Pharm Vaccine Presentation For Power Point 97-2004

Childhood
vaccines at work
in Canada
Presented by:
Date:
Location:
Presentation overview
The case for immunization
Vaccine safety
Vaccines in Canada
Myths, facts and commonly asked questions
Public policy
Resources
2010 Canadian Paediatric Society I www.cps.ca
Sources of information
Based on Your Childs Best Shot:
A parents guide to vaccination
(3rd edition, 2006)
For updates including position statements from the
CPS Infectious Diseases and Immunization Committee
and current information for parents, visit the CPS
websites: www.cps.ca and www.caringforkids.cps.ca
Reviewed by the CPS Infectious Diseases and
Immunization Committee. Lead reviewers:
Dr. Bob Bartolussi and Dr. Dorothy Moore.
The case for

immunization
Why we immunize
Vaccines save lives: A public health success story
Vaccines are safe and effective: The diseases they prevent can
cause permanent disability or even death
Its a small world: Travel can spread rare diseases quickly
Many vaccine-preventable diseases have no effective treatments
For some diseases, like tetanus, infection does not produce
immunity: Vaccines produce immunity
Last, but not least
Vaccines protect everyone

Directly: the person vaccinated, and
Indirectly: people who are vulnerable to disease, eg., babies,
children, the elderly, people with a weak immune system
Vaccines keep communities healthier: children in school,
parents working, people interacting normally
How vaccines work

Immunology 101
Bacteria and viruses have unique proteins and polysaccharides
(complex sugars) on their surfaces called antigens
Immune system targets antigens using antibodies and lymphocytes
Lymphocytes (a type of white blood cell): include B-cells, T-cells
and memory cells
Memory cells enable the immune system to recognize germs it has
seen before, creating immune memory
Immunity
Long-lasting immunity depends on memory cells. Immune
memory is the ability the immune system acquires to identify the
presence of a germ and destroy it
Two ways to achieve immunity: Natural infection or
immunization
Natural infection causes illness and can lead to complications,
permanent damage, even death
Vaccines protect without causing severe illness
Immunology of vaccines
Types of vaccines
TYPE OF VACCINE
Killed, intact virus
EXAMPLES
Inactivated polio vaccine, hepatitis A vaccine
Killed, intact bacteria
Oral cholera vaccine (Dukoral)
Killed, disrupted virus
Influenza vaccine
Live, attenuated (weakened) bacteria
Oral typhoid vaccine, BCG vaccine (for TB)
Live, attenuated (weakened) or genetically modified virus Measles, mumps, rubella, varicella, yellow fever
vaccines; oral polio, rotavirus vaccines; intranasal
influenza vaccine
Purified bacterial protein
Acellular pertussis vaccine, injectable typhoid vaccine
Purified bacterial polysaccharide (complex sugar)
Haemophilus influenzae type b, pneumococcal and

meningococcal vaccines
Purified viral protein
Hepatitis B vaccine, human papillomavirus vaccine
Inactivated bacterial toxin
Diphtheria and tetanus toxoids
Vaccine success in Canada

DISEASE
AVERAGE NUMBER OF CASES AND RELATED DEATHS (per year)
Diphtheria
Before Vaccine
12,000 cases with 1,000 deaths
After Vaccine
05 cases with 0 deaths
Tetanus
6075 cases with 4050 deaths
02 cases and no deaths since 1991
Pertussis
30,00050,000 cases with 50100 deaths
3,000 cases with 15 deaths
Polio
2,000 cases in last epidemic in 1959
Hib
1,500 cases of meningitis and 1,500 cases of

infections of blood, bone, lungs, skin, joints
About 30 cases
Measles
95% of children had measles by age 18, or 300,000 Less than 50 cases with 0 deaths
cases with 300 deaths, and 300 children with brain
damage
Mumps
30,000 cases
Rubella
85% of children have rubella by age 20, or 250,000 25 cases. 03 babies with congenital rubella
cases. About 200 cases of congenital rubella
syndrome born to unvaccinated mothers
syndrome
95 cases
Vaccine success in Canada (contd)

DISEASE
AVERAGE NUMBER OF CASES AND RELATED DEATHS (per year)
Pneumococcus
Before Vaccine
3,000 cases of severe disease
(meningitis, bacteremia, pneumonia)
in children < age 5
After Vaccine
About 250 cases
Varicella
300,000 cases
By 2007, an 85% reduction in hospitalizations in

provinces with early (2000-02) school programs;
a 65% reduction for later (2004-06) programs
Hepatitis B
20,000 new cases, with 480-500

deaths
< 1,000 cases
Meningococcus
200-400 cases, with 20-40 deaths
Program too new to see full effect
Hepatitis A
10,000-20,000 cases
Human papillomavirus
(HPV)
1,350 cases of cervical cancer, with

400 deaths and 200 deaths from
other forms of cancer caused by
HPV
Rotavirus
400,000 cases, with 2-4 deaths

in children under age 2
Risks and benefits of vaccines

DISEASE
EFFECTS OF DISEASE
Diphtheri Severe sore throat, marked weakness,
a
nerve damage, heart failure. Death in
10% of cases
Tetanus
Toxin affects nerve endings leading to

painful muscle spasms and seizures
Pertussis Severe spasms of cough lasting 36
weeks, pneumonia, convulsions. Brain
damage or death in 1 of every 400
infants
Polio
Muscle paralysis in 1 out of 100 persons
infected with polio. Death in severe
cases
Hib
Meningitis kills in 5% of cases and leads
to brain damage and deafness in 10
15% of survivors
Measles
Severe bronchitis, high fever, rash for 7
14 days; death in 1 per 1,000 cases;
encephalitis in 1 per 1,000 cases
Mumps
SIDE EFFECTS OF VACCINE

DTaP vaccine: 20% of infants have local
redness, pain; < 5% have fever; more
redness and swelling with booster at 46
years
See above for DTaP. Local redness and pain
common with adult booster
See above for DTaP. The risk of brain damage
after pertussis vaccine is too small to be
measured
IPV. No risk of disease from vaccine. Given
combined with DTaP (see above for side
effects)
Given in combination with DTaP/IPV (see
above for side effects)
Given combined with mumps and rubella

vaccines (MMR). 510% have fever with or
without rash 810 days after vaccine. No risk
of disease from vaccine. Risk of encephalitis
1 case per 1 million doses. 1 in 24,000
develops low platelets
Fever, swollen salivary glands. No visible See MMR above
illness in > 50% of cases. Encephalitis in
2010 Canadian
Paediatric Society I www.cps.ca
1 per 200 cases; deafness
in 1 per
200,000 cases
Risks and benefits of vaccines (contd)

