Induce New Induce New vaccinevaccine

Pneumococcal disease:Pneumococcal disease:

Is one of leading causes of death in the world.Is one of leading causes of death in the world.

• As WHO estimation , more than 1.6 million As WHO estimation , more than 1.6 million people including more than 800,000 children people including more than 800,000 children under 5 years die every year from under 5 years die every year from pneumococcal infection. pneumococcal infection.

• Up to 60% of children carry pneumococcal Up to 60% of children carry pneumococcal bacteria.bacteria.

• There are more than 90 subtypes of SP.There are more than 90 subtypes of SP.

Streptococcus pneumonia:Streptococcus pneumonia:

• Gram-positive bacteria.Gram-positive bacteria.

• 90 known serotypes.90 known serotypes.

• Polysaccharide capsule important Polysaccharide capsule important virulence factor.virulence factor.

• Type-specific antibody is protective.Type-specific antibody is protective.

Pneumococcal Disease Burden: Pneumococcal Disease Burden:

1.1. Pneumococcal infections are estimated to Pneumococcal infections are estimated to cause >700,000 deaths annually among cause >700,000 deaths annually among children under 5 worldwide; most deaths children under 5 worldwide; most deaths occur in developing countries.occur in developing countries.

2.2. Important clinical syndromes include Important clinical syndromes include pneumonia, bloodstream infections, pneumonia, bloodstream infections, meningitis, and acute otitis media.meningitis, and acute otitis media.

3.3. Emerging antibiotic resistance increases Emerging antibiotic resistance increases the cost of treatment of pneumococcal the cost of treatment of pneumococcal infections and can result in treatment infections and can result in treatment failuresfailures

Pneumococcal Disease in Children:Pneumococcal Disease in Children:

• Bacteremia without known site of Bacteremia without known site of infection most common clinical infection most common clinical presentation.presentation.

• S. pneumoniaeS. pneumoniae leading cause of bacterial leading cause of bacterial meningitis among children younger than 5 meningitis among children younger than 5 years of age.years of age.

• Highest rate of meningitis among children Highest rate of meningitis among children younger than 1 year of age.younger than 1 year of age.

• Common cause of acute otitis media.Common cause of acute otitis media.

Diagnosing Pneumococcal Disease:Diagnosing Pneumococcal Disease:

• The diagnosis of pneumococcal The diagnosis of pneumococcal disease is difficult and microbiological disease is difficult and microbiological proof of infection may not be possible.proof of infection may not be possible.

• There are various ways of finding out There are various ways of finding out whether a patient has a pneumococcal whether a patient has a pneumococcal infection.infection.

• Which tests are used will depend on the Which tests are used will depend on the patient’s signs and symptoms.patient’s signs and symptoms.

• As other types of bacteria can also As other types of bacteria can also cause infections with similar symptoms, cause infections with similar symptoms, testing specifically for the presence of testing specifically for the presence of S. pneumoniaeS. pneumoniae is important. is important.

Types of pneumococcal diseases:Types of pneumococcal diseases:

• 1) Non-invasive pneumococcal diseases.1) Non-invasive pneumococcal diseases.

• 2) Invasive pneumococcal diseases (IPD).2) Invasive pneumococcal diseases (IPD).

Types:Types:

• 1) Non-invasive pneumococcal 1) Non-invasive pneumococcal diseases.diseases.

• Infection occures through the Infection occures through the nasopharynx (nose and throat) to the nasopharynx (nose and throat) to the upper and lower respiratory tract and upper and lower respiratory tract and can cause:can cause:

Pneumococcal Pneumonia:Pneumococcal Pneumonia:

Clinical FeaturesClinical Features

• Abrupt onset.Abrupt onset.

• Fever.Fever.

• Shaking chills.Shaking chills.

• Pleuritic chest pain. Pleuritic chest pain.

• Productive cough.Productive cough.

• Dyspnea, tachypnea, hypoxia.Dyspnea, tachypnea, hypoxia.

Pneumococcal acute otitis media - Pneumococcal acute otitis media - signs and symptoms:signs and symptoms:

• Earache.Earache.

• An elevated body temperature (fever).An elevated body temperature (fever).

• Vomiting.Vomiting.

• Diarrhea.Diarrhea.

• Temporary hearing loss.Temporary hearing loss.

• Ear discharge.Ear discharge.

