Progrese in Vaccinologie
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1 Progrese in Vaccinologie
2 Cadrul general Vaccinuri combinate Programe Nationale de Imunizare tendinte Programul National de Imunizare din Romania Imunizari la diverse grupe de varsta
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4 Vaccinarea este una din cele mai mari realizări ale sănătăţii publice 1 Cu excepţia apei potabile, vaccinurile sunt cea mai eficientă intervenţie în reducerea şi prevenirea re-emergenţei bolilor infecţioase 1 26 de boli sunt prevenibile prin vaccinare 2 Imunitatea colectivă : imunizarea majorităţii duce indirect la protecţia indivizilor susceptibili din populaţie 2, 3 1 European Vaccine Manufacturer s paper International Federation of Pharmaceutical Manufacturing Associations. May 2003, 3 Fine P E M in Vaccines (4th Edn) 2004 Plotkin SA and Orenstein EA, p.1451
5 Morbiditatea anuala prin bolile infectioase preventibile prin vaccinare in sec.xx si morbiditatea anuala actuala in SUA Boala Morbiditatea anuala in Sec. XX Reducerea(%) Variola Difteria Rujeola >99 Parotidita >99 Pertussis Polio(v.paralitic) >99 Rubeola >99 Sindr.rubeolic congenital >99 Tetanus Haemophylus infl CDC : MMWR,1999,48, Paralizie acuta asociata virusului polio vaccinal de import (VAPP) 2. CDC: MMWR,2006, 55, H.influenzae b si alte serotipuri (<5 ani varsta) Shaw Alan R,Feinberg MB, Vaccines In Clinical Immunology. Principles and Practice, third edition, Ed.Elsevier, 2008,
6 Morbiditatea prin bolile infetioase preventibile prin vaccinare, estimata in era pre-vaccinala, comparativ cu morbiditatea curenta Boala Morbiditatea anuala estimata in era pre-vaccinala Reducerea(%) Hepatita A Hepatita B (acuta) Inf.pneumococica (invaziva) - toate varstele -<5 ani Varicela CDC : date raportate in Shaw Alan R,Feinberg MB, Vaccines In Clinical Immunology. Principles and Practice, third edition, Ed.Elsevier, 2008,
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8 Regulile esenţiale ale programelor de vaccinare Acoperire înaltă Imunitate de grup
9 Acoperirea vaccinală minimă necesară pentru a opri transmiterea infecţiei Infecţia Acoperirea vaccinală minimă Rujeolă Pertussis Oreion Rubeola Difteria Polio Anderson and May, Lancet 1990
10 Imunitatea de grup heard immunity
11 Cele mai mari succese sunt acelea pe care nu le putem vedea: toţi cei care NU au suferit sau nu au murit de boli prevenibile prin vaccinare Walter Orenstein, MD, National Immunization Conference April 29, 2002
12 Am uitat gravitatea unor boli. Vaccinurile sunt victimele propriului lor succes. Iron lungs for polio victims. Circa 1950 s. Los Angeles, CA, USA.
13 Vaccinarea ca intervenţie de sănătate publică A avea la dispoziţie o intervenţie atît de eficientă cum este vaccinarea şi a nu o utiliza este o dovadă de iresponsabilitate socială Dar programele de vaccinare au condus nu numai la succese din perspectiva sănătăţii publice, ci şi la paradoxuri
14 Consecinţe: rezistenţă şi îngrijorare Acoperirea vaccinală scade Vaccinurile sunt percepute drept costuri şi nu ca investiţie în sănătate Guvernele sunt rezervate în alocarea de fonduri sustenabilitatea financiară nu este de la sine înţeleasă Populaţia devine rezervată în acceparea vaccinurilor chiar dacă acestea sunt furnizate gratuit
15 ... şi prejudecăţi Părinţii şi medicii au uneori o experienţă limitată în privinţa unor boli cum ar fi tusea convulsivă, aşa încât evenimente adverse potenţiale sunt percepute disproporţionat de importante atunci când se produc Vaccinurile au dovedit siguranţă în administrare, deşi în unele cazuri copii pot face reacţiiadverse (inflamaţie la locul injectării) ce sunt minore şi de scurtă durată (<24 ore după vaccinare) Reacţiile adverse minore sunt cu mult mai puţin grave şi frecvente faţă de consecinţele şi complicaţiile bolilor pe care le previn
16 De aceea... Programele de vaccinare sunt o componentă importantă a îngrijirilor de sănătate, la nivel global Vaccinurile reduc morbiditatea şi mortalitatea şi au dovedit că sunt cost-eficiente Pentru a susţine morbiditatea scăzută după începerea progamelor de vaccinare este necesar: Să se efectueze programe educaţionale referitor la beneficiile vaccinării Să se asigure o acoperire vaccinală bună
17 Progres in vaccinologie Vaccinuri combinate
18 e v a c c i n u r i N u m ă r p o s i b i l d e i n j e c ţ i i p â n ă l a v â r s t a d e 2 a n i N u m ă r p o s i b i l d e i n j e c ţ i i l a o s i n g u r ă v i z i t ă l a Offit P et al, Pediatrics, 2002 Numărul de vaccinuri şi numărul posibil de injecţii (în ultimul secol) Anul Număr d În 1900, copii erau vaccinaţi contra variolei. În 1960, copiii primeau vaccinuri variolic, difteric, tetanic, pertussis celular (ca DTP) şi polio. Vaccinul polio inactivat se administra în serii de 3 injecţii. În 1980, copiii primeau DTP, polio şi MMR. DTP şi MMR erau administrate sub formă de combinaţii, vaccinul polio viu atenuat se administra oral. În 2000 copiii au primit DTPa, MMR, polio inactivat, Hib, varicela, conjugat pneumococcic, şi hepatitic B.