DISEASE
Rubella
EFFECTS OF DISEASE
Fever, swollen glands, rash. No
symptoms in about 50% of cases.
Severe damage to fetus if mother
infected during first trimester of
pregnancy
Pneumococcus
Deaths in approximately 3050

children;
1520% of survivors of meningitis
have brain damage, deafness
Hospitalization in 1,000 and death in Minor local reaction; rash in about 5%
10 cases/year due to pneumonia,
of children
encephalitis, severe skin infections;
shingles (zoster) later in life
Death from complication of chronic
Minor local redness, swelling and pain
infection (cirrhosis, liver cancer) or
from severe acute illness
Death in 10% of cases; brain
damage, deafness, amputations, skin in 15% of recipients
loss in 10%
of survivors
Death from overwhelming liver
Mild pain and redness at injection site
damage in a very small proportion of
cases
Death from
cervical and other forms Mild pain and redness at injection site
of cancer
Varicella
Hepatitis B
Meningococcus
Hepatitis A
Human
Papillomavirus
(HPV)
SIDE EFFECTS OF VACCINE

Given combined with mumps and
rubella vaccines (MMR). 510% have
fever with
or without rash 810 days after
vaccine.
No risk of disease from vaccine. Risk
of encephalitis 1 case per 1 million
doses.
1 in 24,000 develops low platelets
in 15% of recipients
Vaccine success stories

Smallpox has been eradicated. No cases anywhere in the world
since 1979. Children are no longer vaccinated against smallpox
Paralytic polio eliminated from most of the world. Today,
endemic in only four countries: Afghanistan, India, Nigeria,
Pakistan
Cases dropped from 350,000 in 1988 to 1606 in 2009
Recent outbreaks in former Soviet republics of Tajikistan,
Uzbekistan
To completely eradicate polio, all children must be vaccinated
Why we (still) immunize

When vaccination rates decline, rates of disease increase
Example: In the late 1980s, former Soviet Union states saw vaccine
supplies disrupted, collapse of their public health system and
socioeconomic instability
Result: decrease in childhood immunization rates
Diphtheria epidemic followed: more than 150,000 cases and more
than 4,000 deaths in the newly independent and Baltic states
Mass vaccination program eventually controlled the epidemic
Lesson: Complacency can be fatal
Why outbreaks (still) occur

Outbreaks occur for different reasons, such as:
Public doubt: In the early 2000s, a flawed autism/MMR study in the
U.K. led to decline in measles vaccination
Results: Increase in local measles infection rates and deaths, and
spread of measles to other countries
Lesson: Vaccination must continue to prevent disease outbreaks
Travel: Measles and mumps have been introduced into Canada by
travellers, causing local outbreaks
2008: Polio spread by travellers from the 4 countries where it remains
endemic to 20 others
Lesson: Its a small world! Travel can spread a rare disease very
quickly
Why outbreaks (still) occur (contd)

Waning immunity: Large mumps outbreak in 2007-08. Started in
Nova Scotia, spread to New Brunswick and Alberta, with sporadic
cases elsewhere
Mainly affected 20 to 29-year-olds in school settings
Prompted recommendation for a second dose of vaccine for high
school, college/university students who had received only one dose in
early childhood
Lesson: There may be a need for a second booster dose of
mumps vaccine
Vaccine safety
How vaccines are approved

for use in Canada
The Biologics and Genetic Therapies Directorate (BGTD),
Health Canada, reviews and approves all vaccines for human use in
Canada
To be approved, vaccine providers must meet acceptable standards
of safety, quality (efficacy)
Production: All aspects of production are supervised by the BGTD
Safety: BGTD does independent lab testing to evaluate safety and
efficacy of early batches of vaccine
Quality: Specified by the BGTD, and repeatedly tested by lot
sampling before and after vaccine is released for sale
Recommendations for
vaccine use
NACI: National Advisory Committee on Immunization makes
recommendations to the Chief Public Health Officer
CIC: Canadian Immunization Committee assesses NACI
recommendations and advises on operational plans
Provinces/territories use NACI and CIC recommendations to
develop immunization programs
NACIs Canadian Immunization Guide: Web-based guidelines
from the Public Health Agency of Canada, published every 4 years
(most recent edition 2010), at www.phac-aspc.gc.ca
Canadian Paediatric Society: Infectious Diseases and
Immunization Committees position statements, at www.cps.ca
Monitoring vaccine safety

Adverse events: Health effects occurring after immunization that
may or may not be related to the vaccine
Mild adverse events, such as fever and swelling at the injection site,
are common. More serious reactions are rare
Post-marketing surveillance of adverse events: The system for
reporting and reviewing adverse events once a vaccine has been
approved for use
Information gets to the Public Health Agency of Canada through
doctors and nurses reporting to health officials
Doctors and nurses providing vaccines should know the local
procedure for reporting vaccine adverse events to public health
Entities involved in
monitoring vaccine safety
Canadian Adverse Events Following Immunizations Surveillance
System (CAEFISS): Receives reports from doctors, nurses
Advisory Committee on Causality Assessment (ACCA): Reviews all
reported cases of serious adverse events
IMPACT: Immunization Monitoring Program, ACTive
The Vaccine Adverse Event Reporting System (VAERS): Postmarketing safety surveillance program in the U.S.
Institute of Medicine (IOM, U.S.): Immunization Safety Review
Committee
GACVS (WHO): Global Advisory Committee on Vaccine Safety
Vaccines in Canada
Routine childhood vaccines

