Calender of Pediatric Immunizations in Brazil Otávio Augusto Leite Cintra 1. Background Immunization or vaccination is one of the more effective actions for disease prevention in the individual and community level. From the introduction of the first vaccine to nowadays, marked by the control of some infectious disease associated with high rates of morbidity and mortality, such as hepatitis b and Haemophilus infl uenzae type B infections, vaccination schedules are continuing expanding and therefore health care professionals should be continuously updated on that issue. The knowledge in correct vaccine recommendations and specially do not make mistakes in vaccine indications without an evidence based information is today an obligation of every health care providers. Talk about disease prevention is a very important issue in medical appointment and physicians should expend enough time to talk about vaccines for all age groups. The objective of this brief review was to explore some relevant aspects of vaccine schedules elaborated by Brazilian Pediatric Society and Brazilian Society for Immunizations to help the health care provider to talk with his patient about vaccines. 2. Vaccine schedules Vaccine schedules are general recommendations about vaccine dose administrations according to patients age and recommended dose intervals. The rationale for those schedules is based on each vaccine product and could change from each institution and country. Vaccine schedules can be also changed according to specific patients requirements and for this issue a consultation with a vaccine expert will be helpful to individualize schedules. Table 1 and Table 2 presents a synopsis of an adapted vaccine schedule from Brazilian Society for Immunizations. Table 1. Vaccine schedule children 0 to 15 years Brazilian Society for Immunizations Age Vaccine Remarks Birth HBV + BCGid 2 mo DTaP + Hib + HBV + IPV + PnC7V + Rotavirus DTaP or DTP, IPV or OPV Combined Six components 3 mo MnCC 4 mo DTaP + Hib + IPV + PnC7V + Rotavirus DTaP or DTP; IPV or OPV Combined Five components 5 mo MnCC 6 mo DTaP + Hib+ HVB + IPV + PnC7V DTaP or DTP; IPV or OPV Combined Six components 7 mo Influenza + MnCC(1) 8 mo Influenza Annual vaccination 9 mo Yellow fever Booster every 10 years 12 mo MMR + Varicela(2) + HAV 15 mo DTaP + Hib + IPV + PnC7V DTaP or DTP; IPV or OPV Combined Five components 18 mo HAV 5 y DTaP + MMR 15 y dtap National Immunizations Campaign OPV Introduction after 6 mo of age.
26 V IAPO MANUAL OF PEDIATRIC OTORHINOLARYNGOLOGY Table 2. Abreviations Abreviation Full term Availability Public health Private services clinics BCGid Intradermal BCG tuberculosis vaccine HBV Hepatitis B vaccine DTP Diphtheria, Tetanus and whole cell Pertussis (whooping cough) vaccine DTaP Diphtheria, Tetanus and acelullar Pertussis (whooping cough) vaccine No (isolated B. Pertussis antigens) Hib Conjugated Haemophilus influenzae type B vaccine PnC7V Conjugated Streptococcus pneumoniae seven valent vaccine No with seven pneumococci serotypes McCC Conjugated Neisseria meningitidis type C vaccine No OPV Oral poliovirus vaccine live attenuated poliovirus IPV Inactivated poliovirus vaccine No MMR Measles, Mumps and Rubella vaccine HAV Hepatitis A vaccine No dtap Adult type Diphtheria, Tetanus and acelullar Pertussis No (whooping cough) vaccine (isolated B. Pertussis antigens) Combined Hexavalent Combined vaccine with six components: DTaP + Hib + IPV + Hepatitis B No vaccine Combined Pentavalent Combined vaccine with five components: DTaP + Hib + IPV No Vaccine Combined tetravalent Combined vaccine with four components: DTP + Hib No vaccine CRIE Reference Center for specials immunobiological products - - - - - - Remarks: 1. The vaccines DtaP, Hib, IPV and Hepatitis B are preferably administered in the combined version (six component or HEXAVALENT), avoiding the second hepatitis B vaccine with 1 month of