrow
Vaccination is not earlier than 24 months and the absence of Immunosuppression (increased granulocytes and lymphocytes in peripheral blood > 1000 cells / mcl / > 1.0 *109 / l 

Primary immunodeficiency without T-cell lesions

Hepatitis B
Vaccination of children not vaccinated before
Chronic liver damage (infectious and noninfectious genesis)

Transplantation

Children who are on hemodialysis
See subsection 2.2. Scheme vaccination hepatitis in children with malignant neoplasms, children are on hemodialysis and receiving long-term repeated blood transfusion
Children who receive long term repeated blood transfusion

Children who need a landmark surgery

Hepatitis А
Is made to persons over 12 months of life double at intervals of 6 months
Chronic liver damage (infectious and noninfectious genesis)

Liver transplantation
Optimal to vaccinate before transplantation. Otherwise - best 6 months after transplantation



Influenza vaccine

Vaccine against meningococcal infection

Varicella-Zoster vaccine


2.2. Hepatitis B vaccination scheme  in children with malignant neoplasms, children that are on hemodialysis and receiving long-term repeated blood transfusion
Vaccination
Vaccination Term
Notes
The first  
Begins at any age
Vaccination by a double dose of vaccine in an outpatient department
Or in a specialized department where the child receives the first course of treatment - if not vaccinated earlier.
Those HBsAg "+" (positive) are also subject to vaccination

The second
1 month after first vaccination
Third
1 month after the second vaccination
The fourth
6 months after the third vaccination

Section 3. Vaccines, held in endemic and enzootic areas and the epidemic evidences

Vaccines for the prevention
 Vaccination Date
Revaccination Dates
Notes
Tularemia1
From 7 years
Every 5 years
Rroutine immunization for separate professional groups and those living in endemic regions

Brucellosis2
From 18 years of age

After 1 year
Anthrax3
From 14 to 60 years
After 1 year
Unscheduled Immunization is conducted by a territorial
authorities, local government and health service
Leptospirosis
From 7 years
After 1 year
Ku fever
From 14 years
According vaccine application instruction
Tick borne encephalitis
Since 4 years
Every year for three years
Plague
Since 2 years
According vaccine application instruction
Vaccination by the epidemiological evidences
Typhoid fever4
Since 7 years
Two years
Immunization is done in determining territory as unfavourable 2-3 months before epidemiological growth by a territoryChief Medical Officer 
Influenza5
According vaccine application instruction
According vaccine application instruction

Yellow fever
Since 9 months
In 10 years
Immunization 10 days before traveling to countries endemic for this infection
Rabies6
When applying for medical assistance at the biting, scratches, salivation by animals ill or suspicious of rabies 
According vaccine application instruction
Routine immunization of rabies risky individuals.
A course of vaccine and antirabic immunoglobulin
Diphtheria7
Vaccination by the epidemiological evidences
According vaccine application instruction

Tetanus
Vaccination by the epidemiological evidences
According vaccine application instruction

Hepatitis А8
Vaccination by the epidemiological evidences
According vaccine application instruction

Polio9
Vaccination by the epidemiological evidences
According vaccine application instruction

Measles10
Vaccination by the epidemiological evidences
According vaccine application instruction

Mumps10
Vaccination by the epidemiological evidences
According vaccine application instruction

Rubella10
Vaccination by the epidemiological evidences
According vaccine application instruction

Meningococcal infection11
Vaccination by the epidemiological evidences
According vaccine application instruction

Hepatitis В12
Vaccination by the epidemiological evidences
According vaccine application instruction