2- Invasive pneumococcal diseases (IPD):2- Invasive pneumococcal diseases (IPD):

These tend to be more serious and occur inside a These tend to be more serious and occur inside a major organ, or in the blood. Examples of IPDs major organ, or in the blood. Examples of IPDs include:include:

• Bacteremia (sepsis) - bacterial infection of the Bacteremia (sepsis) - bacterial infection of the blood.blood.

• Bacteremia refers to the presence of live Bacteremia refers to the presence of live bacteria in the blood, while sepsis means a bacteria in the blood, while sepsis means a blood infection which is associated with blood infection which is associated with capillary leak, shock and an increased risk of capillary leak, shock and an increased risk of mortality.mortality.

Pneumococcal bacteremia - signs Pneumococcal bacteremia - signs and symptoms may include:and symptoms may include:

• An elevated body temperature (fever). An elevated body temperature (fever).

• Headache.Headache.

• Muscular aches and pains.Muscular aches and pains.

• Rapid heart rate.Rapid heart rate.

• Rapid breathing.Rapid breathing.

Pneumococcal Meningitis:Pneumococcal Meningitis:

• Estimated 3,000 - 6,000 cases per year Estimated 3,000 - 6,000 cases per year in the United States.in the United States.

• Case-fatality rate ~30%, up to 80% in Case-fatality rate ~30%, up to 80% in the elderly.the elderly.

• Neurologic sequelae common among Neurologic sequelae common among survivors.survivors.

Pneumococcal meningitis - signs and Pneumococcal meningitis - signs and symptoms may include:symptoms may include:

• An elevated body temperature (fever).An elevated body temperature (fever).

• Headache.Headache.

• Nausea.Nausea.

• Vomiting.Vomiting.

• Sleepiness.Sleepiness.

• Irritability.Irritability.

• Stiff neck.Stiff neck.

• Seizures.Seizures.

• Sometimes coma.Sometimes coma.

Treatment: Treatment:

• in case the S. pneumoniae has developed in case the S. pneumoniae has developed resistance.resistance.

• The emergence of resistant pneumococcal The emergence of resistant pneumococcal strains over the last few years is making strains over the last few years is making treatment more difficult, extending the period treatment more difficult, extending the period of many hospitalizations, as well as of many hospitalizations, as well as increasing the likelihood of more expensive increasing the likelihood of more expensive alternative therapy.alternative therapy.

Treatment Options for Pneumococcal Treatment Options for Pneumococcal Disease:Disease:

• Despite early and adequate treatment, Despite early and adequate treatment, there can still be serious and potentially there can still be serious and potentially life threatening complications arising life threatening complications arising from pneumococcal infection.from pneumococcal infection.

• Otitis media.Otitis media.

• May need to be treated with antibiotics.May need to be treated with antibiotics.

• Bacterial pneumonia.Bacterial pneumonia.

• Needs to be treated with antibiotics.Needs to be treated with antibiotics.

Invasive pneumococcal infections Invasive pneumococcal infections treatment: treatment:

• antibiotics for invasive pneumococcal antibiotics for invasive pneumococcal infections. If the infection is mild the infections. If the infection is mild the patient will take oral antibiotics.patient will take oral antibiotics.

• Serious infections will require intravenous Serious infections will require intravenous administration a solution containing administration a solution containing antibiotics will be administered directly antibiotics will be administered directly into the venous circulation via a syringe or into the venous circulation via a syringe or intravenous catheter.intravenous catheter.

Pneumococcal Disease Transmition:Pneumococcal Disease Transmition:

• S. pneumoniaeS. pneumoniae, the bacterium, is most , the bacterium, is most commonly found in the throat and nose commonly found in the throat and nose (nasopharynx) of infants and young (nasopharynx) of infants and young children.children.

• They may also exist in the nasopharynx They may also exist in the nasopharynx of adults, but this is less likely. of adults, but this is less likely.

• The bacterium spreads from person to The bacterium spreads from person to person via respiratory droplets if the person via respiratory droplets if the infected person coughs or sneezes in infected person coughs or sneezes in close proximity to other people, the close proximity to other people, the other people may become infected. other people may become infected.