19 Numarul bolilor preventibile prin vaccinare (SUA) Anul 1985 (nr. 7) 1995 (nr.10) 2007 (nr.16) Boala Rujeola Rujeola Rujeola Rubeola Rubeola Rubeola Parotidita Parotidita Parotidita Difteria Difteria Difteria Tetanus Tetanus Tetanus Pertussis Pertussis Pertussis Poliomielita Poliomielita Poliomielita Haemophylus infl.b Haemophylus infl.b Hepatita B Hepatita B Varicela Varicela Inf. Pneumococica Gripa Boala meningococica Hepatita A Rotaviroze HPV Shaw Alan R,Feinberg MB, Vaccines In Clinical Immunology. Principles and Practice, third edition, Ed.Elsevier, 2008,
20 Clasificarea vaccinurilor combinate (dupa numarul componentelor antigenice) Vaccinuri cu antigene de la o singura specie microbiana simple (monovalente ) complexe (polivalente) Vaccinuri combinate (asociate) care contin amestecuri antigenice de la specii microbiene diferite dar administrate printr-un singur preparat bivaccinuri (DT, Rujeola-Rubeola, Tific-HAV) trivaccinuri ( DTP,DT-VPI, Rujeola-Rubeola-Urlian) tetravaccinuri (DTP-VPI, DTP-HVB) pentavaccinuri (DTP-VPI-Hib) hexavaccinuri (DTP-VPI-HVB-Hib)
21 Particularităţile vaccinurilor combinate imunogenicitate similară cu a vaccinurilor monocomponent administrate simultan adaptate programelor de vaccinare moderne nu suprasolicită sistemului imun al copilului* diminuă expunerea la proteine şi polizaharide vaccinale în exces, acestea fiind înlocuite cu componente înalt imunogene şi mai puţin reactogene (ex: componenta pertussis acelulară vs.celulară) * *Offit P.A. et al : Adressing parent s concerns: do multiple vaccines overhelm or weaken the infant system? Pediatrics, 2002, 109,1
22 Dificultăţi în dezvoltarea vaccinurilor combinate Antigene multiple Posibile interacţiuni şi consecinţe nedorite Adjuvanţi Stabilizatori Soluţii tampon Excipienţi Conservanţi Reducerea imunogenicităţii Creşterea reactogenicităţii Stabilitate scăzută Producţie complicată Temeri legate de aspectele imunologice
23 Sunt necesare vaccinurile combinate? Tendinţe în vaccinările pediatrice: Vaccinarea în masă contra hepatitei B Introducerea vaccinului Hib Interesul crescând pentru DTPa Trecerea de la OPV la IPV Noi vaccinuri: S Pneumo, Men C Nevoia de vaccinuri combinate
24 Avantajele vaccinurilor combinate Pentru copii şi părinţi mai puţine injecţii = disconfort redus mai puţine vizite la medic Pentru furnizorii serviciilor de sănătate acceptare mai bună logistica pentru stocare şi transport simplificată personalul medical devine disponibil pentru alte activităţi medicale
25 Avantajele vaccinurilor combinate Pentru comunitate Scăderea costurilor per ansamblu (lanţul de frig, ambalaje ) Complianţă mai bună Acoperire vaccinală îmbunătăţită Eficienţă mai mare a programelor de vaccinare Reducerea costurilor economice legate de boală
26 Programe Nationale de Imunizare
27 The Austrian Childhood Vaccination Schedule DTaP Hib IPV HepB PCV7 MMR dt- IPV dtap Var HPV RTV 7 weeks-6 months Yes 7 2 months Yes 1 Yes 1 Yes 1 Yes 1 Yes 2 4 months Yes 1 Yes 1 Yes 1 Yes 1 Yes 2 6 months Yes 1 Yes 1 Yes 1 Yes 1 Yes months Yes 1 Yes 1 Yes 1 Yes 1 Yes 2 Yes years Yes 9 years + Yes 5 Yes 6 13 years Yes years Yes The Austrian Childhood Vaccination Schedule as on 14 January 2008
