Vaccine Preventable Diseases

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4

Type of Hepatitis

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A

Source of virus Route of transmission Chronic infection Prevention

B

C

D

E

blood/ blood/ blood/ blood-derived blood-derived blood-derived body fluids body fluids body fluids

fecal-oral

percutaneous percutaneous percutaneous permucosal permucosal permucosal

no

2

1

feces

yes

yes

feces

4 yes

fecal-oral

no

pre/postpre/postblood donor pre/postensure safe exposure exposure screening; exposure drinking immunization immunization risk behavior immunization; water modification risk behavior modification

Hepatitis A Virus 0011 0010 1010 1101 0001 0100 1011

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Hepatitis A - Clinical Features

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Incubation period:



Jaundice by age group:



Complications: hepatitis



Chronic sequelae:

Average 30 days Range 15-50 days <6 yrs, <10% 6-14 yrs, 40%-50% >14 yrs, 70%-80% Fulminant hepatitis Cholestatic

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Relapsing hepatitis None

Hepatitis A Virus Transmission 0011 0010 1010 1101 0001 0100 1011

• Close personal contact (e.g., household contact, sex contact, child day care centers)

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• Contaminated food, water (e.g., infected food handlers, raw shellfish) • Blood exposure (rare) (e.g., injecting drug use, transfusion)

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Laboratory Diagnosis 0011 0010 1010 1101 0001 0100 1011

• Acute infection is diagnosed by the detection of HAV-IgM in serum by EIA.

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• Past Infection i.e. immunity is determined by the detection of HAV-IgG by EIA.

Hepatitis A Vaccination Strategies 0011 0010 1010 1101 0001 0100 1011 Epidemiologic • Many cases occur in community-wide outbreaks Considerations no risk factor identified for most cases – highest attack rates in 5-14 year olds – children serve as reservoir of infection • Persons at increased risk of infection – travelers – homosexual men – injecting drug users –

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Hepatitis B Virus 0011 0010 1010 1101 0001 0100 1011

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Hepatitis B - Clinical Features

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 Incubation period:  Clinical illness (jaundice):  Acute case-fatality rate:  Chronic infection:  Premature mortality from chronic liver disease:

Average 60-90 days Range 45-180 days <5 yrs, <10% 5 yrs, 30%-50%

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0.5%-1% <5 yrs, 30%-90% 5 yrs, 2%-10% 15%-25%

Spectrum of Chronic Hepatitis B Diseases 0011 0010 1010 1101 0001 0100 1011 1Chronic Persistent asymptomatic

Hepatitis

-

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2. Chronic Active Hepatitis symptomatic exacerbations of hepatitis 3. Cirrhosis of Liver 4. Hepatocellular Carcinoma

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Concentration of Hepatitis B Virus in Various Body Fluids 0011 0010 1010 1101 0001 0100 1011

High

Moderate

blood serum wound exudates

semen vaginal fluid saliva

Low/Not Detectable

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1

4 urine feces sweat

tears breastmilk

Hepatitis B Virus Modes of Transmission 0011 0010 1010 1101 0001 0100 1011

 Sexual - sex workers and homosexuals are particular at risk.

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1

 Parenteral - IVDA, Health Workers are at increased risk.

4

 Perinatal - Mothers who are HBeAg positive are much more likely to transmit to their offspring than those who are not. Perinatal transmission is the main means of transmission in high prevalence populations.

Diagnosis 0011 0010 1010 1101 0001 0100 1011

• • • • • • • •

A battery of serological tests are used for the diagnosis of acute and chronic hepatitis B infection. HBsAg - used as a general marker of infection. HBsAb - used to document recovery and/or immunity to HBV infection. anti-HBc IgM - marker of acute infection. anti-HBcIgG - past or chronic infection. HBeAg - indicates active replication of virus and therefore infectiveness. Anti-Hbe - virus no longer replicating. However, the patient can still be positive for HBsAg which is made by integrated HBV. HBV-DNA - indicates active replication of virus, more accurate than HBeAg especially in cases of escape mutants. Used mainly for monitoring response to therapy.

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Treatment 0011 0010 1010 1101 0001 0100 1011

• Interferon - for HBeAg +ve carriers with chronic active hepatitis. Response rate is 30 to 40%.

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1

• Lamivudine - a nucleoside analogue reverse transcriptase inhibitor. Well tolerated, most patients will respond favorably. However, tendency to relapse on cessation of treatment. Another problem is the rapid emergence of drug resistance.

