Update of Paediatric Vaccinations

Dr Emma Best
Paediatric Infectious Diseases Consultant
Starship Children’s Hospital

Vaccine preventable diseases
Dr Emma Best
Senior Lecturer, Department of Paediatrics, University
of Auckland
Paediatric Infectious Diseases Specialist
Starship Children’s Hospital
Acknowledgements for slides
Dr. Cameron Grant, Associate Professor, Paediatrics, University of Auckland
Paediatrician, Starship Children’s Hospital, Auckland
Dr Nikki Turner, Director, Immunisation Advisory Centre, University of Auckland
Dr Anusha Ganeshalingham PICU fellow intensive care for pertussis info
Google Images

Immunisations again…

Declarations
• Today am invited speaker by GSK who have paid my
travel and accommodation
• Do not accept honoraria
• Participant in research groups with consumables funded
by Wyeth (Pfizer) and GSK
• Member of the Anti-infectives committee of Pharmac

Outline
Describe vaccine preventable diseases which
I still see
• Using presentations and complications
• To help understand importance of vaccinating
still and the public health significance
• Discuss aspects of prevention of the
disease and vaccine uptake

Immunology made simple
Vaccines stimulate body’s defence
mechanisms (immune system) against an
infection
Help immune system detect and destroy
infection when encountered in the future
without development of significant
symptoms or complications of that disease
www.science.org.au/immunisation.html

Some vaccines can provide herd immunity
Indirect protection from infection caused by
immune individuals

Exposure to antigens?

Will use Photos to introduce some
vaccine preventable diseases and some
of their complications

Name the vaccine preventable
disease

Explain what caused the bleeding
Coughed so hard that she has burst the blood vessels on the
surface of her eyes

“100 day
cough”
Whooping cough
Pertussis
Illness with
paroxysms of
coughing, plus
whoop, apnoea and
vomiting.

Presentation of pertussis varies
with age .. and immunisation status
• Infant
• Apnoea and/or cyanosis and/or paroxysmal cough
• Children
• Non-immunised cough increasing in severity over
several weeks rapidly repeated, forceful coughs
followed by desperate gasps
• Well between paroxysms
• Immunised – milder disease – still cough, less forceful

Presentation of pertussis
varies with age
• Adult
• Persistent cough,worse at night and often
paroxysmal
• Awoken by a ‘choking sensation’
• scratchy throat, sweating attacks
• Post-tussive vomiting and whoop

Every 3-5 years escalating epidemics
at the end of 2011 – it was that time
again, and proving to be a record
breaker

Number of pertussis notifications by week
reported, 2010 - 2013
ESR, Pertussis Report: April 2013.

NZ epidemic statistics are being mirrored around the world – in the
UK

USA..

Australia

34
Admissions to SSH PICU…and
counting

3 deaths
And cohorting up to 4 apnoeic babies
per bay (4 times this epidemic)

Critical Pertussis
• Malignant or
fulminant
• Infants
• 6/10 will be
hospitalized in

To control pertussis you have to do
immunisation well
Increase coverage from < 80% to 80- 90% and you decrease disease burden 10 fold,
Increase coverage to 95% or greater and you get another 10 fold reduction

Pertussis hospital discharge rate in NZ
per 100,000 person years
J Paed Child Health 2007 Somerville, Grant et al

Vaccination has changed pertussis
epidemiology
Primary vaccination:
4-6
Unvaccinated or
partly vaccinated
infants: susceptible
Booster vaccination:
Prolonged protection
6-10 years
Susceptible adults:
reservoir of
pertussis
No additional booster:
immunity wanes

Why are pertussis outbreaks
occurring worldwide?
• Vaccination does not change the
periodicity of epidemics
• Immunity wanes – perhaps faster than
imagined
• The current vaccine is not perfect and
needs very good coverage

Why is pertussis in NZ so bad?
• Very infectious and imperfect vaccine
• + NZ has not achieved good coverage
• + NZ has not achieved timeliness
• + NZ has changed our schedule several
times (including dropping a dose in 1970’s)
• + NZ has poverty and crowded housing
issues

Protect the young
immunise …
• Pregnant women, post partum
• Older siblings/school aged children
• Close contacts – fathers, grandparents
• Early childcare workers
• Healthcare workers (!)
• Give vaccines on time and boosters

Name the Vaccine preventable disease
affecting this newborn baby?