5-in-1 (DTaP-IPV-Hib): Protects
against diphtheria, tetanus, pertussis,
polio, and bacterial infections
caused by Hib (Haemophilus
influenzae type b), including
meningitis (a brain infection), and
other serious infections
MMR: Protects against measles,
mumps, and rubella
Hepatitis B vaccine
Varicella (chickenpox) vaccine
Seasonal influenza (flu) vaccine
Tdap: Tetanus, diphtheria and
pertussis booster for teens and
adults
Pneumococcal vaccine: Protects

against bacterial infections caused by
Streptococcus pneumoniae, including
meningitis, pneumonia, and ear
infections
Meningococcal vaccine: Protects
against bacterial infections caused by
Neisseria meningitidis, including
meningitis and septicemia, a serious
blood infection
HPV vaccine: Protects against human
papillomavirus types that cause
cervical/vaginal cancer and genital
warts
Rotavirus vaccine: Prevents
rotavirus diarrhea
Additional vaccines or a
catch-up schedule
Children with certain chronic conditions or who travel outside of
North America may require additional vaccines
Children new to Canada may not have received vaccines which are
routine here
Children who move within Canada may miss a dose of vaccine
because schedules are not uniform across the country
Contraindications to
vaccination
Anaphylactic or other serious allergic reaction after receiving a
vaccine is a contraindication to further doses of that vaccine
People with certain immune system disorders should not be given
live vaccines (eg., measles, mumps, rubella, varicella, oral
typhoid)
Avoid live vaccines during pregnancy, except when expected
benefits to mother and baby outweigh risk
Precautions
Delay giving vaccine if child has:
Moderate to severe illness
People treated with blood products should not get a live vaccine
(eg., measles, mumps, rubella, varicella) for 3 months or more.
Depending on the blood product and dose received, these vaccines
may not work
Dont delay vaccination because of minor illness (eg., a cough or
cold, with or without fever).
Diphtheria
Caused by a toxin made by bacteria that infect the nose, throat or
skin
Can cause breathing problems, heart failure, nerve damage, kidney
failure
About 1 person in 10 dies
Spread by close, direct contact with droplets from a cough or
sneeze
Before 1900, one of the main causes of childhood death. An
estimated 12,000 cases/year in Canada, with 100 deaths
1924: 9,000 cases in Canada
Routine immunization of Canadian children after 1930
Since 1983: 5 cases/year, no deaths
Diphtheria vaccine
Given with tetanus, acellular pertussis, polio and Hib vaccines as
5-in-1
Also given with tetanus and pertussis as a booster in adolescence
Also given with tetanus as a boosterrecommended every 10
years for adults
Common local reactions: redness, swelling, pain and tenderness at
the injection site
Only contraindication: anaphylactic or other serious allergic
reaction to a previous dose of the vaccine
Tetanus
Caused by a toxin made by bacteria that block normal control of
nerve reflexes in the spinal cord: also known as lockjaw
Not contagious: Spread through spores (seed-like cells) in the
environment, especially contaminated soil and dust
Before vaccine: 60-75 cases/year in Canada, with 40-50 deaths
Routine immunization began in 1944
Today 2 cases/year in Canada
Since tetanus spores are in the environment, vaccination is the
only means of prevention
Tetanus infection does not produce immunity to tetanus
In countries without vaccination, tetanus still kills
Tetanus vaccine
Most often given with diphtheria, acellular pertussis, polio and
Hib vaccines as 5-in-1
Also given with diphtheria and pertussis as a booster in
adolescence
Also given with diphtheria as a boosterrecommended every
10 years for adults
Common local reactions: redness, swelling, pain and tenderness
at the injection site
Only contraindication: an anaphylactic or other serious allergic
Pertussis
Respiratory infection caused by bacteria: whooping cough

Causes severe coughing spells followed by a whoop sound
Lasts 6 to 12 weeks
20-30% of infants with pertussis will be hospitalized
1 in 400 infants will have brain damage
Very contagious: Spread by close, direct contact with droplets
from a cough or sneeze
Before vaccine: 30,000-50,000 cases/year with 50-100 deaths
Today: 3,000 cases in Canada, with about 5 deaths each year
Recent years: increasing number of cases in teens, young
adults. Pertussis still a common cause of chronic cough
(> 2 weeks) in teens and adults
Pertussis vaccine
Whole-cell vaccine introduced in Canada in 1943

Acellular pertussis replaced whole-cell vaccine in 1997
Purified bacterial proteins: fewer side effects
Given with diphtheria, tetanus, polio and Hib vaccines as 5-in-1
Also given to older children, teens and adults as a booster,
combined with Td
Immunizing parents, adults working with children protects
babies too young to be fully immunized
Does not prevent infection in everyone but effective in reducing
severity of illness and the risk of complications
Minor local side effects are common
Polio
Caused by poliovirus
Before 1955, a common infection in Canada
Most infections asymptomatic (no symptoms) or mild, but 1-5%
cause meningitis and 1%, paralytic polio
Virus in throat and feces of people who are infected: spreads by
close direct contact with throat secretions and indirect contact
(eg., contaminated hands, water, food)
1959: last epidemic in Canada, with 2,000 cases of paralytic polio
Children ages 5 to 9 years the most affected.
1989: last case of paralytic polio due to poliovirus in Canada
2008: still seen regularly in 4 countries, and can be spread by
travellers
Polio vaccine
IPV (inactivated polio vaccine): killed, intact virus
Given with diphtheria, tetanus, pertussis and Hib vaccines as
5-in-1
OPV (oral polio vaccine): live, attenuated virus. Not used in
Canada since 1997-98, but still used in many countries
Side effects of IPV are rare
Effective and long-lasting: After 3 doses, 100% of infants develop
antibodies against all 3 types of poliovirus
Only contraindication to IPV: an anaphylactic or other serious
allergic reaction to a previous dose of the vaccine
Haemophilus influenzae type B (Hib)