age. 2. Conjugated Neisseria meningitidis type C vaccine could be started with 2 months of age. Three vaccines products are available. a. MnCC conjugated with mutant diphtheria protein (CRM197) manufactured by Wyeth laboratories; b. MnCC conjugated with tetanus toxoid protein manufactured by Chiron laboratories; c. MnCC de-o-acetylated conjugated with tetanus toxoid protein manufactured by Baxter laboratories. The first two vaccines are recommended in a three dose schedule in the first year of life. Baxter s vaccine can be administered in a two dose schedule in the first year of life. All vaccines are administered in a single dose after the first year of life. Table 3 shows vaccines schedules according to manufacturer. Table 3. Vaccines schedules according to manufacturer Vaccine Age Doses Interval Route Baxter 2 to 11 mo 2 2 mo IM Chiron and Wyeth 2 to 11 mo 3 2 mo IM Any vaccine > 1 y 1 Single dose IM Today is discussed the introduction of a booster dose of conjugated meningococcal type C vaccine after 1 year old. This recommendation still not present in the schedule but should be introduced based on efficacy data in the
V IAPO MANUAL OF PEDIATRIC OTORHINOLARYNGOLOGY United Kingdom campaign showed a decreased efficacy in children after 4 years old which had received 3 doses of the vaccine in the first year of life. 3. The available vaccines for Bordetella pertussis are whole cell (DTP) and acelullar pertussis vaccine (DtaP). Both vaccines effective but DtaP is associated with less adverse events and currently is available in combined vaccines products. 4. Oral live attenuated poliovirus vaccine (OPV) has a risk of development of vaccine associate paralysis in 1 to 750,000 administered doses. It does not happen with inactivated poliovirus vaccine (IPV), which is an advantage point for IPV use. Besides that IPV has other advantages like fewer doses for full immunization therefore decreasing expenses with OPV. IPV also can be combined with other vaccines reducing the number of shots. IPV is the preferred vaccine and OPV should be maintained in National Immunization Campaign and could be delivered for all children over 6 months old after received three doses of IPV. 5. Influenza virus vaccine is recommended for all healthy children aged 6 to 23 months included in the high risk groups for severe influenza infections. In the other age ranges this vaccine is recommended for all persons who do not wish to have influenza. The recommendations for persons with baseline conditions should be kept for all persons over 6 months old. Vaccine schedule should have two doses for children aged less than 9 years old in the first time of immunization and after this one annual dose is recommended as showed in Table 4. Table 4. Vaccine schedule for Influenza Virus Age Vaccine Doses Interval Route 6 to 35 mo 0.25 ml 1-2 * 1 mo IM 3 to 8 y 0.5 ml 1-2 * 1 mo IM > 9 y 0.5 ml 1 - IM (*) Only in the first year of vaccination. 27 6. Yellow fever vaccine recommendation is base don epidemiological data of the disease in each state. This vaccine could be administered for children aged 9 months old in areas with high risk of yellow fever virus urbanization. In other areas could be administered for children aged 12 months old. 7. All children that received combined vaccines with association DtaP + Hib should receive a booster dose of Hib vaccine with 15 months of age, therefore they should received a combined DTaP + Hib vaccine also in the 15 months dose. 8. The minimum recommended schedule for poliovirus immunization with IPV should be 4 doses of this vaccine, with 1 dose after 1 year old. Therefore in 15 months old dose children should received the five component combined vaccine (PENTAVALENT) with DtaP + Hib + IPV. OPV administration in 15 months dose is acceptable but IPV is preferred. All children could receive extra doses of OPV in the national immunization campaign.