4

• Successful response to treatment will result in the disappearance of HBsAg, HBV-DNA, and seroconversion to HBeAg.

Prevention 0011 0010 1010 1101 0001 0100 1011

• Vaccination - highly effective recombinant vaccines are now available. Vaccine can be given to those who are at increased risk of HBV infection such as health care workers. It is also given routinely to neonates as universal vaccination in many countries.

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1

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• Hepatitis B Immunoglobulin - HBIG may be used to protect persons who are exposed to hepatitis B. It is particular efficacious within 48 hours of the incident. It may also be given to neonates who are at increased risk of contracting hepatitis B i.e. whose mothers are HBsAg and HBeAg positive.

• Other measures - screening of blood donors, blood and body fluid precautions.

Hepatitis B Virus 0011 0010 1010 1101 0001 0100 1011

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Hepatitis B Infection in Children 0011 0010 1010 1101 0001 0100 1011

• About 40% of infants born to HBsAg-carrier mothers will be infected at birth – if mothers HBeAg + transmission rate about 90% – risk of chronic carrier at least 90% • Contribute as reservoir, source of transmission to others (Euler, Gary et al., PIDJ Feb. 2003)

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• Vaccination of infants and children, highest priority for Hepatitis B programs

MMWR, Sept. 2003

Hepatitis B Vaccine, Birth Dose 0011 0010 1010 1101 0001 0100 1011

• To prevent perinatal HBV transmission, first dose should be given within 24 hrs. (MMWR, Sept. 2003)

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1

– Prevent vertical and diminish horizontal transmission – Safety net to infants born to mothers with unknown status

4

• HBV vaccine strategies  universal immunization must be started at birth.

Hepatitis C - Clinical Features

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Incubation period:

Average 6-7 wks Range 2-26 wks

Clinical illness (jaundice):

30-40% (20-30%)

Chronic hepatitis:

70%

Persistent infection:

85-100%

Immunity:

No protective antibody response

identified

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Chronic Hepatitis C Infection 0011 0010 1010 1101 0001 0100 1011

• The spectrum of chronic hepatitis C infection is essentially the same as chronic hepatitis B infection.

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• All the manifestations of chronic hepatitis B infection may be seen, albeit with a lower frequency i.e. chronic persistent hepatitis, chronic active hepatitis, cirrhosis, and hepatocellular carcinoma.

Risk Factors Associated with 0011 0010 1010 1101 0001 0100 1011 Transmission of HCV  Transfusion or transplant from infected donor  Injecting drug use  Hemodialysis (yrs on treatment)

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 Accidental injuries with needles/sharps

 Sexual/household exposure to anti-HCV-positive contact  Multiple sex partners  Birth to HCV-infected mother

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Laboratory Diagnosis 0011 0010 1010 1101 0001 0100 1011

• HCV antibody - generally used to diagnose hepatitis C infection. Not useful in the acute phase as it takes at least 4 weeks after infection before antibody appears.

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• HCV-RNA - various techniques are available e.g. PCR and branched DNA. May be used to diagnose HCV infection in the acute phase. However, its main use is in monitoring the response to antiviral therapy. • HCV-antigen - an EIA for HCV antigen is available. It is used in the same capacity as HCV-RNA tests but is much easier to carry out.

Treatment 0011 0010 1010 1101 0001 0100 1011

• Interferon - may be considered for patients with chronic active hepatitis. The response rate is around 50% but 50% of responders will relapse upon withdrawal of treatment.

2

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• Ribavirin - there is less experience with ribavirin than interferon. However, recent studies suggest that a combination of interferon and ribavirin is more effective than interferon alone.

Prevention of Hepatitis C

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2

 Screening of blood, organ, tissue donors

1

4

 High-risk behavior modification

 Blood and body fluid precautions

δ

Hepatitis D (Delta) Virus HBsAg antigen

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RNA

4

Hepatitis D - Clinical Features

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 Coinfection – severe acute disease. – low risk of chronic infection.  Superinfection – usually develop chronic HDV infection. – high risk of severe chronic liver disease. – may present as an acute hepatitis.

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Hepatitis D Virus Modes of Transmission

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 Percutanous exposures  injecting drug use  Permucosal exposures  sex contact

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Hepatitis D Prevention

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

HBV-HDV Coinfection

2

1

Pre or postexposure prophylaxis to prevent HBV infection. 