Not to be confused with seasonal influenza or flu
Young children most at risk
Until 1985, the most common cause of bacterial
meningitis in Canada: 1,500 cases/year in children
5 years old
Another 1,500 cases/year with serious infections (eg.,
of the blood, epiglottis, lungs, joints, bones and skin)
Meningitis: infection of the fluid and membranes
covering the brain and spinal cord
Without treatment, all children with Hib meningitis die
Complications from Hib meningitis: brain damage,
developmental delay, speech and language disorders,
deafness
Not highly contagious: Hib bacteria in mouth, nose
secretions spread by close, prolonged exposure or
contact with droplets from a cough or sneeze
A recent
success story
1986: vaccine
approved for
use in Canada
Since 2000:
5-16 cases/
year of invasive
Hib disease in
children
Hib disease is
disappearing
from every
country with
routine
immunization
for infants
Hib vaccine
Purified bacterial polysaccharide linked to a protein carrier, such
as diphtheria or tetanus toxoid
Given with diphtheria, tetanus, pertussis and polio vaccines as
5-in-1
Protects child against Hib and helps decrease spread among
children generally
Local redness and pain in 5-15% of infants
Pneumococcal disease
Streptococcus pneumoniae: most common cause of
meningitis and other invasive, serious bacterial
infections in children in Canada, especially in children
< 2 years of age
Older children, teens and adults with certain chronic
conditions are also at higher risk
Infection starts in nose or throat. Many people are
asymptomatic carriers (have no symptoms)
Not highly contagious, but spreads through close, direct
contact: children in day care more at risk
Local infections: acute otitis media, acute sinusitis,
acute bronchitis, pneumonia
Invasive infections: meningitis, bacteremia, septicemia,
endocarditis, septic arthritis, osteomyelitis, peritonitis
Many pneumococci are becoming antibiotic-resistant
A recent
success story
Since routine
vaccination of
infants began in
2005: 94%
decrease in
invasive disease
in children < 2
years old
Indirect effect:
decreased
exposure has led
to a 91%
decrease in
invasive disease
in the elderly
Pneumococcal vaccine
Two types available: polysaccharide and conjugate
Polysaccharide: not effective in children < 2 years of age. Used in older
children, teens and adults. Contains the 23 serotypes that cause > 90% of
serious infections
Conjugate: approved in 2001. Effective at 2 months of age. Contains
7 serotypes. Vaccines containing 10 and 13 serotypes were recently
licensed in Canada and have replaced the 7-serotype vaccine in some
jurisdictions
Vaccines have dramatically reduced local and invasive forms of
infections in all age groups
Strains that cause serious infections reduced by 40-50%
Local reactions: redness, swelling, pain and tenderness at injection site
in
10-20% of people
Only contraindication: an anaphylactic or other serious allergic reaction
to a previous dose of the vaccine
Meningococcal disease
Neisseria meningitides: can cause meningitis, bacteremia, septicemia and
other invasive infections
Before vaccine, 200-400 cases of invasive infection/year in Canada, with
20-40 deaths. Since 2001, rate in Canada has decreased, to about 200
cases/year
People with certain chronic diseases are at higher risk
Death from serious disease in 5% of cases, even with treatment, and can
occur within 6-12 hours of first signs of illness
Meningococcal bacteria are fragile and infections are not very contagious
Most spread occurs via healthy carriersabout 1 in 5 adolescents and
adultsby close, direct contact with mouth secretions, respiratory droplets
5 serogroups (A, B, C, Y, and W135) cause nearly all infections in Canada,
with Groups B and C causing the most illness
Infections caused by serogroups A, C, Y, and W135 will likely drop, now
that conjugate quadrivalent vaccine (MCV4) is available in Canada
Meningococcal vaccine
Vaccine Type Introduced
in Canada
Given to
Duration
Effective Result
against
C conjugate
2001-05
Infants, children
< 2 years, with a
booster at age 12
Immune memory
occurs: Program too
new to see full effect
Group C
only
Conjugate
quadrivalent
(MCV4)
2007
Children age 2
years and older,
with a booster at
age 12
Immune memory
occurs: Program too
new to see full effect
A, C, Y,
W135
Meningococcal C
infection rates down
by 50% in 2006
A routine booster dose of either conjugate C or MCV4 is recommended for all

children at about age 12
More frequent boosters may be needed for people at higher risk of
meningococcal infections
There is no vaccine available against type B meningococcus
Mild local reactions (redness, swelling, pain or tenderness at the infection site)
reported for all vaccine types in 10-20% of people
Only contraindication is an anaphylactic or other serious allergic reaction to a
previous dose of the vaccine
Measles
Severe viral infection. Causes high fever, runny nose, cough, conjunctivitis, rash
of 1-2 weeks. Pneumonia is common (1-6% of cases)
Encephalitis: 1 in 1,000 cases, can lead to brain damage or death
Rare cases: SSPE (subacute sclerosing panencephalitis)
Highly contagious: Spreads by direct contact and through the air. Germs
become airborne in a cough or sneeze
Before vaccine: large epidemics every 2-3 years. Most children had measles,
usually by 18 years of age
300,000 cases/year in Canada, with 300 deaths and 300 children with brain
damage
Vaccine approved in 1963; two-dose schedule in 1996-97
2001-06: fewer than 20 cases/year
2007 outbreak in Quebec: 95 cases, almost all in persons who refused
vaccination
2008 outbreak in Ontario: in over 50 cases, most had received only one dose
of vaccine or had never been vaccinated
Measles vaccine
Live, attenuated (weakened) virus
Given with mumps and rubella vaccines as MMR or with varicella as MMR-V
2 doses required, since about 5% of vaccinated children remain unprotected after
first dose
Mild side effects: fever (in 5-10% of children) or rash (in 2% of children)
Severe adverse events rare: risk of encephalitis is less than 1 case per one million
doses
No evidence of links to other diseases/disorders (such as autism, developmental
delay, Crohns disease, ulcerative colitis)
Contraindications:
Allergic reaction to neomycin, gelatin, or a previous dose of the vaccine
Certain immune system disorders
Pregnancy
Precautions:
Delay vaccine for moderate to severe illness
Delay vaccine for 3 months or more for anyone who has received blood products,
as the vaccine may not work
Mumps
Viral infection that can cause fever, headache and swelling of salivary
glands around the jaw and cheeks
Can also cause a mild form of meningitis (in 1 in 10 cases) or severe
encephalitis, leading to brain damage
Complications: deafness, swelling of testicles, infection of ovaries and
(rarely) sterility
Virus in mouth and nose secretions spreads easily by close, direct
contact and in droplets from a cough or sneeze
Before vaccine, over 30,000 cases/year reported in Canada
Vaccination programs began in the 1970s
Cases dropped to < 400/year with one-dose schedule, and to an average
79 cases/year in 2000-06, with a two-dose schedule
Increasing numbers of cases in adolescents and young adults since
2007 may reflect waning immunity after single dose of vaccine
Mumps vaccine
Live, attenuated virus
Given in combination with measles and rubella vaccines as MMR or
with varicella as MMR-V: 2 doses
Side effects are rare: Meningitis reported to occur in 1 case per 800,000
doses
Contraindications:
Allergic reaction to neomycin, gelatin, or a previous dose of the vaccine
Pregnancy
Precautions:
Delay vaccine for 3 months or more for anyone who has received blood
products, as the vaccine may not work
Rubella
Viral infection, also known as German measles
Can lead to fever, sore throat, swollen glands, rash
Usually mild in children. More severe in teens and adults: arthralgias,
arthritis are common in adults
In pregnancy, can infect the fetus, causing severe disabilities: congenital
rubella syndrome (CRS), which can result in heart disease, deafness,
cataracts, mental retardation
Spreads by direct contact with mouth or nose secretions and droplets from
a cough or sneeze. Less contagious than chickenpox or measles
Before vaccine, 85% of children had rubella by age 20: 250,000
cases/year, with 200 cases of congenital rubella syndrome
Worldwide epidemic in 1964: In U.S., ~30,000 babies infected during first
20 weeks of pregnancy. Of those, ~20,000 cases of CRS and 8,000 deaths
Since routine immunization began in 1980: Only 0-3 babies with CRS are
born in Canada each year to unvaccinated mothers
Rubella vaccine
Given to infants with measles and mumps vaccines as MMR or with
varicella as MMR-V: 2 doses
Contraindications:
Allergic reaction to neomycin, gelatin, or a previous dose of vaccine
Pregnancy
Precautions:
Delay vaccine for 3 months or more for anyone who has received blood
products, as the vaccine may not work
Rubella vaccine and pregnancy