28 V IAPO MANUAL OF PEDIATRIC OTORHINOLARYNGOLOGY 9. Second BCGid dose was recently stopped because lack of evidence that this second dose reduces pulmonary tuberculosis incidence. 10. Diphtheria, tetanus and acelullar pertussis vaccine for adults should be administered instead of only diphtheria and tetanus because this is the only effective action for reducing pertussis infections in adolescents and adults. 3. Respiratory Syncytial Virus (RSV) The prevention of RSV severe infections with monoclonal humanized antibodies (palivizumab) is recommended for children with high-risk conditions for severe RSV disease. Those children are premature infants, children with broncopulmonary displasya and children with hemodynamic significant congenital heart disease. The prophylaxis goal is decrease the morbidity of RSV infections estimated by decreases in hospitalization rates due to RSV infection in high-risk children, and this reduction could be up to 90%. The prophylaxis depends on RSV seasonality and palivizumab should be administered monthly for high-risk children during the RSV season. For indications please refer to reference number one. 4. Availability of vaccines and other immunobiological products. Vaccines actually could be find in Brazil both in the public and private clinics. In the public sector vaccines are available in clinics and in the Reference Center for Specials Immunobiological Products. The CRIE is responsible to delivery all immunobiological products that are not included in the regular Schedule of the National Immunization Program (PNI) and will be administered for special populations under specific recommendations that are available in the home page of Brazilian Ministry of Health. Addendum Influenza Test The clinical based specific etiologic diagnosis of acute respiratory infections (ARI) is very difficult because clinical syndromes are very similar and not characteristic of one specific agent. In the first evaluation of a patient presenting an ARI the health care provider will make your decision based only on clinical and unspecific laboratory tests such as chest films, white blood cells counts and C reactive protein. Therefore rapid tests for specific etiological diagnosis are desirable and could help the providers decisions tree avoiding misuse of antimicrobial agents and help the correct use of antiviral agents. This will help speed patient improvement and also reduces growing emergence of resistant bacterial agents due to incorrect antibiotic use. Rapid tests for influenza* are very useful and we have today many manufacturers with these tests. Those tests are based on membrane enzyme linked assays (EIA) and the result will be available in 10 to 20 minutes. The sensitivity and specificity are up to 95% and are more reliable during epidemic periods. Other rapid tests such as immunofluorescence are time consuming and needs expertise and a well- * A commercial kit can be found - QuickVue+ Influenza type A and B viral antigens (Quidel Corporation, San Diego, California, USA)
V IAPO MANUAL OF PEDIATRIC OTORHINOLARYNGOLOGY equipped laboratory with a fluorescence microscope. Membrane EIA could be done bedside and are easy to do and read. Many reports have shown that rapid influenza and other virus or bacterial rapid tests use are associated with cost savings, due to less hospitalizations and labs requisitions, and improvement of patients care. Recommended readings 1. American Academy of Pediatrics Committee on Infectious Diseases and Committee on Fetus and Newborn. Revised indications for the use of respiratory syncytial virus immune globulin intravenous for the prevention of respiratory syncytial virus infections. Pediatrics 2003 ;112(6):1442-6. 2. Brazilian Society for Immunizations vaccination schedules www.sbim. org.br. 3. Brazilian Ministry of Health www.saude.gov.br. Vaccination schedule http://dtr2001.saude.gov.br/svs/imu/imu00.htm 4. American Academy of Pediatrics. www.aap.org 5. Centers for Disease Control and Prevention. www.cdc.gov 6. World Health Organization. www.who.org. 7. Poehling KA, Zhu Y, Tang YW, Edwards K. Accuracy and impact of a pointof-care rapid influenza test in young children with respiratory illnesses. Arch Pediatr Adolesc Med. 2006;160:713-8. 8. Bonner AB, Monroe KW, Talley LI, Klasner AE, Kimberlin DW. Impact of the rapid diagnosis of influenza on physician decision-making and patient management in the pediatric emergency department: results of a randomized, prospective, controlled trial. Pediatrics. 2003;112:363-7. 9. Pregliasco F, Puzelli S, Mensi C, Anselmi G, Marinello R, Tanzi ML, Affinito C, Zambon MC, Donatelli I; The Collaborative Group Influchild. Influenza virological surveillance in children: the use of the QuickVue rapid diagnostic test. J Med Virol. 2004;73:269-73. 10. Poehling KA, Edwards KM, Weinberg G et al. The Underrecognized Burden of Influenza in Young Children. N Engl J Med 2006;235:31-40. 29