Vaccinations for:
1
·        Personal  of business items harvesting the industrial animal skin, their primary processing;
·        Vegetable, grain, sugar mills, elevators workers;
·        Hunters, forest guard, meliorators;
·        Medical staff of the especially dangerous infections departments and laboratories, plague agencies that work with live tularemia cultures or infected material;
·        Mills, feed mills, linen factories, enterprises processing agricultural products and raw materials of animal origin workers, who work with feed; shepherds, farmers, meliorators, geologists, builders who work in natural foci of tularemia;
·        Others.
2
·        Livestock farms workers, not prosperous for brucellosis, regardless of ownership;
·        Meat workers, slaughter points and other enterprises on processing of raw materials and livestock products in the coming agricultural animals or raw materials originating from raising farms, not prosperous for brucellosis;
·        Veterinary staff who work with live Brucella cultures or contaminated material, and serve economy not prosperous for brucellosis;
·        Other categories of the population in case of trouble sustainable territories according to the decision of the territorial institutions of state sanitary-epidemiological service, emergency and preventive antiepizootic commissions.
3
·        Employees of the especially dangerous infections laboratory departments of sanitary-epidemiological and veterinary laboratory workers who work with live anthrax cultures or infected material.
4
·        Waterway and sewage networks employees;
·        Others.
5
·        Groups of medical risk (high chance of influenza clinical complications):
o       persons with chronic diseases (respiratory and cardiovascular system, kidneys, metabolism);
o       persons aged over 60 years;
o       persons who are in special groups (orphanages, homes for the elderly, children's homes, etc.).
·        Epidemic risk groups (high possibility of influenza infection):
o       children of preschool age, children, adolescents, students of secondary and tertiary institutions;
o       healthcare personnel;
o       preschool staff, secondary and other schools, orphanages, children’s homes and homes for the elderly, etc.;
o       service sector workers, trade, transport, military, and persons who are in contact with many people;
o       personnel of enterprises, institutions and organizations (to prevent outbreaks).
6
·        Employees of veterinary laboratories and clinics, hunters, veterinarians, dogs catchers, slaughter-houses workers;
·        Person applying for medical help because the bites, scratches, salivation by ill or rabies suspected animals.
7
In case of diphtheria focus:
·        Vaccination (after quarantine in this focus) persons not vaccinated against diphtheria (vaccination  and the first booster vaccination according the age);
·        Booster immunization according the calendar to individuals who are subject to re-vaccination in the current year;
·        Supplementary immunization to persons vaccinated without scheme violating by one-dose D or D-M toxoid vaccination according the age, if the last vaccination for diphtheria has been more than a year.
8
With the epidemic rise:
·        Children from 2 to 10 years living in endemic areas (average incidence of hepatitis A in the last 5 years higher than average incidence in Ukraine more than 2 times);
·        In case of focus development contacts need to be vaccinated during the first week;
·        Staff of the water treatment facilities, water mains, sewerage service and sewage treatment facilities;
·        Persons involved in peacekeeping activities, humanitarian assistance, etc.;
·        Travelers to regions with high hepatitis A.
9
·        In case of importation of "wild" poliovirus to Ukraine.
10
·        In case of measles, mumps or rubella focus vaccination in the first three days from the date of contact children over 1 year who were not ill these infections and were not vaccinated. Adults (before 30 years) if they were not ill these infections and were not vaccinated and revaccinated against them.
11
When epidemic rise of morbidity with generalized forms vaccination of:
·        Persons living in endemic areas;
·        In infection focus caused by appropriate serogroup of meningococcus.
12
·        Medical staff, students of secondary and higher educational institutions that have professional contact with blood, its preparations and carry parenteral manipulations;
·        Persons who have contact with hepatitis B patients;
·        Recipients of donor blood and blood products;
·        Children in the orphanages and child homes;
·        Family members who have hepatitis B patients and hepatitis B virus carriers;
·        Patients with chronic liver disease;
·        Patients who are planned to the surgical intervention.