4

HBV-HDV Superinfection Education to reduce risk behaviors among persons with chronic HBV infection.

Hepatitis E Virus

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Hepatitis E - Clinical Features 0011 0010 1010 1101 0001 0100 1011



Incubation period:



Case-fatality rate:

Average 40 days Range 15-60 days Overall, 1%-3% Pregnant women, 15%-25%



Illness severity:

Increased with age



Chronic sequelae:

None identified

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Hepatitis E Epidemiologic Features

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





Most outbreaks associated with faecally contaminated drinking water. Several other large epidemics have occurred since in the Indian subcontinent and the USSR, China, Africa and Mexico. In the United States and other nonendemic areas, where outbreaks of hepatitis E have not been documented to occur, a low prevalence of anti-HEV (<2%) has been found in healthy populations. The source of infection for these persons is unknown. Minimal person-to-person transmission.

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Prevention and Control Measures for Travelers to HEV0011 0010 Endemic 1010 1101 0001 0100 1011 Regions 

Avoid drinking water (and beverages with ice) of unknown purity, uncooked shellfish, and uncooked fruit/vegetables not peeled or prepared by traveler.



IG prepared from donors in Western countries does not prevent infection.



Unknown efficacy of IG prepared from donors in endemic areas.



Vaccine?

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Hepatitis G 0011 0010 1010 1101 0001 0100 1011

• Worlwide occurrence in adults and children, seen in about 1.5% of blood donors in the US. • Infection has been reported in 10%-20% of adults with chronic HBV or HCV infection • Transmission: blood transfusion, transplantation, IV drug use, hemodialysis, sexual transmission, vertical transmission

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Hepatitis G 0011 0010 1010 1101 0001 0100 1011

• Clinical manifestation- associated only with mild illness or no disease • Diagnosis

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– detection of HGV RNA by PCR in chronically infected patients – Detection of antibody to HGV in patients with resolved infection

• Complications: no conclusive evidence for fulminant or chronic liver disease • Treatment - supportive

Diphtheria

• 0010 Greek diphtheria hide) 0011 1010 1101 0001(leather 0100 1011

• Recognized by Hippocrates in 5th century B.C. • Epidemics described in 6th century • C. diphtheriae described by Klebs in 1883 • Toxoid developed in 1920s

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Corynebacterium diphtheriae 0011 0010 1010 1101 0001 0100 1011

• Aerobic gram-positive bacillus

2

1

• Toxin production occurs only when C. diphtheriae infected by virus (phage) carrying tox gene

4

• If isolated, must be distinguished from normal diphtheroid

Diphtheria Clinical Features 0011 0010 • 1010 1101 0001 0100 1011

Incubation period 2-5 days (range, 1-10 days)

• May involve any mucous membrane • Classified based on site of infection – Anterior nasal – Tonsillar and pharyngeal – Laryngeal – Cutaneous – Ocular – Genital

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Pharyngeal and Tonsillar Diphtheria

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• Insidious onset of exudative pharyngitis

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1

• Exudate spreads over 2-3 days and may form adherent membrane

4

• Membrane may cause respiratory obstruction

• Fever usually not high but patient appears toxic

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2

1

Cutaneous diptheria

4

Diphtheria Complications 0011 0010 1010 1101 0001 0100 1011

• Most attributable to toxin

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1

• Severity generally related to extent of local disease

4

• Most common complications are myocarditis and neuritis • Death occurs in 5%-10% for respiratory disease

Diptheria complications 0011 0010 1010 1101 0001 0100 1011

• Myocarditis – Usually occurs during 2nd or 3rd week – Cardiac failure may also occur

• Neuritis

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Treatment 0011 0010 1010 1101 0001 0100 1011

1. antitoxin 2. antibiotics: to eradicate the organisms and halt toxin production and prevent carrier state • PCN G 100,000 units/kg/day IV x 14 days • Erythromycin 40 mg/kg.day oral or parenteral x 14 days 3. supportive: bedrest, adequate nutrition and hydration, tracheostomy

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Isolation of patient: • Droplet precautions until 2 cultures are negative taken at least 24 hours apart after cessation of antimicrobial therapy

Control measures 0011 0010 1010 1101 0001 0100 1011

• Care of exposed persons: – All contacts irrespective of immunization status should be cultured, kept under surveillance for 7 days – Antimicrobial prophylaxis: erythromycin

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Diphtheria Antitoxin 0011 0010 1010 1101 0001 0100 1011