Women of child-bearing age should be tested for immunity to rubella
before first pregnancy
Women not immune and not pregnant should be vaccinated
If pregnant and not immune, delay vaccine, but mother should be
vaccinated as soon as possible after delivery for future protection
Side effects of vaccine rare in infants
25% of vaccinated women experience joint pain
Varicella (chickenpox)
Caused by varicella-zoster virus

Fever, headache, aches and pains, and itchy rash
Usually a mild (but costly) disease: Parents often stay home for
3 days; 30-65% of children are brought to a clinic or hospital
Can lead to complications such as pneumonia, bacteremia, or
severe skin infections
Illness is more severe, and complications more common, in
teenagers and adults
Severe cases can pose serious health risks, especially for newborn
babies, adults, or anyone with a weakened immune system
Highly contagious: Viruses from the throat and scratched
skin lesions spread easily through the air. Also spreads by
contact with rash
Contagious 2 days before rash appears until the last blister has
crustedusually about 5 days after rash begins
Virus remains dormant in the nervous system and can be
reactivated later to cause shingles (zoster)
A recent success
story
Before vaccine
> 300,000 cases/year
(95% of Canadians
got chickenpox)
Number of children
hospitalized with
varicella has dropped
dramatically since
vaccination programs
began. By 2007, an
84% reduction in
hospitalizations in
provinces/territories
with early (2000-02)
programs; a 65%
reduction for later
(2004-06) programs
Varicella vaccine

85-90% effective in preventing chickenpox and 100% effective in preventing moderate to
severe disease
2 doses of vaccine now recommended for all children > one year of age (previously,
2 doses given only to people vaccinated at 13 years of age)
Duration of protection at least 20 yearspossibly lifelong
Mild local reactions in about 20% of children
Vaccine-modified disease does occur but is uncommon, and the illness less severe
Transmission of vaccine virus from healthy vaccinated children to susceptible contacts is rare
Given as varicella vaccine or in combination as MMR-V
Contraindications:
Allergic reaction to neomycin or gelatin, or to a previous dose of the vaccine
Pregnancy
Precautions:
Delay vaccine for 3 months or more for anyone who has received blood products, as the
vaccine may not work
Hepatitis B
Viral infection of the liver
Half of infected people have no symptoms. Other half
become ill: fever, fatigue, loss of appetite and jaundice,
which may last weeks or months
10% of those infected become chronic carriers, who
may develop liver disease or cancer years later
Spread through blood and genital secretions. Found in
very low concentrations in saliva, but not in breast milk
Sexual activity and shared needles the most common
means of spread in Canada
Can be passed by an infected mother to her child during
pregnancy or delivery
Before vaccine, nearly 500 deaths/year in Canada and
about 1 person in 200 was a chronic carrier
A recent
success story
Since 1997,
average number
of new cases
/year in Canada
has decreased
from 20,000 to
about 1,000
School
vaccination
programs have
reached more
than 90% of
eligible children
Hepatitis B vaccine
Purified viral protein
Available alone or with hepatitis A vaccine
No uniform schedule for routine immunization, but school programs are
widespread. In some provinces/territories, vaccine given during infancy
Recommended for:
Newborns of mothers who have hepatitis B
Children attending child care programs and their caregivers
All children before or in early adolescence
People travelling to countries where there is a risk of contracting
hepatitis B
Children under 7 years of age who have immigrated to Canada from
areas with high rates of hepatitis B
Household or close contacts of an infected person
People who are at higher risk of contact with blood, such as:
health care workers
patients on hemodialysis (treatment for kidney disease)
Hepatitis A
Infection of the liver caused by hepatitis A virus
Many young children have no symptoms or fever only, but they are still
contagious and can infect others
Adolescents and adults more likely to become ill
Infection causes fever, fatigue, loss of appetite, nausea, vomiting and
jaundice
Does not cause chronic hepatitis
Spreads through contact with stool, which contains virus for as long as
14 days before onset of symptoms. Also through contaminated water or
food
Infection most common in travellers to countries where hepatitis A is
endemic, and in Canadian communities where basic sanitation, clean
water supply are inadequate
Before vaccine, 10,000-20,000 cases/year in Canada
Hepatitis A vaccine
Killed, intact virus vaccine

Not on the routine childhood immunization schedule, except in Quebec
> 95% effective in preventing infection
Not recommended for children < 1 year of age
For longer protection, 2 doses given 6 to 12 months apart are recommended
Recommended for:
People travelling to places where hepatitis A is common, including
children of new Canadians who visit relatives abroad
People with chronic liver disease or hemophilia
Communities lacking adequate sanitation or safe water supply
People in hazardous occupations (eg., relief workers, sewer workers) or
with riskier lifestyles (eg., illicit drug users, men who have sex with men)
Close contacts of known cases
Local reactions: mild pain and redness at injection site
Only contraindication: anaphylactic or other serious allergic reaction to a
previous dose of the vaccine
Seasonal influenza (flu)