28 The German Childhood Vaccination Schedule DTaP IPV Hib HepB PCV7 MenC MMR Var 7 dtap HPV At birth Yes month Yes 1 Yes 1 Yes 1 Yes 1 Yes 3 months Yes 1 Yes 1+2 Yes 1+2 Yes 1+2 Yes 4 months Yes 1 Yes 1 Yes 1 Yes 1 Yes months Yes 1 Yes 1 Yes 1 Yes 1 Yes Yes 6 Yes months Yes months Yes years Yes 9-17 years Yes Yes 4 Yes 8 Yes years Yes 9 The German Childhood Vaccination Schedule as on 12 November 2007
29 The Greek Childhood Vaccination Schedule DTaP Hib 1 IPV MMR HepB 2 MenC 3 PCV7 4 Var 5 BCG dt 6 2 months Yes Yes Yes Yes Yes Yes 4 months Yes Yes Yes Yes Yes Yes 6 months Yes Yes Yes 6-18 months Yes Yes months Yes Yes Yes months Yes months Yes Yes 4-6 years Yes Yes Yes 6 years Yes years Yes years Yes
30 The Hungarian Childhood Vaccination Schedule DTaP IPV Hib MMR HepB dt BCG At birth Yes 1 Yes 2 months Yes 2 Yes 2 Yes 2 3 months Yes 2 Yes 2 Yes 2 4 months Yes 2 Yes 2 Yes 2 15 months Yes 18 months Yes 2 Yes 2 Yes 2 6 years Yes 3 Yes 3 11 years Yes Yes 14 years Yes The Hungarian Childhood Vaccination Schedule as on 15 January 2007
31 The Italian Childhood Vaccination Schedule DTaP IPV Hib HepB MMR dtap PCV7 MenC Var At birth Yes months Yes Yes Yes Yes 4-5 months Yes Yes Yes Yes months Yes Yes Yes Yes months Yes 2 months-2 years Yes 2 2 months-3 years Yes 2 1 year-2 years Yes years Yes Yes Yes years Yes years Yes 4 Yes 5 The Italian Childhood Vaccination Schedule as on 21 October 2008
32 The Spanish Childhood Vaccination Schedule DTaP Hib IPV MenC MMR HepB Var dt HPV Birth-1 month Yes 2 months Yes Yes Yes Yes Yes 4 months Yes Yes Yes 6 months Yes Yes Yes Yes 1 Yes months Yes months Yes Yes Yes Yes years Yes years Yes years Yes 4 Yes years Yes years Yes The Spanish Childhood Vaccination Schedule as on 1 June 2008
33 The United Kingdom Childhood Vaccination Schedule DTaP IPV Hib MenC PCV7 MMR BCG 5 Td At birth Yes 6 2 months Yes 1 Yes 1 Yes 1 Yes 3 months Yes 1 Yes 1 Yes 1 Yes 4 months Yes 1 Yes 1 Yes 1 Yes Yes Around 12 months Yes 2 Yes 2 Around 13 months Yes Yes 3 years 4 months-5 years Yes 3 Yes 3 Yes years Yes 4 Yes 4 The United Kingdom Childhood Vaccination Schedule as on 10 January 2007
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35 Programul National de Imunizare din Romania
36 Varianta de tranzitie a Calendarului de vaccinare propusa de CNV,valabila pentru perioada 1 ianuarie - 30 iunie 2009 Vârsta recomandată Vaccin Comentarii Primele 24 de ore 2-7 zile Hep B BCG În maternitate 2 luni DTPa-VPI, HepB Simultan 4 luni DTPa-VPI Simultan 6 luni DTPa-VPI, HepB* Simultan 12 luni DTPa VPI, RRO Simultan 4 ani DTPa** 7 ani (în cls I-a) RRO Campanii şcolare 9 ani (în cls III-a) VPI Campanii şcolare 12 ani ( in cls a VI-a) HPV*** Campanii şcolare 14 ani (în cls VIII-a) dt, Rubeolic *** Campanii şcolare 24 ani dt In luna calendaristica a nasterii * vaccinurile DTP-HB si VPO vor fi administrate la varsta de 6 luni pana la finalizarea stocului de vaccin DTP-HepB, dupa care acesta va fi inlocuit cu DTPa-VPI si HepB **pentru cohortele de copii care nu primit DTP doza a 5-a pana la data de 30 septembrie 2008 precum si cohorta de copii care implinesc 30 de luni in luna octombrie 2008 se va realiza vaccinarea cu DTPa la implinirea varstei de 4 ani, incepand din anul 2010 ***numai fetele