What is this complication from the same
vaccine preventable disease?

Congenital cataracts – opaque
lenses

Rubella
• Was a common childhood
illness -mild symptoms
• Transmission by respiratory
secretions
• Rash is similar to many other
infections
• enlarged lymph nodes (back of
neck, behind ears)

But for newborns whose mothers
acquire rubella in the first
trimester …..
Blueberry muffin
baby - due to bone
marrow failure
Inflammation
• Liver
• Lungs
• Bone marrow
Cataracts
Nerve deafness
Heart defects
Microcephaly (small brain)
Mental retardation
Behavioural problems

Rubella in New Zealand
New Zealand Immunisation Handbook 2011

Rubella in New Zealand
• Not common
• Between 2005 and 2010, 49 cases of rubella
were notified.
• 43 cases in children < 9 year
• Worldwide, less developed countries offer
only monovalent measles vaccine (India,
Indonesia, Timor) so no control/monitoring
of rubella

Measles
Conjunctivitis, rash (cough) look
miserable/sick!

Measles
• Transmission by respiratory secretions
• Highly infectious
• Rash is similar to many other infections
• Measles
• Days 2-4: Fever, red eyes, runny nose, Koplik spots
• Day 3-7: Maculopapular rash (confluent)
• Child most unwell day 1-2 of rash
• Complications in 10%
• Diarrhoea and dehydration
• Otitis media, pneumonia, croup
• Encephalitis 1:1,000 cases

1969-1970
introduced
1990 MMR
Two dose
schedule 1992,
changed to 15 mths in 1996
Deaths in early 90’s and one in 1997 outbreaks

Measles in New Zealand
• Epidemics still occur but immunisation
has increased the time between them
and many less cases
• To prevent epidemic 95% of the
population must be immune
• Vaccine efficacy of 90-95%
• Hence 2 dose schedule needed
• WHO global eradication goal

Name vaccine preventable disease and
country where these resurgent cases
still seen

Poliomyelitis NZ 1915-2000
Western pacific
polio free since
2000
Imported Case of Poliomyelitis, Melbourne, Australia, 2007- 22-yr-old
Pakistani student who had travelled home to Nthern Pakistan on holiday

• Measles, rubella and polio are examples of
• herd immunity
• and how we are part of both a mobile and global
community
• Polio will be eradicated but is not yet!
• South East Asia is aiming for measles
eradication ..but it is years away
• Millions receive monovalent measles vaccine (M
not MMR) so areas with little rubella control

Tetanus
u
Clinical term for muscular rigidity caused by
the toxin produced by Clostridium tetani
u
Spores found everywhere in environment
particularly manure/soil, not “infectious” or
passed between people
u
Easily introduced to a wound at time of injury
especially deep penetrating dirty wounds

New Zealand, tetanus
New Zealand Immunisation Handbook 2011

New Zealand tetanus
• Last 15 years, 30 cases of tetanus (2 cases
per year in NZ) notified*
• Mostly older adults - vaccinated ‘years
ago’, no booster
• Children – all unimmunised (4)

Starship experience with tetanus

• Difficult to achieve full immunisation in
families with fixed anti-immunisation beliefs
• Publicity around cases increases discussion
and may help some reconsider stance
Tetanus - a good reminder that for
some diseases there is no herd
immunity

Haemophilus influenzae type b (Hib) causes
meningitis, periorbital cellulitis or
epiglottitis
Epiglottitis
Fever, breathing difficulties, to
painful swallowing, drooling and then
complete airway obstruction

Haemophilus influenzae type b…………
used to be the paediatrician’s bread and butter