• First used in 1891 • Produced in horses

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• Used only for treatment of diphtheria • Neutralizes only unbound toxin

Diphtheria Epidemiology 0011 0010 1010 1101 0001 0100 1011

• Reservoir

Human carriers Usually asymptomatic

• Transmission

Respiratory Skin and fomites rarely

• Temporal pattern

Winter and spring

• Communicability

Up to several weeks without antibiotics

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Tetanus • First described by Hippocrates

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• Etiology discovered in 1884 by Carle and Rattone

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• Passive immunity used for treatment and prophylaxis during World War I

• Tetanus toxoid first widely used during World War II

Clostridium tetani • Anaerobic gram-positive, spore-forming bacteria

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• Spores found in soil, dust, animal feces; may persist for months to years

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• Multiple toxins produced with growth of bacteria

• Tetanospasmin estimated human lethal dose = 2.5 ng/kg

Tetanus Pathogenesis • Anaerobic conditions allow germination of spores and 0011 0010 1010 1101of 0001 0100 1011 production toxins. • Toxin binds in central nervous system

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• Interferes with neurotransmitter release to block inhibitor impulses.

4

• Leads to unopposed muscle contraction and spasm.

Clinical Features 0011 0010 1010 1101 0001 0100 1011

Incubation period 2 – 14 days • 1. Generalized tetanus: trismus is the presenting symptom in half of the cases • 2. localized tetanus: painful spasms of the muscles adjacent to the wound site

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Generalized tetanus 0011 0010 1010 1101 0001 0100 1011

• Most common form • A. Neonatal tetanus:

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1

– Onset: between 3 and 12 days old with progressive difficulty in feeding with associated hunger and crying – Jaw become so stiff the baby cannot suck or swallow – Varied degrees of sustained, tonic or rigid states of muscle contractions occurring spontaneously or provoked by stimuli – Cry: varies from repeated , short, mildly hoarse cry to noiseless – Constipation or urinary retention – Cyanosis or pallor – May end with flaccidity, anoxemia, exhaustion and finally death

4

Generalized tetanus 0011 0010 1010 1101 0001 0100 1011

• B. in older children

2

– Progressively increasing stiffness of voluntary muscles. Usual sequence of involvement: • • • • • •

1

4

Jaw: trismus or lock jaw Neck and back: opisthotonus Face: risus sardonicus Trunk: abdomen boardlike Extremities: stiff and extended In more severe cases: laryngeal spasm, respiratory distress, coma and death

Tetanus 0011 0010 1010 1101 0001 0100 1011

• Excitants: touch, bright lights, noise or mobement of the patient will produce the spasm • Fever usually absent may be high grade • Sensorium intact

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Risus sardonicus

4

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Trismus or lock jaw

4

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Tetanus 0011 0010 1010 1101 0001 0100 1011

• Diagnosis : clinical • Laboratory tests : normal

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Tetanus Complications 0011 0010 1010 1101 0001 0100 1011

• • • • • • •

Laryngospasm Fractures Hypertension Nosocomial infections Pulmonary embolism Aspiration Death

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Tetanus treatment 0011 0010 1010 1101 0001 0100 1011

a. eradication of C. tetani: • drug of choice: Penicillin G; metronidazole ( equally effective) b. Neutralization of toxin: antitoxin c. control of seizure and respiration • muscle relaxants: diazepam d. palliation and provision of meticulous supportive acre • quiet, dark, secluded setting e. prevention of recurrences: immunize

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Tetanus Wound Management 0011 0010 1010 1101 0001 0100 1011

Clean, minor wounds

All other wounds

Vaccination History

Td

TIG

Td

Unknown or <3 doses

Yes

No

3+ doses

No*

No

* Yes, if >10 years since last dose ** Yes, if >5 years since last dose

2 TIG

1

4 Yes

Yes

No** No

Tetanus Prognosis 0011 0010 1010 1101 0001 0100 1011

• Favorable prognosis: long incubation period, absence of fever, localized disease • Unfavorable prognosis: short Incubation period ( week or less between injury and trismus; with 3 days or less between trismus and onset of generalized tetanic spasm)

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Tetanus Epidemiology 0011 0010 1010 1101 0001 0100 1011

• Reservoir

Soil and intestine of animals and humans

• Transmission

Contaminated wounds Tissue injury

• Temporal pattern

Peak in summer or wet season

• Communicability

Not contagious

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• Which of the following WBC is most suggestive of pertussis? • a. 49,000 with 30% eosinophils c. 25,000 with 80% neutrophils • b. 8,000 with 80% lymphocytes d. 40,000 with 80% lymphocytes

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• A. B. C. D.