37 Calendarul de vaccinare propus de CNV,valabil pentru perioada 1 iulie-31 decembrie 2009 Vârsta recomandată Vaccin Comentarii Primele 24 de ore 2-7 zile Hep B BCG În maternitate 2 luni DTPa-VPI-HepB-Hib, Rota, PCV Simultan 4 luni DTPa-VPI-Hib, Rota, PCV Simultan 6 luni DTPa-VPI-HepB-Hib, PCV Simultan 12 luni RRO, Varicelic Simultan 14 luni DTPa-VPI-Hib, PCV Simultan 36 luni RRO, Varicelic Simultan 4 ani DTPa* 9 ani (în cls III-a) VPI Campanii şcolare 12 ani ( in cls a VI-a) HPV** Campanii şcolare 14 ani (în cls VIII-a) dt, Rubeolic ** Campanii şcolare 24 ani dt In luna calendaristica a nasterii * pentru cohortele de copii care nu primit DTP doza a 5-a pana la data de 30 septembrie 2008, precum si cohorta de copii care implinesc 30 de luni in luna octombrie 2008 se va realiza vaccinarea cu DTPa la implinirea varstei de 4 ani, incepand din anul 2010 ** numai fetele
38 Imunizari la diverse grupe de varsta
39 Vaccinarea adolescenţilor şi a adultului tânăr.
40 Verifică statusul vaccinal anti-hepatita B şi vaccinează dacă este cazul. Vaccinarea antigripală pentru protectie si pentru evitarea absenteismului. Verifica statusul vaccinal/antecedente infecţioase pentru cele trei boli R-O-R şi varicelă. Vaccinează dacă este cazul. Vaccinarea antirubeolică este deosebit de importantă pentru adolescente. Vaccinarea anti hepatită A.
41
42 Vaccinarea gravidelor.
43 Vaccinurile viu atenute sunt contraindicate pentru imunizarea femeilor gravide. Vaccinurile inactivate se pot administra femeilor însărcinate fără riscuri. Vaccinarea gravidei cu rapelul tetanic este obligatorie şi are rolul de a preveni cazurile de tetanos neonatal. Conform consensului ştiinţific, vaccinarea antigripală (vaccinuri inactivate) este recomandată de rutină gravidelor
44
45 Vaccinarea adultului.
46 Anti-Hepatita B, dacă este cazul. Anti-gripa de rutină, pentru raţiuni socio-economice. Rapelul dt odată la 10 ani. Anti- Hepatita A, dacă este cazul.
47
48 Vaccinarea bolnavilor cronici.
49 Vaccin anti-gripa, obligatoriu anual. Vaccin anti-pneumococic R1 :cinci ani. Rapelul dt odată la 10 ani. Vaccinare antimeningococică: insuficienţă hepatică, renală,
50 Vaccinarea vârstnicilor.
51 Vaccinarea anti-gripal este obligatorie. Vaccinarea anti-pneumococică este obligatorie(1 doză la 5 ani) Rapelul dt.
52 În continuare se fac eforturi mari pentru : ameliorarea continuă a preparatelor existente pentru a reduce cât mai mult preţul lor dar şi efectele secundare (ex: vaccinul anti-pertussis acelular). obţinerea de noi vaccinuri împotriva altor boli de mare actualitate şi gravitate : HIV, HVC, gripa H5N1, anticancer etc.
53 Concluzii Vaccinurile combinate moderne: O bună imunogenicitate Reactogenicitate redusă Reduc numărului de injecţii necesare pentru protecţia conferită prin vaccinare Fac posibilă introducerea de noi vaccinuri Pentru o bună prescriere e nevoie de o informare corectă!
54 Vaccinuri combinate nou introduse! Rotavirus HPV Varicelic (RORV) Pneumococic (7, 11 si 23 valent)
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