Influenza virus causes yearly epidemics of respiratory illness
Can cause periodic pandemics when the virus changes suddenly and no one
is immune
During outbreaks, hospitalization rates for infants and the elderly increase
Highly contagious: spreads in respiratory secretions, on contaminated
hands, droplets from a cough or sneeze, and on contaminated objects or
surfaces
Spreads easily in schools and child care settings. Children bring the infection
home to family members
Complications of flu in young children can include: pneumonia, otitis media,
febrile seizures, severe muscle inflammation, and encephalopathy
Annual seasonal influenza shot is recommended for people at high risk of
complications from the flu, including:
all children aged 6 to 23 months, and older children with certain chronic
disorders
parents, siblings, household contacts and caregivers of high-risk children
Influenza (flu) vaccine

Killed, disrupted virus, with vaccine strains changing every year
Virus changes every year: annual vaccination in fall needed to protect
against seasonal flu
First year of immunization: children < 9 years old need 2 doses, 4 weeks
apart
Local reactions in 10-50% of recipients: soreness at injection site for
1-2 days
Some vaccines contain a trace amount of thimerosal (0.01% /dose, or
100 parts per million), to prevent bacterial contamination
Not recommended for:
children < 6 months old (not effective)
people with anaphylactic or other serious allergic reaction to eggs or to
a previous dose of the vaccine
People allergic to thimerosal should receive thimerosal-free vaccine
A new flu vaccine

A live, attenuated intranasal vaccine (LAIV) licensed in Canada in
2010
Not yet funded by any province/territory, or incorporated into any
public program
Licensed for all healthy children > 2 years of age, and all healthy
persons younger than 59 years of age
Some evidence that in children it works better than inactivated flu
vaccine
Vaccine strains are adapted to grow only in the nasal passages, where
they induce immunity but cannot invade the body
The flu strains vary each year and are the same ones included in the
inactivated vaccine
Pandemic vs. seasonal influenza

In a pandemic:
Influenza virus changes suddenly, spreads quickly around the world, and
no oneor only a very small segment of the populationhas immunity
to the new virus
Populations at risk of developing severe illness may be different than
during yearly seasonal influenza
Seasonal influenza vaccine is ineffective against the new virus strain
Pandemic influenza vaccine

Global, national and regional health authorities respond to a declared
pandemic by:
Being prepared. Government, health authorities worldwide:
activate pandemic plans for health care workers and the general public,
to prevent spread and protect groups most vulnerable to severe illness
conduct aggressive messaging on how to minimize spread of the new
strain (eg., wash hands, cough into a sleeve not hands, and stay home
if ill)
Surveillance. Positive cases are tracked, monitored and reported
Immunization. A pandemic influenza vaccine intended for at-risk
populations anywhere in the world is developed and tested:
vaccine becomes available in allotments, not all at once
new vaccines go through a stiff approval process to ensure high quality
Human papillomavirus (HPV)

Most common sexually transmitted infection in Canada
Prevalence in Canada: between 11% and 29%
Highest rates of HPV acquisition occur in the first 5 years following
onset of sexual activity. About 3 in 4 sexually active Canadians are
infected at some point
Usually no symptoms, but HPV is the major cause of cervical and vaginal
cancer in women. Can cause genital warts in both men and women
An average 1,350 cases of cervical cancer diagnosed/year in Canada,
with 400 deaths, and 200 deaths from other forms of cancer caused by
HPV
HPV vaccine highly effective in preventing infection with the most
common cancer-causing types of HPV
Vaccination programs are still too new for data on the long-term effect on
disease rates
HPV vaccine
Purified viral protein vaccine
2006: Vaccine approved for use in Canada in girls/women 9 to 26 years of
age
2007: Federal government announced funding to implement HPV
immunization programs
2010: Quadrivalent vaccine approved for use in both females and males
ages 9 to 26. NACI reviewing recommendations with a view to expanding
school programs to boys and young men
Bivalent vaccine against HPV-16 and -18 and quadrivalent vaccine against
HPV-6, -11, -16 and -18 genotypes
Either vaccine needs to be given before the onset of sexual activity,
between the ages of 9 and 13 years of age
Local reaction: soreness at injection site for 1-2 days
Only contraindication: an anaphylactic or other serious allergic reaction to
a previous dose of the vaccine
Mild to moderate illness not a reason to delay vaccination
Rotavirus
Leading cause of acute diarrhea in babies and young children
worldwide: at least 20% of all childhood gastroenteritis caused by
rotavirus
Almost all children are infected by 5 years of age
Outbreaks usually happen February to May
Causes fever, vomiting, severe watery diarrhea, and rapid dehydration
in young children who cannot keep down enough fluid
Death is rare in Western countries, but in the developing world rotavirus
kills as many as 5 in 100 children before their 5th birthday
Highly contagious before and after symptoms develop: viruses in
stool spread easily by contact with contaminated hands, objects or
surfaces that then touch the mouth
Vaccine effective in preventing severe disease and hospitalization due to
rotavirus infection
Rotavirus vaccine
2010: Recommended for routine use in Canada
Two live, attenuated (weakened) oral vaccines available for preventing rotavirus
gastroenteritis in infants 6 to 32 weeks of age
Both safe, effective, and given orally, in liquid form
Given in 2 or 3 doses, usually at 2, 4 and 6 months of age. First dose must be
given between 6-14 weeks of age, and all doses completed before 8 months of
age
Doses are given at least 4 weeks apart
Contraindications:
Anaphylactic or other serious allergic reaction to a previous dose of the vaccine
A history of bowel obstruction
Disorders of the immune system (as safety data is not yet available)
Precautions
A weakened immune system
Delay vaccine for moderate to severe illness, especially diarrhea
Myths, facts and

commonly asked
questions
Myth:
Vaccines can cause brain damage and other

illnesses that cant otherwise be explained
FACTS:
Vaccinations are frequently given in early infancy
Brain abnormalities are often not recognizable this early.
Diagnosis of cerebral palsy, mental retardation or developmental
delay are usually not made until a child is several months old
An abnormality is often recognized only after one or more
vaccine doses have been given, but this does not mean the
vaccine caused the problem
Myth:
Rates of disease were declining before the

use of vaccines
FACT:
Not so. There were fewer deaths from some diseases (eg., measles,
diphtheria) because of improved nutrition and health care, but for
other diseases (eg., polio) healthy children continued to die or
become disabled
Myth:
Compulsory vaccination violates civil rights