Section 4. Recommended vaccinations

Vaccines for the prevention
 A high risk groups
Varicella zoster
- Healthy children who have reached 15 months of age and wasn’t ill by chicken pox before;
- Children enrolling schools that have not been sick for varicella (according to documentation);
- Employees of health and education, with high risk of infection and not sick of chicken pox before
Hepatitis A
- Medical staff;
- Nurseries staff;
- The catering and food industry staff , which is involved in the preparation of (production), transportation and sales of food;
- Military personnel, firefighters, special services personnel (operational service);
- Personnel of water treatment facilities, water mains, sewerage service and sewage treatment facilities;
- Staff and patients of private institutions (psychiatric institutions, detention facilities for mentally retarded persons, etc.);
- Personnel and persons who are in penitentiary institutions;
- Students of medical schools;
- Persons who participate in peacekeeping activities, humanitarian assistance, etc.;
- Persons who use intravenous drugs, HIV-positive, individuals with venereal diseases;
- Persons living in endemic areas for hepatitis A;
- Persons traveling to regions with high hepatitis A level;
- Persons who have communicated with hepatitis A patients 
Hepatitis B
- Soldiers, police, firefighters, social services personnel (operational service);
- Staff and patients of private institutions (psychiatric institutions, detention facilities for mentally retarded persons, etc.);
- Personnel and persons who are in penitentiary institutions;
- Staff of the service sector that may have contact with human biological fluids (hairdressers, the staff of beauty salons, masseurs, etc.) as well as those studying in these fields;
- Athletes;
- Persons who use intravenous drugs, HIV-positive, individuals with venereal diseases;
- Persons who frequently change sexual partners, prostitute, homosexual;
- Young people aged 20-40 years, especially women;
- Patients with chronic diseases and cancer, with chronic liver failure;
- Persons traveling to regions with high hepatitis B morbidity
Flu
- Soldiers, builders, workers of the State Automobile Inspection, etc.;
- People who care for flu patients at home;
- Pre-school children and students;
- Collectives of enterprises, institutions and organizations;
- Women who will likely be in the 2nd or 3 rd trimester of pregnancy during flu epidemic
Pneumococcal
infection
- Children older than 2 years;
- Adults with impaired immune status and the elderly, especially those living in boarding

Passive immunization is indicated
·        To children with insufficient antibodies syntheses as a result of congenital or acquired cellular defects of В-lymphocytes.
·        At absence of vaccines against infection, when single way of protection is introduction of ready antibodies.
·        If required immediate preventive maintenance of the disease for epidemiological causes (the contact with sick on measles, preventive maintenance of rabies, tetanus).
·        For neutralization of the antigen-toxin by specific antitoxic antibodies.
·        With medical purpose at the beginning of the diseases (at diphtheria, botulism, tetanus).

  


Vaсcinal process - is a change of homeostasis, which appears in organism in response to introduction of vaccinal preparation and include the complex of reactions to which belongs: formation of antibodies, adaptation and postvaccinal reactions, postvaccinal complications.

Vaccinal reactions appear in response to entering the vaccines, are characterized by appearance of clinical manifestations typical to this type of vaccine, which have a round-robin duration, are short, do not cause serious changes of vital activity in the organism.

List of the preventive vaccinations medical contraindications

Vaccine
Contraindications
All vaccines and toxoids
Severe complications from the previous dose in the form of anaphylactic shock.
Allergy to any vaccine component.
Progressive diseases of the nervous system, hydrocephalus in decompensation stage, epilepsy, epileptic syndrome with convulsions 2 times a month and more often.
Acute illness or chronic disease exacerbation
All live vaccines
Congenital combined immunodeficiency, primary hypogammaglobulinemia (entering the vaccine is not contraindicated in selective Ig A and Ig M immunodeficiency), transitional hypogammaglobulinemia and malignant tumors, pregnancy, AIDS, immune suppression therapy
BCG
baby weight less than 2000 g:
1500 - 1999 g vaccinations are not done up to 1 month.
1000 - 1499 g - up to 2 months.
Complicated reactions to previous vaccine (adenitis, cold abscess, skin ulcers over 10 mm in diameter, kelloid scar, osteomyelitis, generalized BCG infection).
Tubinfection.
Defects of phagocytosis
OPV
Children whom live vaccine is contraindicated, as well as to members of their families is recommended vaccination by polio inactivated vaccine (IPV)
DTP
A history of convulsions (instead DTP vaccine - DTaP vaccine or DT  toxoid is injected)
MMR
Allergic reactions to aminoglycosides.
Anaphylactic reaction to egg protein.
Introduction of blood preparations