The usual course of Pertussis in an infant is characterized by 4-5 days of high grade fever followed by whooping and coughing suddent onset of fever, cough and whooping rhinitis & possibly low grade fever, followed by gradual worsening of cough and finally whooping gradual onset of cough, followed by abrupt onset of fever and cough

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Pertussis • Highly contagious respiratory infection caused by Bordetella pertussis

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• Outbreaks first described in 16th century • Bordetella pertussis isolated in 1906

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• Estimated 285,000 deaths worldwide in 2001

Bordetella pertussis 0011 0010 1010 1101 0001 0100 1011

• Fastidious gram-negative bacteria • Antigenic and biologically active components: – – – – – –

pertussis toxin (PT) filamentous hemagglutinin (FHA) agglutinogens adenylate cyclase pertactin tracheal cytotoxin

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Pertussis Pathogenesis • Attachment to cilia of ciliated epithelial cells in 0011 0010 1010 1101 0001 0100 1011 respiratory tract • Pertussis antigens allow evasion of host defenses (lymphocytosis but impaired chemotaxis)

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• Local tissue damage in respiratory tract

• Systemic disease may be toxin mediated

Pertussis Clinical Features 0011 0010 1010 1101 0001 0100 1011

• Incubation period 5-10 days (up to 21 days)

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1

• Insidious onset, similar to minor upper respiratory infection with nonspecific cough

4

• Fever usually minimal throughout course

Pertussis Clinical Features 0011 0010 1010 1101 0001 0100 1011

• Catarrhal stage

1-2 weeks

• Paroxysmal cough stage 1-6 weeks • Convalescence months

Weeks to

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Pertussis in Adults 0011 0010 1010 1101 0001 0100 1011

• Accounts for up to 7% of cough illnesses per year

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• Disease often milder than in infants and children

• Adults often source of infection for children

Pertussis Complications* 0011 0010 1010 1101 0001 0100 1011

Condition Percent reported Pneumonia 5.2 Seizures 0.8 Encephalopathy 0.1 Death 0.2 Hospitalization 20

2

1

*Cases reported to CDC 1997-2000 (N=28,187)

4

Pertussis Complications by Age Pneumonia Hospitalization 70

0011 60 0010 1010 1101 0001 0100 1011 Percent

50 40 30 20 10 0 <6 m

6-11 m

1-4 y

5-9 y

10-19 y

20+ y

Age group (yrs)

*Cases reported to CDC 1997-2000 (N=28,187)

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Pertussis Epidemiology 0011 0010 1010 1101 0001 0100 1011

• Reservoir

Human Adolescents and adults

• Transmission

Respiratory droplets Airborne rare

• Communicability

Maximum in catarrhal stage Secondary attack rate up to 80%

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Pertussis 0011 0010 1010 1101 0001 0100 1011

Diagnosis: • isolation of B. pertussis in a culture medium is the gold standard • CBC: leukemoid reaction

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Pertussis Treatment: • Effective in aborting/attenuating disease in preparoxysmal stage or catarrhal stage; if after this, may prevent transmission to others but will not alter course • Erythromycin 40 to 50 mg/kg/day x 14 days • Chemoprophylaxis: Erythromycin for 14 days is recommended for all household contacts and other close contacts, such as those in child care, irrespective of age and immunization status

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Whole-Cell Pertussis Vaccine 0011 0010 1010 1101 0001 0100 1011

• Developed in mid-1930s and combined as DTP in mid-1940s • 70%-90% efficacy after 3 doses • Protection for 5-10 years • Local adverse reactions common

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Acellular Pertussis Vaccine (DTaP) 0011 0010 1010 1101 0001 0100 1011

• Purified "subunit" vaccines • Intended to reduce adverse reactions

• Licensed for full series in 1996

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• Licensed for fourth and fifth doses in 1991

Pertussis Vaccination of Children Who Have Recovered From Pertussis 0011 0010 1010 1101 0001 0100 1011

2

• If documented disease, do not need additional doses of pertussis vaccine

1

4

• Satisfactory documentation of disease:

– recovery of B. pertussis on culture, OR – typical symptoms and clinical course when epidemiologically linked to a culture-proven case