DISEASES CAUSED BY STREPTOCOCCUS DISEASES CAUSED BY STREPTOCOCCUS PNEUMONIAEPNEUMONIAE : :

Non-invasive disease• Sinusitis (sinuses)• Otitis media (middle ear)• Pneumonia (lungs)

Invasive disease

• Bacteraemia (blood)

• Meningitis (CNS)• Endocarditis (heart)• Peritonitis (body cavity)• Septic arthritis (bones and joints)• Others (appendicitis, salpingitis, soft-

tissue infections)

PNEUMOCOCCAL INFECTION

Pharynx

Larynx

Nasopharynx

Eustachiantube

Nasal cavity

Trachea

Primarybronchi

Lungs

Lower respiratory

tractinfections

Upper respiratory

tractinfections

Meningitis

Sinusitis

Otitis media

Pneumonia

Parapneumonicempyema

Bacteraemia/septicaemia

Invasivedisease

Colonisation

Pneumococcal bacteria cause disease when they spread beyond the nasopharynx

S. pneumoniae

Pneumococcal Vaccine:Pneumococcal Vaccine:

• There are two kinds of pneumococcal There are two kinds of pneumococcal vaccine:vaccine:

1- Pneumococcal polysaccharide vaccine 1- Pneumococcal polysaccharide vaccine (PPV).(PPV).

2- Pneumococcal conjugate vaccine (PCV)2- Pneumococcal conjugate vaccine (PCV)

Countries Using Pneumococcal Conjugate Countries Using Pneumococcal Conjugate Vaccine in National Immunization Schedule in Vaccine in National Immunization Schedule in 2010 and Planned Introductions for 20112010 and Planned Introductions for 2011

Source: WHO/IVB database, Data as of September 2011 The data for 2011 is provisional

193 WHO Member States. Date of slide: 02 November 2011

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent

approximate border lines for which there may not yet be full agreement . ©WHO 2011. All rights reserved

No (112 countries or 58% of countries)

Yes (54 countries or 28% of countries)

Yes* (Parts of the country ) (1 country or 1% of countries)Yes* (Risk groups only) (9 countries or 5% of countries)

Introduction planned in 2011 (21 countries or 11% of countries)

* Argentina, Chile and Guyana (risk groups) and Columbia (partial introduction) are planning to introduce in 2011

Pneumococcal polysaccharide Pneumococcal polysaccharide vaccine (PPV):vaccine (PPV):

• The first PPV was approved in the USA in 1977 The first PPV was approved in the USA in 1977 containing purified protein from 14 types of containing purified protein from 14 types of pneumococcal bacteria.pneumococcal bacteria.

• In 1983 a PPV vaccine with the purified protein In 1983 a PPV vaccine with the purified protein from 23 pneumococcal bacteria was approved from 23 pneumococcal bacteria was approved (known as PPSV23).(known as PPSV23).

• The PPSV23 is approved for use in adults and The PPSV23 is approved for use in adults and patients with specific risk factors who are at patients with specific risk factors who are at least 2 years of age.least 2 years of age.

Pneumococcal conjugate vaccine Pneumococcal conjugate vaccine (PCV):(PCV):

• The first PCV was approved in the USA The first PCV was approved in the USA in 2000 for use in infants and young in 2000 for use in infants and young children aged six weeks to 5 years for children aged six weeks to 5 years for the prevention of pneumococcal the prevention of pneumococcal disease.disease.

• This vaccine is commonly known as This vaccine is commonly known as PCV7.PCV7.

Pneumococcal Conjugate Vaccine: Pneumococcal Conjugate Vaccine:

A conjugate vaccine is created by covalently A conjugate vaccine is created by covalently attaching a poor (polysaccharide organism) attaching a poor (polysaccharide organism) antigen to a carrier protein, thereby antigen to a carrier protein, thereby conferring the immunological attributes of conferring the immunological attributes of the carrier on the attached antigen.the carrier on the attached antigen.

This technique for the creation of an effective This technique for the creation of an effective immunogen is most often applied to immunogen is most often applied to bacterial polysaccharides for the prevention of for the prevention of invasive bacterial disease.invasive bacterial disease.

Polysaccharide vaccines:Polysaccharide vaccines:

Made from polysaccharide from the Made from polysaccharide from the capsule surrounding the bacteria.capsule surrounding the bacteria.

Works in adults:Works in adults:

•Two major problems:Two major problems:

– Not immunogenic in babies.Not immunogenic in babies.

– No immune memory.No immune memory.

Pnemoumoccal Conjugate Vaccine pcv for Pnemoumoccal Conjugate Vaccine pcv for infant and children:infant and children:

The first PCV was approved in the USA in 2000 The first PCV was approved in the USA in 2000 known as PCV7. known as PCV7.

