FAQs on Vaccines and Immunization Practices Naveen C Thacker, Vipin M Vashishtha, Ajay Kalra
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1FAQs on Vaccines and Immunization Practices
2FAQs on Vaccines and Immunization Practices
Chief Editor Vipin M Vashishtha MD FIAP Pediatric Generalist and Neonatologist Mangla Hospital and Research Centre Shakti Chowk, Bijnor Uttar Pradesh, India e-mail: vmv@manglahospital.org Editors Ajay Kalra MD DCH MNAMS FIAP Consultant Child Health Khandari Road, Agra, Uttar Pradesh, India Naveen Thacker MD Director Deep Children Hospital and Research Centre Gandhidham, Kutch, Gujarat, India
3Published by
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FAQs on Vaccines and Immunization Practices
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First Edition: 2011
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4Contributors 6Foreword
Few measures in preventive medicine can compare with the impact of vaccines. Smallpox has been eradicated and polio is on the verge of eradication. Measles transmission has been terminated in large areas of the world. Most recommended vaccines are highly effective in preventing vaccine-preventable diseases in vaccine recipients. But nearly all vaccines have another special property, the induction of herd immunity. Most vaccine-preventable diseases are transmitted from person to person in a chain of transmission from infectious case to susceptible. When a transmitting case comes in contact with an immune person, transmission does not occur and the chain of transmission is broken. Since infectious cases do not have unlimited contacts, if the immunity levels are high enough in a community, the likelihood that such cases will meet a susceptible is very low. Thus, transmission can be terminated for many diseases in a given community before 100% vaccine coverage is achieved. Who are the people indirectly protected? They are children too young for vaccination, persons with compromised immunity who cannot make adequate immune responses to vaccines, persons with contraindications to vaccination, and persons who do not respond to vaccine for other reasons. All are protected indirectly by high levels of immunity in the population.
Prevention from vaccines is very attractive because generally with a few doses, long term, even lifelong, protection can be achieved with many vaccines. In contrast, the lifestyle changes needed to prevent many chronic diseases require a lifetime of continued implementation.
During the last few decades, there has been a revolution in vaccinology. Vaccines have been produced that prevent cancer. The Human Papillomavirus (HPV) Vaccine prevents approximately 70% of cervical cancers globally. And hepatitis B vaccine can prevent one of the major causes of liver cancer. Antibodies against polysaccharides are key to the defense against several bacteria that cause pneumonia, meningitis, and other serious clinical syndromes. However, young infants make poor immune responses against plain polysaccharides. By conjugating polysaccharides to protein carriers, excellent immune responses can be achieved even in very young infants. Conjugation technology is the basis for vaccines against Haemophilus influenzae type b (Hib), pneumococci, and meningococci. We can now prevent one of the most common causes of severe diarrhea and dehydration, leading to death, rotavirus. And other new technologies, including the use of recombinant DNA, vaccine vectors, genetic reassortment and other techniques are being brought to bear, to bring us new and better vaccines.7
Vaccines are so important that there has been a call for a "Decade of Vaccines" by the Bill and Melinda Gates Foundation. This includes development of new vaccines as well as more widespread and better use of existing vaccines.
But the most favorable benefits of vaccines are only achieved when they are used widely in populations for whom they are recommended. And this handbook provides a major resource to vaccine providers in using vaccines optimally. This book is devoted to answering practical questions on recommended vaccines, recommended schedules, indications, contra-indications, and precautions. It tries to answer questions regarding particular clinical situations, which may not be easily answered from reading existing recommendations. Use of the book, will help you minimize the risks of vaccine-preventable diseases in the populations you serve while maximizing the safe use of those vaccines.
Walter A Orenstein md
Co-editor, Vaccines, Ed Plotkin SA, Orenstein W
Offit
P Saunders Elsevier, 5th Edition, 2008,
Deputy Director for Immunization Programs,
Bill and Melinda Gates Foundation,
Ex-Professor of Medicine and Pediatrics, Emory University
Ex-Associate Director, Emory Vaccine Center
Former Assistant Surgeon General, United States Public Health Service
Former Director, National Immunization Program, Centers for Disease Control and Prevention, Atlanta, Georgia
8Foreword
The two primary biological properties of a vaccine are safety and efficacy. They are like the two sides of the coin. Both these terms and their meanings—safety and efficacy—have to be clearly understood by pediatricians, both in practice and in training. Many questions arise in our minds regarding them as this book well illustrates. They have to be clarified in order for us to advise parents about the best course of actions for protecting the health of their children as far as vaccine-preventable diseases are concerned. Our faulty notions and consequent actions of commission or omission can affect their health; thus, it is our duty to learn and understand the basis of right choices under varying circumstances.