FACT:
Vaccination is not compulsory. But not vaccinating puts others at
risk of disease, compromising their rights
Myth:
Infections like measles stimulate the

immune system
FACT:
No infection acts as a general stimulus to the immune system.
Measles and influenza actually suppress the immune system.
The autism myth: MMR

1998: The Lancet published a study led by Dr. Andrew Wakefield,
which appeared to link vaccine with autism
Caused MMR immunization rates to drop in Britain measles
outbreak
The study itself has since been thoroughly discredited
March 2004: 10 of original studys 13 authors published a retraction of
their interpretation in The Lancet
January 2010: U.K.s regulating General Medical Council, found
Wakefield had acted dishonestly and irresponsibly in doing his
research
February 2010: Editors at The Lancet fully retracted Wakefields paper
from the published record
May 2010: Wakefield was struck off the medical registry in the U.K.
Many recent, large studies by major medical bodies have repeatedly
shown no causal link between MMR vaccine and autism
The thimerosal myth

Thimerosal: A preservative used to prevent growth of bacteria and fungi in
multidose vials of vaccines
Not added to single-dose vaccines
In the body, metabolized to ethyl mercury
1999: Concern in the U.S. about possible toxicity of ethyl mercury
2004: U.S. Institute of Medicine review found no evidence of relationship
between thimerosal and autism or any other neurological disease. More
recent studies confirm their findings
Diagnoses of autism continued to increase after thimerosal was removed
from childhood vaccines
Thimerosal is a component in only one vaccine for routine immunization of
Canadian childrenflu vaccinewhich is generally marketed in multidose
vials
A thimerosal-free, stable, influenza vaccine is also available for children
Still used as a preservative in certain vaccines produced for adults, not
children
Commonly asked questions

Wont breastfeeding protect babies from
infection?
Breast milk is the ideal food for babies. It provides important

nutritional and immune factors, and contains antibodies that help
prevent some infections.
However, this protection is incomplete and breast milk does not
protect against all infections preventable by vaccines
Breastfeeding is not an alternative to immunization and does not
enhance responses to vaccines
Protection decreases rapidly when breastfeeding stops

Is natural immunity more effective?
Immunity after most vaccines is just as effective as that induced by

disease, without the risks of disease
Every vaccine-preventable infection can cause serious harm
Immune response to natural infection may be too late to prevent
serious harm
With vaccines, the immune system is stimulated to develop
protection against the disease without full-blown infection
Shouldnt vaccines be delayed until children

are older and there is less risk of side
effects?
No evidence that side effects are more common in infants or babies
than in older children
Delaying vaccination leaves very young children at risk of
complications and death from common diseases (eg., pertussis, Hib
and pneumococcal infections are more severe for babies)
Can too many vaccines overload a babys

immune system?
Infants can respond to about 10,000 different antigens at any one
time
Bacteria and viruses expose an infant to large numbers of antigens
at oncefar more than are found in vaccines
Giving combined vaccines and multiple shots means fewer needles
for a child
Since most other children are vaccinated

and diseases are disappearing, why bother
vaccinating my child?
As long as a vaccine-preventable disease exists somewhere in the
world, any unimmunized child is at risk:
A traveller may bring the disease to any area
A child may travel to an area where the disease is more common
Vaccination does not get rid of some germs (eg., pneumococcus)
which may still be carried by older children and adults
Tetanus bacteria are present in soil and dust everywhere in the
world. Any child can be infected from a dirty wound

Why should my pre-teen be vaccinated
against HPV?
For maximum protection, complete vaccine series well before

sexual activity starts
School-based programs more effective in reaching target
populations in primary school than in secondary school
Younger children have a better immune response to the vaccine
Can vaccines cause the infection they are

supposed to prevent?
Inactivated vaccines do not contain live germs and cannot cause the
infections they protect against
Live vaccines contain viruses that have been changed so that they
are very weak and unable to cause disease in healthy people.
Rarely, they may cause a very mild form of the infection. Children
with certain immune system disorders may develop an infection
with these vaccines, and should not receive them
Speaking with parents about

vaccination
Listen, evaluate and categorize

Recognize legitimate concerns
Provide context
Refute misinformation
Provide valid information
Recognize that immunizing is a parents decision
Educate about potential consequences of the decision
Make a clear recommendation
Source: Dr. Scott A. Halperin, Dalhousie University, Canadian Journal of CME, January 2000
Public policy
Public support for

vaccination
In 2010, 14 vaccines are publicly funded by all provinces/territories
Schedules for some publicly funded programsmeningococcal
conjugate, pneumococcal conjugate, hepatitis B, flu, and HPV
vary by province/territory
Rotavirus vaccine is not currently funded by any province/territory
(as of Dec. 2010)
Cost can be substantial for governments, as well as for individual
parents
National Immunization
Strategy (NIS)
Canadas roadmap for ensuring vaccine access, supply, safety and
efficacy
Established in 2003, with five mandates:
Develop national goals and recommendations for immunization
programs
Immunization program planning
Vaccine safety
Vaccine supply
An immunization registry network
Cross-cutting issues: immunization research, professional and public
education, special populations (immigrants, refugees, travellers and
First Nations and Inuit), and vaccine-preventable disease surveillance
Progress toward NIS

2003: Launched with $45 million over five years to improve
Canadas vaccination programs, and $32 million over five years for a
national on-reserve immunization strategy. Part of a $1.3-billion
program for First Nations and Inuit health
2004: Another $300 million over three years for vaccine
procurement, to allow the provinces/territories to add newly
recommended vaccines to publicly funded programs
2007: Federal government created a trust fund for three years for
provinces/territories to initiate HPV program
Further advocacy is needed to ensure other vaccines continue to have
support
Federal government currently provides some annual funding to
improve effectiveness and efficiency of immunization programs in
Canada
Calls to action
Provide sustained funding and support for a comprehensive National
Immunization Strategy
Provide sustained funding to the provinces and territories to allow
them to offer newly recommended vaccines at no cost to the public
Develop a national immunization registry to track numbers of
children and youth who are receiving vaccines. Ideally, this registry
would include electronic record-keeping functions, for easy
transmission and monitoring, and for making sure every childs
schedule is up-to-date
Standardize immunization schedule across Canada
Ensure the involvement of nongovernmental and professional
organizations, such as the CPS, with expertise in immunization
Resources
Professional learning
Immunization Competencies for
Health Professionals
Published by the
Public Health Agency of Canada
in November 2008
www.phac-aspc.gc.ca/im/pdf/ichp-cips-eng.pdf
Immunization Competencies for Health