(PCV7): vaccine protects against 7 serotypes, (PCV7): vaccine protects against 7 serotypes, (PCV10): vaccine protects against 10 serotypes (PCV10): vaccine protects against 10 serotypes 2009 .2009 .

(PCV13): vaccine protects against 13 (PCV13): vaccine protects against 13 serotypes. This type will be used in Palestin. serotypes. This type will be used in Palestin.

PolysaccharideAnd lipid (LPS)

Pneumococcalbacterium

Lipid CRM197 Protein Carrier

ChemicalReaction

Purificationprocess

Polysaccharide-proteinconjugate

Conjugate vaccineConjugate vaccine

DOSES OF VACCINE:DOSES OF VACCINE:

• First dose: 2 month.First dose: 2 month.

• Second dose: 4 month.Second dose: 4 month.

• Third dose: 6 month.Third dose: 6 month.

Symptoms of an allergic reaction Symptoms of an allergic reaction may include:may include:

• • Shortness of breath.Shortness of breath.

• • Wheezing or difficulty breathing.Wheezing or difficulty breathing.

• • Swelling of the face, lips, tongue or Swelling of the face, lips, tongue or other parts of the body.other parts of the body.

• • Rash, itching or hives on the skin.Rash, itching or hives on the skin.

Vaccine administrationVaccine administration::

* PPSV23 - given as an injection either * PPSV23 - given as an injection either in the muscle or the fatty tissue of the in the muscle or the fatty tissue of the arm or leg.arm or leg.

* PCV7 - as an injection into the muscle * PCV7 - as an injection into the muscle of the antero-lateral thigh or deltoid.of the antero-lateral thigh or deltoid.

* PCV10 - given as an injection into the * PCV10 - given as an injection into the muscle of the antero-lateral thigh or muscle of the antero-lateral thigh or deltoid.deltoid.

جدول التطعيم المقترح في جدول التطعيم المقترح في 20122012فلسطين للعام فلسطين للعام

جدول التطعيم المقترح في جدول التطعيم المقترح في 20122012فلسطين للعام فلسطين للعام BCG + HB0BCG + HB0 At BirthAt Birth

IPV1IPV111 monthmonth

PCV1 + Penta1 + TOPV1 + IPV2PCV1 + Penta1 + TOPV1 + IPV222 monthmonth

Penta2 + TOPV2Penta2 + TOPV2 PCV2PCV2+ + 44 monthmonth

Penta3 + TOPV3Penta3 + TOPV3 PCV3PCV3+ + 66 monthmonth

MMR1MMR11212 monthmonth

MMR2+DTP4+TOPV4MMR2+DTP4+TOPV41818 monthmonth

DT + TOPVDT + TOPV66 yearsyears

RubellaRubella1212 yearsyears

dTdT1515 yearsyears

Penta Vaccine = (HB1+DTP1+Hib1)Penta Vaccine = (HB1+DTP1+Hib1)

Administration of prefilled syringe:Administration of prefilled syringe:

1. Holding the syringe barrel (not the plunger) in one hand, unscrew the syringe cap by twisting anticlockwise.

2. To attach the needle to the syringe, twist the needle clockwise into the syringe until you feel it lock.

3. Remove the needle protector and administer the vaccine.

Side effects of PCV7:Side effects of PCV7:

• Vaccine is safe. Vaccine is safe.

• Between 10% and 20% of children Between 10% and 20% of children develop redness.develop redness.

• Tenderness.Tenderness.

• Swelling at the injection site.Swelling at the injection site.

• Approximately 11% get a mild fever.Approximately 11% get a mild fever.

How effective is PCV7?How effective is PCV7?

• A large clinical study showed that PCV7 A large clinical study showed that PCV7 is 97% effective in preventing invasive is 97% effective in preventing invasive disease caused by the pneumococci disease caused by the pneumococci contained in the vaccine.contained in the vaccine.

• Children with chronic diseases, such as Children with chronic diseases, such as HIV infection and sickle cell disease HIV infection and sickle cell disease appear to respond well to PCV7.appear to respond well to PCV7.

Contraindications of VaccineContraindications of Vaccine::

• Anaphylactic shock due to previous Anaphylactic shock due to previous dose of vaccine.dose of vaccine.

• Moderate or sever illness (temporary).Moderate or sever illness (temporary).

• Pregnancy.Pregnancy.