In many cases there are several vaccine products against given diseases. For live vaccines, the products may contain different strains of the attenuated microbes, but all may be known simply as the vaccine against that particular disease. There may be differences between such strains and we should know how to choose from those that are available. For non-replicating antigens in vaccines, the products may vary according to the specific antigen(s), peptide ligands in protein-conjugated polysaccharide vaccines, the presence and nature of adjuvants and/or preservatives and so on. Again, we need clarity of concepts, and become conscious of convenience and costs in order to do the best for children.
In India there are two streams of childhood vaccinations—the State-sponsored and revenue-funded minimum essential vaccinations under the Universal Immunisation Programme and the self-help or private provision of vaccinations. There are ethical and practical issues in both streams of vaccinations; and as advocates of child-health, we ought to be clear about them. The Indian Academy of Pediatrics provides guidelines for the second stream of vaccinations. New products get licensed in India and there will be a long time lag before such vaccines get included in the State-sponsored stream. The idea of childhood target age is shifting and expanding to vaccinations in adolescents, adults, and senior citizens.
Thus it is natural that many questions arise. Here is a book that addresses innumerable frequently asked questions and provides answers articulated by the leaders in pediatric profession. It is well worth keeping this on the shelf and referring to when questions crop up in our minds in the middle of pediatric practice—all in the best interests of the children of our communities.
T Jacob John fams fna
Past President, Indian Academy of Pediatrics
Co-Chair of the Indian National Technical Advisory
Group on Immunization (NTAGI)
9Preface
"The Greeks had two gods of health: Aesculapius and Hygeia, therapy and prevention, respectively. Medicine in the twentieth century retains those two concepts, and vaccination is a powerful means of prevention. What follows is information on the vaccines that, together with sanitation, make modern society possible, and that if wisely used will continue to bestow on humankind the gift of prevention, which according to proverb is worth far more than cure."
—Stanley A Plotkin and Edward A Mortimer, Jr in the preface to the first edition of their book, "Vaccines"
Immunization is a lively subject where changes in the field happen more rapidly than one can anticipate. This makes it a very dynamic subject and underlines the need to remain updated more frequently. Though the general attitude of both physicians and patients finds cure more interesting than prevention, the truth is the latter is far more vital than the former though less appealing. While dealing with infections, development of newer antibiotics may have some limitations but the possibilities of developing vaccines are immense. Despite the high cost involved in developing a new vaccine, the opening up of the huge markets of developing world has offered a new incentive to vaccine industry. With the advent of vaccine industry in the developing world, and ample availability of global funding opportunities through giant philanthropic organizations have further reinvigorated the vaccine manufacturers to readily invest in developing newer products for future needs by embracing newer technologies. Therefore, any discussion on the subject of Vaccinology covers not only the several vaccines per se but also the changes in technology and the exciting possibilities of various combinations and permutations in the making of various vaccines, which further extend to the ingenuity of newer modes of vaccines’ delivery.
In view of the above, it is no wonder that medical students, pediatricians and general practitioners are paying more attention to vaccines than ever before. As a proof of this trend, the sessions on Vaccinology get a prime slot in all Pediatric conferences and are usually jam-packed. Yet, in the short time frame that these conferences allow, not all questions can be answered and many a delegates have often gone back home with doubts and queries unanswered.
Therefore, this book is an attempt to fill this void by providing contributions from experts who have a vast information and knowledge on 10the subject. They have devoted a lot of time and efforts to answer the questions on the basis of the latest information that is available today right from the Basics of Immunology to Vaccines in the pipeline and Therapeutic vaccines, besides talking about the changes in technologies and evolution of different adjuvants and combinations.
Of late, there is a paucity of a decent book on immunization in this format. Often, the FAQ books are criticized as being meant only to provide a superficial account of the subject; however, our effort is to provide a more in-depth account of the given subject. The hallmark of this book is its comprehensive naturealmost all the aspects related to pediatric vaccination today are covered in depth. Hopefully, the book will not only be handy for the busy practitioners but even Postgraduate students will find it attractive to browse pages to find answers of their queries.
Vipin M Vashishtha
Ajay Kalra
Naveen Thacker
11Acknowledgments
Editors, Dr Naren Aggarwal, Dr Madhu Choudhary, Dr Neeraj Choudhary, Dr Geeta Mayor, Dr Eti Dinesh, Shaila Prashar and Maheshweta Trivedi of Physician Education Resources (PER) Division, Jaypee Brothers Medical Publishers (P) Ltd., New Delhi, for their untiring efforts to publish this book in time.
Indian Academy of Pediatrics for the excerpts from the e-manual of its program, "IAP Advancing Science of Vaccinology 2009."
IAP Committee on Immunization for the excerpts from its guide book, "IAP Guide Book on Immunization, 2007-08."
Claire-Anne Siegrist, for allowing us to use excerpts from her chapter on Vaccine Immunology from the book, "Vaccines" (Ed. Plotkin SA, Orenstein W, Offit P Saunders Elsevier, 5th Edition, 2008) and her presentations delivered during 11th ADVAC at Annecy, France 2010.