Cases
60
Hib laboratory confirmations 1990 - 1995
and notified cases 1996 - 2010
50
Source: Immunisation Advisory Centre, University of Auckland
40
30
20
10
0
1st 4th 3rd 2nd 1st 4th 3rd 2nd 1st 4th 3rd 2nd 1st 4th 3rd 2nd 1st 4th 3rd 2nd 1st 4th 3rd 2nd 1st 4th 3rd
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 20092010
Pre immunisation was the commonest cause of
bacterial meningitis in children
1 in 350 NZ children aged < 5 years had an episode of
invasive Hib infection

Hib epidemiology
• Transmission by direct contact and
respiratory secretions
• Immunisation reduces carriage of bacteria
in nose
• Preschool children are ones affected so
immunisation works very well - provide
immunity for crucial age
• If 80% of population vaccinated disease
virtually disappears
Leung B , Best EJ et al ‘Haemophilus influenzae type b disease in Auckland children
during the Hib vaccination era, 1995–2009.’ NZ Med Journal, Nov 2012
1-2 cases per year, disease still same spectrum, most unimmunised

Neisseria meningitidis
Meningococcaemia
Meningococcal meningitis (brain inflammation)

Meningococcal
epidemiology
Asymptomatic
colonisation
5 to 15% of population
Carriage increased by
smoking (also
passive), crowding,
viral infections
Respiratory droplet and
secretion spread,
then infection in those
at increased risk
Meningococcal
bacteriology
Not as simple
as Hi type b
5 serogroups
that cause
disease
A, B, C, W135
and Y

Which New Zealanders?
• Those in crowded houses
• Doubling of risk with the addition of 2 adolescents or adults to
a 6-room house (Baker PIDJ 2000;19 )
• Age < 5 years, especially age 6 to 12 months
• Maori and Pacific children (2 to 3x increased
risk)
• Household contacts 600x risk in week after
index case
• Students in hostels (adolescence the other risk
group)
• …anyone ..

Meningococcal disease

Age range
Meningococcal Vaccines available
• No longer MenzB
• Conjugate meningococcal C
• Polysaccharide quadrivalent A,C,W135 Y
Any but not long
lasting protection
particularly in infants
All ages and long
lasting
Over 2 years and
lasts about 5 years
• Menactra conjugate A,C,W135,Y
Over 9months and
long lasting

Otitis media
Pneumonia (and empyema)
Meningitis pus and inflammation in the membrane
around the brain
Streptococcus pneumoniae
Pneumococcal disease

Pneumococcal
epidemiology
Asymptomatic
colonisation in 30-
60% of young
children
Changed by season,
viral illness, antibiotic
prescribing,
socioeconomic
status
Pneumococcal
bacteriology
Also not simple
90 (!) serotypes
Some more
invasive than
others
Invasive disease for
some
65yrs,
medical conditions
Non invasive disease
Ear infections,
pneumonia

S. pneumoniae substantial burden
of disease
Estimated annual hospital admissions per
100,000 in NZ children aged

Paediatric pneumococcal disease in New
Zealand
• Life threatening
• Each year ≈ 150 cases of pneumococcal meningitis
and bacteraemia in children under 5 years old
• 10-11 deaths
• 13-26 cases of severe long-term disability
• Pneumonia
• 3000 admissions per year
• 20 to 40% due to pneumococcal infection
• Otitis media
• A large proportion of antibiotic prescriptions

Pneumococcal vaccines
• 23 valent polysaccharide vaccine
• Not immunogenic in children < 2 years old
• Conjugate vaccines
• Antigens from most invasive pneumococcal
serotypes
• Joined (conjugated) to a carrier protein
• More complex molecule - creates an immune
response in infants

Percentage of Serotypes Isolated
Serotypes Causing IPD in Children

PCV vaccines
Prevenar
Serotypes
4, 6B, 9V, 14, 18C, 19F, 23F
CRM 197 Diphtheria carrier protein
PCV7 licensed in
2000
Introduced NZ June
2008
Serotypes
Prevenar13 4, 6B, 9V, 14, 18C, 19F, 23F 1, 5, 7F 3, 6A, 19A
CRM 197 Diphtheria carrier protein
Synflorix
Serotypes
4, 6B, 9V, 14, 18C, 19F, 23F 1, 5, 7F
NTHi protein D T D NTHi protein D
Switched
to PCV 10
June 2011
3 + 1 schedule
6wks, 3mths, 5mths and 15 mths