Notes:
1.     Routine vaccination is delayed until the acute manifestations of the disease and exacerbation of chronic diseases will disappear and carried out immediately after recovery or during remission. Acute respiratory disease, that has a mild course and no increase in body temperature, is not a contraindication for the routine vaccinations. Contact with infectious patients, quarantine is not a contraindication for the routine vaccinations. Features of vaccination against tuberculosis – see paragraph 3 of these notes.
2.     Immunosuppressive therapy is a therapy carried out by cytotoxic drugs, including cyclosporine A monotherapy, and others, immunosuppressive doses of corticosteroids and radiotherapy. Immunosuppressive therapy with corticosteroids is recognized, if the prednisolone dose is more than 1mg/kg/day and it lasts longer than 14 days, as systemic use. Routine vaccinations with inactivated vaccines and toxoids are conducted after the end of therapy, vaccination with live vaccines - at least 1 month after cessation of therapy. If the duration of corticosteroid therapy is less than 14 days regardless of dose or more than 14 days and a dose of prednisolone is less than 1mg/kg/dayi, or it is used as replacement therapy, or locally, such therapy is not immunosuppressive and is not a contraindication for the routine vaccination.
3.     It is unacceptable to unite in a same day immunization against tuberculosis with other vaccines, and parenteral manipulations. BCG and Mantoux test should be done within 4 weeks after infection, which was accompanied by fever or quarantine.
4.     After OPV vaccination is proposed to restrict parental interventions during the 40 days.
5.     Vaccinations against measles, mumps and rubella after the introduction of blood products (whole blood, plasma, immunoglobulin preparations, packed red blood cells), except for washed red blood cells, is possible within the time specified in the instructions to the drug, but not earlier than 3 months. After the emergency prevention of neonatal tetanus by tetanus human immune globulin BCG vaccination is carried out according to the standard scheme. If the interval between vaccination against measles, mumps, rubella and the introduction of blood products with therapeutic and prophylactic purposes less than 14 days, vaccination against these infections should be repeated.

Recommended intervals between the administration of blood products containing specific antibodies, and vaccination against measles, mumps, rubella and varicella

Drug / indication for use
The recommendedinterval (months)
Tetanus emergency immunoprophylaxis by the tetanus immunoglobulin
3
Hepatitis A passive immunoprophylaxis by the normal human
immunoglobulin
3
Hepatitis B passive immunoprophylaxis by the specific immunoglobulin
against hepatitis B
3
Measles passive immunoprophylaxis by the normal human
immunoglobulin
- Standard contact (without immunodeficiency)
- Immunocompromised


5
6
Blood Transfusion
- The washed erythrocytes
- Red blood cells with the addition of preservative (adenine saline)
- Whole blood (Ht 65%)
- Whole blood (Ht 35-50%)
- Plasma / Platelets


-
6
6
6
7
CMV Immunoglobulin IV
6
IV immunoglobulin
- Sepsis
- Thrombocytopenic purpura
Kawasaki disease

8
10
11

Postvaccinal complications - all pathological phenomena, which appear after vaccination and are not inherent to the usual vaccinal process, but obvious, their relationship with performed vaccination:
1.  Postvaccinal unusual reactions and complications, caused strictly by vaccine ("true").
2.  Joining of intercurrent infections in postvaccinal period.
3.  Exacerbation of chronic diseases and primary manifestations of latent diseases.

Postvaccinal reactions and complications
Postvaccinal reactions:
1.     Increased temperature to 39˚ C.
2.     Increased temperature over 39˚ C (severe total reaction).
3.     Temperature, which is not registered in medical documentation.
4.     Pain, soft tissue swelling > 50 mm, hyperemia in the place of injection > 80 mm, infiltration > 20 mm (severe local reaction).
5.     Lymphadenopathy.
6.     Headache.
7.     Irritability, sleep disturbance.
8.     Non allergic rash.
9.     Anorexia, nausea, abdominal pain, indigestion and diarrhea.
10. Catarrhal phenomena.
11. Myalgia, arthralgia.
Postvaccinal complications:
1.     Abscesses.
2.     Anaphylactic shock and anaphylactic reactions.
3.     Allergic reaction (Quincke’s edema, urticaria rash, Stevens-Johnson’s, Lyell’s syndrome).