DTP Contraindications 0011 0010 1010 1101 0001 0100 1011

• Serious allergic reaction to vaccine component or following prior dose

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• Encephalopathy occurring within 7 days after vaccination not due to another identifiable cause

DTP Precautions (Warnings)* 0011 0010 1010 1101 0001 0100 1011

• Moderate or severe acute illness

2

• Temperature >105 F (40.5 C) or higher within 48 hours with no other identifiable cause

1

4

• Collapse or shock-like state (hypotonic-hyporesponsive episode) within 48 hours

• Persistent, inconsolable crying lasting >3 hours, occurring within 48 hours • Convulsions with or without fever occurring within 3 days *may consider use in outbreaks

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• Causative Agent: Ricketsia rickettsii • Incubation Period: 3-12 days • Period of Communicability: Not communicable from person to person

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• Mode of Transmission: Wood, dog or rabbit tick • Immunity: Rocky Mountain spotted fever vaccine

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• Seen most often during spring & early summer • Signs & Symptoms: • Reddened area develops on the site of tick bite • Typical rash (2-8 days)

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• Persistent headache • High fever (104 degrees Fahrenheit) • Mental confusion

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• Rash begins as reddened macules then changing to petechiae • Begins on the wrists & ankles, spreads up the arms, legs & trunk • Cover the palm of the hand & soles of the feet

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Complications: 0011 0010 1010 1101 0001 0100 1011

• It can affect the central nervous system, like seizures & stiff neck • Cardiac & pulmonary symptoms – pneumonia & heart failure • Treatment: Tetracycline (7-10 days)

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Poliomyelitis • First by Michael 0011 0010 1010 described 1101 0001 0100 1011

Underwood in 1789

• First outbreak described in U.S. in 1843

2

1

• 21,000 paralytic cases reported in the United States in 1952 • Global eradication in near future

4

Poliovirus • Enterovirus (RNA) 0011 0010 1010 1101 0001 0100 1011 • Three serotypes: 1, 2, 3

2

1

• Minimal heterotypic immunity between serotypes

4

• Rapidly inactivated by heat, formaldehyde, chlorine, ultraviolet light

Poliomyelitis Pathogenesis • Entry 0011 0010 1010 into 1101 mouth 0001 0100 1011 • Replication in pharynx, GI tract, local lymphatics

2

1

• Hematologic spread to lymphatics and central nervous system • Viral spread along nerve fibers • Destruction of motor neurons

4

Outcomes of poliovirus infection 0011 0010 1010 A s y m1101 p to m0001 a tic 0100 M in1011 o r n o n -C N S illn e s s A s e p tic m e n ig itis P a ra ly tic

0

20

40

60

Percent

80

100

2

1

4

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2

1

Paralytic polio

4

Poliovirus Epidemiology 0011 0010 1010 1101 0001 0100 1011

• Reservoir

Human

• Transmission

Fecal-oral Oral-oral possible

• Communicability

2

1

4

7-10 days before onset Virus present in stool 3-6 weeks

Polio Vaccination of Adults 0011 0010 1010 1101 0001 0100 1011

• Routine vaccination of U.S. residents >18 years of age not necessary or recommended

2

1

4

• May consider vaccination of travelers to polio-endemic countries and selected laboratory workers

Polio Vaccination of Unvaccinated Adults 0011 0010 1010 1101 0001 0100 1011

• IPV

2

1

• Use standard IPV schedule if possible (0, 1-2 months, 6-12 months)

4

• May separate doses by 4 weeks if accelerated schedule needed

Polio Vaccination of Previously Vaccinated Adults 0011 0010 1010 1101 0001 0100 1011

• Previously complete series – administer one dose of IPV

• Incomplete series

2

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4

– administer remaining doses in series – no need to restart series

Polio Vaccine Adverse Reactions 0011 0010 1010 1101 0001 0100 1011

• Rare local reactions (IPV)

2

1

• No serious reactions to IPV have been documented • Paralytic poliomyelitis (OPV)

4

Vaccine-Associated Paralytic Polio • Increased risk in persons >18 years

0011 0010 1010 1101 0001 0100 1011

• Increased risk in persons with immunodeficiency

2

1

• No procedure available for identifying persons at risk of paralytic disease

4

• 5-10 cases per year with exclusive use of OPV

• Most cases in healthy children and their household contacts

0011 0010 1010 1101 0001 0100 1011

2

1

4

Measles

0011 0010 1010 1101 0001 0100 1011

• Highly contagious viral illness • First described in 7th century

2

1

4

• Near universal infection of childhood in prevaccination era

• Frequent and often fatal in developing areas

Measles Virus • Paramyxovirus (RNA)