New Zealand IPD rates
90% reduction in VT IPD
70% reduction in overall IPD
Heffernan et al INVASIVE PNEUMOCOCCAL DISEASE IN
NEW ZEALAND, 2010

Young girl with a rash

Varicella – common childhood
illness
• COMMON YES – 90% have had
chicken pox by age 14 yrs
• So common that complications also
common!

What is this common
associated skin complication?
Cellulitis

What is this rare complication of this VPD?
Necrotising fasciitis – “flesh eating bug”
Typically Streptococcus pyogenes

Not so benign - severity of chicken pox
• Mild disease 50 lesions (most breakthrough
disease in vaccinated children is 1000 lesions
• Although more severe in immunocompromise
most deaths and hospitalisations occur in
healthy people/children

SSH PICU again; varicella
admissions
• 10 years review – 2-3 children per year
• 4 deaths
• Currently looking at all hospitalisations
due to varicella across New Zealand over
2 years in

Varicella vaccine
• Varicella vaccine available since 1996 (live attenuated vaccine)
• Recommended but not funded, (about 17% uptake)
• Vaccines available in New Zealand:
• Varilirix Varivax
• Quadrivalent MMRV vaccine (Priorix-Tetra or ProQuad)
• Zostavax (herpes zoster vaccine for adults ≥ 50 years of age)
• Recommended for children from age 12m to 12yrs
1 dose effective for 80%, very effective at reducing serious infection
• Administered at 15m (with MMR, Hib & PCV10)
• Second dose (debatable) at 4yrs with MMR (effectiveness 2 doses
>95%)

Varicella vaccine
USA
USA since 1995
Australia –
AUSTRALIA
recommended 2003,
funded since 2005

Common questions raised when talking about
vaccinating chicken pox
• Why – common childhood disease and better
immunity from wild infection?
• Vaccine immunity only lasts 20 years?
• More shingles
• 2 doses?
• Use MMRV or MMR + V ?

Common questions raised when talking about
vaccinating chicken pox
• Why? common and nasty
• Vaccine immunity only lasts 20 years – no
reason to believe this – live viral vaccine and
antibody should present lifelong but without wild
virus may need other boosting
• More shingles? Less shingles after vaccine
– theoretical concern of increased shingles in
those whilst we “eradicate varicella with vaccine”
– development of zostavax
Reid S NZMJ 2012 125; 1354

Varicella vaccine or MMRV
• Give the varicella vaccine or the MMRV??
• So 1 jab (MMRV) or 2 jabs (MMR + V) at 15 months?
• NZ MOH recommends MMR+V at 15 months due to risk of febrile
seizures
• What is the risk for febrile seizures?
• 1 additional febrile seizure is expected per 2500children
vaccinated with MMRV when compared with MMR + V (if receive it
aged 1-2 yr)
• No increased risk seen in those aged 4-6yrs who received MMRV
• Weigh up with other costs – pain of extra injection, risk of falling
behind schedule, missing opportunity of vaccinating

• A very current vaccine preventable
disease - PERTUSSIS
• Global community, herd immunity and not
Polio, rubella
Measles
Tetanus
• Bacterial vaccines - the old’ish and new’ish
• HIB, MENINGOCOCCAL AND PNEUMOCOCCAL
• What’s in store?
Varicella

Key messages
• VPD -a reality in NZ and cause morbidity and
death
• Improved coverage and timeliness will change
this
• We are part of a global community of people
(measles) and microbes (tetanus)
• Effective bacterial vaccines give new invasive
disease priorities - surveillance is important
• Pertussis control is complicated
• New vaccines such as varicella likely to impact
positively both at population and individual level