Quincke’s edema

urticaria rash

Stevens-Johnson’s  syndrome

Lyell’s syndrome

4.     Hyporesponsive-hypotensive syndrome (acute circulatory failure, hypotension, decrease muscle tone, short-term breach or loss of consciousness, vascular abnormalities in anamnesis).
5.     Arthritis.
6.     Continuous scream (duration of 3 hours or more).
7.     Febrile seizures.
8.     Afebrile seizures.
9.     Meningitis / encephalitis.
10. Anesthesia / paresthesia.
11. Acute flaccid paralysis.
12. Vaccinassociated paralytic polio.
13. Guillain-Barre syndrome (poliradiculoneuritis).
14. Subacute sclerotizing panencephalitis.
15. Mumps, orchitis.
16. Thrombocytopenia.
17. Subcutaneous cold abscess.
18. Superficial ulcers over 10 mm.
19. Regional lymphadenitis.
20. Kelloid scar.
21. Generalized BCG infection, osteomyelitis, osteitis.
22.  

Postvaccinal reactions
Postvaccinal complications
DTP-vaccination
1.       Temperature 37.5-39 ºС, anxiety, poor sleeping, rarely - vomiting.
2.       Local reaction (more often on revaccination) - in the manner of hyperemia, infiltration.
3.      Reinforcement of the allergic manifestations (in children with exudative-catarrhal diathesis)
1.       Quincke’s edema.
2.       Anaphylactic shock, collapse.
3.       Continuous scream (duration of 3 hours or more)
4.       Febrile seizures (on background of the quick ascent of the temperature).
5.      Afebrile seizures, absances.
6.      Encephalitis
OPV-vaccination
Does not call any reactions
1.      Reinforcement of the allergic manifestations (in children with exudative-catharrhal diathesis)
2.      Quincke’s edema, urticaria.
3.       Vaccine associated poliomyelitis in immunized and in contact persons (on background of immunodeficiency) - 1:1,500,000.
Vaccination against measles
1.   Specific vaccinal reaction from 4 to 14 days:
- temperature 37,5-38 ºС,
- catarrhal manifestations, conjunctivitis,
- pale-rose rash in a small amount,
- duration - 2-3 days,
- is not contagious
2. Lymphadenopathy.
1.        In children with exudative-catarrhal diathesis: Quincke’s edema, urtica
2.        Hemorrhagic vasculitis.
3.        Hyperthermia 39-40 ºС with febrile seizures
Vaccination against mumps
1.       In some cases from 4 to 12 days - fever, catarrhal manifestations.
2.       Rare - a slight enlargement of parotid glands for a short time.
3.       Hyperthermia.
1.       Febrile seizures.
2.       Abdominal syndrome.
3.       Allergic rash.
4.       Very rare - serous meningitis.
 BCG-Vaccination
1.      Local reaction: papule, vesicle, rib; lymphadenitis
1.       Subcutaneous cool abscess (BCG-tis).
2.       Superficial ulcers over 10 mm.
3.       Purulent lymphadenitis.
4.       Kelloid scars.
5.       Lymph nodes calcification.
6.       Generalized BCG-infection on background of immune deficiency (4: 1000000).
7.      Osteitis, osteomyelitis with dominating damage of long bones.


 References:
Main:      
1.     Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia: WB Saunders; 2000.
2.     Current therapy in pediatric infectious diseases – 2 edited by John D. Nelson, M. D. – B.C. Decker  inc. Toronto, Philadelphia, 1988.
3.     Dershewitz RA, Macknin ML: Ambulatory Pediatric Care, 3rd ed. Lippincot – Raven, 1999.
4.     Feigin RD, Cherry JD, eds. Textbook of Pediatric Infectious Diseases. Vol 2. 4th ed. WB Saunders Co; 1998.
5.     Krugman, Saul, et al. Infectious Diseases of ChildrenSt. Louis: Mosby Year Book, 1992.
6.     Oski's Pediatrics: Principles and Practice. 3rd ed. Lippincott Williams and Wilkins; 1999.
7.     Principles and Practice of Pediatric Infectious Diseases. / Edited by Saran S. Long, Larry K. Pickering, Charles G. Prober, PhiladelphiaPa: Churchill Livingstone; 1997. – 1921 p.