Professionals
Essential knowledge and skills for effective immunization
Developed to support the National Guidelines for Immunization
Practices, published in the Canadian Immunization Guide
Can be adapted and incorporated into all immunization training or
performance evaluations
To educate health professionals involved in immunization
To promote safe and competent practices
Immunization Competencies for Health

Professionals (contd)
The competencies cover:
1. the scientific basis of immunization
2. essential and safe practices
3. relevant contextual issues
Handbook includes a practical tool for measuring competency
levels
Immunization Competencies Education Program

An online course for health professionals, developed by CPS and the Public Health Agency
of Canada, is available at www.cps.ca/English/ProEdu/OnlineEdu.htm
Multidisciplinary: to meet the needs of the growing number, wider range of health professionals
involved in administering vaccines
Course designed to:
build immunization skills and knowledge
promote public confidence around vaccine effectiveness and delivery, and
foster relationships among health professionals unaccustomed to working together
Basic competencies:
how vaccines work
the rationale and benefits of immunization
the main steps in vaccine development and evaluation,
the components and properties of immunizing agents
principles of population health for improving coverage rates
Each competency is supported by a learning domain and a number of guiding learning objectives.
Immunization websites
for professionals and parents
Canadian Paediatric Society: www.cps.ca
Health Canada, Public Health Agency of Canada:
www.phac-aspc.gc.ca/im/index.html
National Advisory Committee on Immunization: www.naci.gc.ca
Canadian Coalition for Immunization Awareness and Promotion:
www.immunize.cpha.ca
American Academy of Pediatrics: www.aap.org
Centers for Disease Control and Prevention: www.cdc.gov
Advisory Committee on Immunization Practices (ACIP)
www.cdc.gov/vaccines/recs/ACIP/default.htm
Immunization Action Coalition: www.immunize.org
Institute of Medicine: www.iom.edu
Assessing vaccine
information on the Internet
Asking a few key questions can help you tell whether or not you can trust the
information you find on the Internet:
1. What is the source of the information? Does the site:
Identify who has produced the information
List all sources of funding
Provide a way to contact the provider of information
2. Has the medical information been reviewed by scientific experts?
3. Is there a date showing when the information was posted online and/or last
revised?
4. Is there scientific evidence to back up the claims? (e.g., articles from
respected medical journals)
Not all studies or reports are necessarily reliable
Books and printable resources

for professionals and parents
Canadian Paediatric Society. 3rd edn. 2006. Your Childs Best Shot:
A Parents Guide to Vaccination.
Canadian Paediatric Society. MMR vaccine: Myths and Facts.
A tear-away pad for informing families.
Fisher, Margaret C. (2006) Immunization and Infectious Diseases: An
Informed Parents Guide. Elk Grove Village, Ill.: American Academy
of Pediatrics.
Public Health Agency of Canada. 2008. Immunization Competencies
for Health Professionals.
Public Health Agency of Canada. 2009. A Parents Guide to
Vaccination.
Public Health Agency of Canada. Canadian Immunization Guide.
8th edn. 2010.
Questions? Comments?
Leave-behind materials
A list of resources and the routine immunization schedule are

available as pdfs on the CPS website, so users can print,
photocopy and distribute for their presentations at no cost.

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Childhood

2010 Canadian Paediatric Society I www.cps.ca

2010 Canadian Paediatric Society I www.cps.ca

The case for

2010 Canadian Paediatric Society I www.cps.ca

Last, but not least

2010 Canadian Paediatric Society I www.cps.ca

Vaccines protect everyone

2010 Canadian Paediatric Society I www.cps.ca

How vaccines work

2010 Canadian Paediatric Society I www.cps.ca

2010 Canadian Paediatric Society I www.cps.ca

Killed, intact bacteria

Oral cholera vaccine (Dukoral)

Killed, disrupted virus

Live, attenuated (weakened) bacteria

Oral typhoid vaccine, BCG vaccine (for TB)

Acellular pertussis vaccine, injectable typhoid vaccine

Purified bacterial polysaccharide (complex sugar)

Haemophilus influenzae type b, pneumococcal and

Purified viral protein

Hepatitis B vaccine, human papillomavirus vaccine

Inactivated bacterial toxin

Diphtheria and tetanus toxoids

2010 Canadian Paediatric Society I www.cps.ca

Vaccine success in Canada

AVERAGE NUMBER OF CASES AND RELATED DEATHS (per year)

6075 cases with 4050 deaths

02 cases and no deaths since 1991

30,00050,000 cases with 50100 deaths

3,000 cases with 15 deaths

2,000 cases in last epidemic in 1959

1,500 cases of meningitis and 1,500 cases of

2010 Canadian Paediatric Society I www.cps.ca

Vaccine success in Canada (contd)

AVERAGE NUMBER OF CASES AND RELATED DEATHS (per year)

By 2007, an 85% reduction in hospitalizations in

20,000 new cases, with 480-500

< 1,000 cases

200-400 cases, with 20-40 deaths

Program too new to see full effect

Program too new to see full effect

1,350 cases of cervical cancer, with

Program too new to see full effect

400,000 cases, with 2-4 deaths

Program too new to see full effect

2010 Canadian Paediatric Society I www.cps.ca

Risks and benefits of vaccines

Toxin affects nerve endings leading to

SIDE EFFECTS OF VACCINE

Given combined with mumps and rubella

Risks and benefits of vaccines (contd)

Deaths in approximately 3050

SIDE EFFECTS OF VACCINE

Vaccine success stories

2010 Canadian Paediatric Society I www.cps.ca

Why we (still) immunize

2010 Canadian Paediatric Society I www.cps.ca

Why outbreaks (still) occur

2010 Canadian Paediatric Society I www.cps.ca

Why outbreaks (still) occur (contd)

2010 Canadian Paediatric Society I www.cps.ca

2010 Canadian Paediatric Society I www.cps.ca