0011 0010 1010 1101 0001 0100 1011

• Hemagglutinin important surface antigen • One antigenic type

2

1

4

• Rapidly inactivated by heat and light

Measles Pathogenesis 0011 0010 1010 1101 0001 0100 1011

• Respiratory transmission of virus

2

1

• Replication in nasopharynx and regional lymph nodes

4

• Primary viremia 2-3 days after exposure

• Secondary viremia 5-7 days after exposure with spread to tissues

Measles Clinical Features

0011 0010 1010 1101 0001 0100 1011

• Incubation period 10-12 days

Prodrome

2

1

• Stepwise increase in fever to 103 F or higher • Cough, coryza, conjunctivitis • Koplik spots

4

Measles Clinical Features

Rash

0011 0010 1010 1101 0001 0100 1011

• 2-4 days after prodrome, 14 days after exposure • Maculopapular, becomes confluent • Begins on face and head • Persists 5-6 days • Fades in order of appearance

2

1

4

0011 0010 1010 1101 0001 0100 1011

Enanthem: Koplik’s Spots •Appear 1-2 days after onset of symptoms

2

1

4

0011 0010 1010 1101 0001 0100 1011

2

1

4

0011 0010 1010 1101 0001 0100 1011

• Missing 8

2

1

4

0011 0010 1010 1101 0001 0100 1011

2

1

4

Slide 9

0011 0010 1010 1101 0001 0100 1011

2

1

4

0011 0010 1010 1101 0001 0100 1011

2

1

4

Measles Complications 0011 0010 1010 1101 0001 0100 1011

Condition Diarrhea Otitis media Pneumonia Encephalitis Death Hospitalization

Percent reported 8 7 6 0.1 0.2 18

Based on 1985-1992 surveillance data

2

1

4

0011 0010 1010 1101 0001 0100 1011

2

1

4

Measles pneumonia

Measles Complications by Age Group 30 0011 0010 1010Pneumonia 1101 0001Hospitalization 0100 1011 25

Percent

20 15 10 5 0 <5

5-19

Age group (yrs)

20+

2

1

4

Measles Laboratory Diagnosis 0011 0010 1010 1101 0001 0100 1011

• Isolation of measles virus from a clinical specimen (e.g., nasopharynx, urine)

2

1

4

• Significant rise in measles IgG by any standard serologic assay (e.g., EIA, HA)

• Positive serologic test for measles IgM antibody

Measles Epidemiology 0011 0010 1010 1101 0001 0100 1011

• Reservoir

Human

• Transmission

Respiratory Airborne

• Temporal pattern

Peak in late winter and spring

• Communicability

4 days before to 4 days after rash onset

2

1

4

Measles Clinical Case Definition 0011 0010 1010 1101 0001 0100 1011

• Generalized rash lasting >3 days, and • Temperature >38.3 C (101 F), and • Cough or coryza or conjunctivitis

2

1

4

Measles Vaccines 0011 0010 1010 1101 0001 0100 1011

1963 1965 1967 1968 1971 1989

Live attenuated and killed vaccines Live further attenuated vaccine Killed vaccine withdrawn Live further attenuated vaccine (Edmonston-Enders strain) Licensure of combined measlesmumps-rubella vaccine Two dose schedule

2

1

4

Measles Vaccine • Composition Live1011 virus 0011 0010 1010 1101 0001 0100 • Efficacy

95% (range, 90%-98%)

• Duration of Immunity

Lifelong

• Schedule

2 doses

2

1

4

• Should be administered with mumps and rubella as MMR

MMR vaccination • First dose of MMR at 12-15 months

0011 0010 1010 1101 0001 0100 1011

• Second dose of MMR at 4-6 years

2

1

4

• Second dose may be given any time >4 weeks after the first dose

Measles Mumps Rubella Vaccine 0011 0010 1010 1101 0001 0100 1011

• 12 months is the recommended and minimum age

2

1

4

• MMR given before 12 months should not be counted as a valid dose • Revaccinate at >12 months of age

Second Dose of Measles Vaccine 0011 0010 1010 1101 0001 0100 1011

• Intended to produce measles immunity in persons who failed to respond to the first dose (primary vaccine failure)