Additional:
1.     2000 Red Book: Report of the Committee on Infectious Diseases. American Academy of Pediatricians. 2000: 243-7.
2.     Bella J, Rossmann MG: Review: rhinoviruses and their ICAM receptors. J Struct
3.     Bellet, Paul S. The Diagnostic Approach to Common Symptoms and Signs in Infants, Children, and Adolescents. New York: Lea and Febiger, 1989.
4.     Bialecki C, Feder HM Jr, Grant-Kels JM: The six classic childhood exanthems: a review and update. J Am Acad Dermatol 1989 Nov; 21(5 Pt 1): 891-903
5.     Chameides L, Hazinski MF, eds. Textbook of pediatric life support. Dallas: American Heart Association, 1994:5-5­5-6.
6.     Collins PL, McIntosh K, Chanock RM: Respiratory Syncytial Virus. In: Fields' Virology. 3rd ed. 1996: 1313-1351.
7.     Committee on Infectious Diseases; American Academy of Pediatrics: Respiratory Syncytial Virus. In: Pickering LK, ed. 2000 Red Book: Report of the Committee on Infectious Diseases. 2000: 483-487.
8.     Dudas RA, Karron RA: Respiratory syncytial virus vaccines. Clin Microbiol Rev 1998 Jul; 11(3): 430-9
9.     Emmerson AM, Hawkey PM, Gillespie SH: Principles and Practice of Clinical Bacteriology. John Wiley & Sons; 1997: 373-88.
10. Fleisher, GR, Ludwig, SL: Gastrointestinal infections. In: Textbook of Pediatric Emergency Medicine. 4th ed. BaltimoreMd: Williams & Wilkins; 2000:757-762.
11. Garwood, John, and Amanda Bennett. Your Child's Symptoms. New YorkBerkeley Books, 1995.
12. Griffin, DE: Billeter M, ed. Measles Virus. New YorkNY: Springer-Verlag; 1995: 117-34.
13. Hostetter MK: Epidemiology of travel-related morbidity and mortality in children. Pediatr
14. Ledwith CA: Fluids and electrolytes. In: Handbook of Pediatrics. 17th ed. 1994:94-99.
1.     Levin M, Nadel S: Bacterial meningitis: pathophysiology and causes and therapeutic approach. In: Oxford Textbook of Critical Care. Oxford University Press; 1999.
2.     Nadel S, Levin M, Habibi P: Treatment of meningococcal disease in childhood. In: Meningococcal Disease. John Wiley & Sons; 1995:207-43.
3.     Nelson, WE, Behrman, RE: Infections due to Salmonellae. In: Textbook of Pediatrics. 14th ed. 1992:729-734.
4.     Ng VL, Balistrera WF: Hepatitis B-clinical perspectives in pediatrics. Clin Liver Dis 1999; 3 (2): 267-90.
5.     Northrup RS, Flanigan TP. Gastroenteritis. Pediatr Rev 1994;15:461-72.
6.     Pediatrics ( 2nd edition, editor – Paul H.Dworkin, M.D.) – 1992. – 550 pp.
7.     Smith MB: Acute rhinitis and pharyngitis. In: Evidence-Based Pediatrics. 2000: 83-90.
8.     Textbook of Pediatric Nursing.  Dorothy R. Marlow; R. N., Ed. D. –London, 1989.-661p.
9.     Viral Infections of Humans. Epidemiology and Control. 4th edition. New YorkNY: Plenum Medical Book Company, 1997.
10. Ward DG: Acute infectious diarrhea disease and dehydration. In: Rosen P, Barkin RM. Emergency Medicine: Concepts and Clinical Practice. 4th ed. Mosby; 1998:1200-1212.

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