2

1

4

• May boost antibody titers in some persons

ACIP Recommendations 0011 0010 1010 1101 0001 0100 1011

• All states ensure that 2 doses of MMR required for school entry

2

1

4

• All children in kindergarten through grade 12 have 2 doses of MMR by 2001

Measles Prevention 0011 0010 1010 1101 0001 0100 1011

• Active immunization with live, attenuated measles vaccine

2

1

– DOH, EPI : 9 months of age – Measles epidemic: early 2 dose measles

4

• 6 months: 1 dose; 12 months : booster dose st

– If exposed ( unimmunized host) : within 3 days of exposure

Measles prevention 0011 0010 1010 1101 0001 0100 1011

• Passive immunization with immunoglobulin a. Susceptible child with definite exposure to measles given within 6 days of exposure

2

1

4

– Dose: 0.25 ml/kg ( normal child)

0.5 ml /kg ( immunocompromised)

Measles prevention 0011 0010 1010 1101 0001 0100 1011

• Passive immunization with immunoglobulin b. Children with contraindication to vaccination when there is an outbreak of measles dose: 0.5 ml/kg ( max. 15 ml)

2

1

4

Measles prevention 0011 0010 1010 1101 0001 0100 1011

• Passive immunization with immunoglobulin c. Infants younger than 5 months of age whose mothers develop measles also should receive IG

2

1

4

Measles Immunity 0011 0010 1010 1101 0001 0100 1011

• Born before 1957

• Serologic evidence of immunity

2

1

• Documentation of physician-diagnosed measles

4

• Documentation of receipt of measlescontaining vaccine

MMR Adverse Reactions • Fever

5%-15%

• Rash

5%

0011 0010 1010 1101 0001 0100 1011

• Joint symptoms

25%

• Thrombocytopenia

<1/30,000 doses

• Parotitis

rare

• Deafness • Encephalopathy

rare

2

1

4

<1/1,000,000 doses

MMR Vaccine and Autism 0011 0010 1010 1101 0001 0100 1011

• Measles vaccine connection first suggested by British gastroenterologist

2

1

• Diagnosis of autism often made in second year of life

4

• Multiple studies have shown no association

MMR Vaccine Contraindications and Precautions 0011 0010 1010 1101 0001 0100 1011

• Severe allergic reaction to vaccine component or following prior dose • Pregnancy • Immunosuppression

4

• Moderate or severe acute illness • Recent blood product

2

1

Measles Vaccine and HIV Infection 0011 0010 1010 1101 0001 0100 1011

• MMR recommended for persons with asymptomatic and mildly symptomatic HIV infection

2

1

4

• NOT recommended for those with evidence of severe immuno- suppression • Prevaccination HIV testing not recommended

PPD and Measles Vaccine 0011 0010 1010 1101 0001 0100 1011

• Apply PPD at same visit as MMR

2

1

• Delay PPD >4 weeks if MMR given first

4

• Apply PPD first - give MMR when skin test read

0011 0010 1010 1101 0001 0100 1011

2

1

4

Mumps 0011 0010 1010 1101 0001 0100 1011

• Acute viral illness

2

1

• Parotitis and orchitis described by Hippocrates in 5th century B.C.

4

• Viral etiology described by Johnson and Goodpasture in 1934

• Frequent cause of outbreaks among military personnel in prevaccine era

Mumps Virus 0011 0010 1010 1101 0001 0100 1011

• Paramyxovirus • RNA virus • One antigenic type

2

1

4

• Rapidly inactivated by chemical agents, heat and ultraviolet light

Mumps Pathogenesis 0011 0010 1010 1101 0001 0100 1011

• Respiratory transmission of virus

2

1

• Replication in nasopharynx and regional lymph nodes

4

• Viremia 12-25 days after exposure with spread to tissues • Multiple tissues infected during viremia

Mumps Clinical Features

Incubation 14-18 days 0011 • 0010 1010 1101period 0001 0100 1011

• Nonspecific prodrome of low-grade fever, headache, malaise, myalgias • Parotitis in 30%-40% • Up to 20% of infections asymptomatic

2

1

4

• May present as lower respiratory illness, particularly in preschool-aged children

Mumps Complications

0011 0010 1010 1101 0001 0100 1011

CNS involvement

15% of clinical cases

Orchitis

20%-50% in postpubertal males

Pancreatitis

2%-5%

Deafness

1/20,000

Death

1-3/10,000

2

1

4

Mumps Laboratory Diagnosis 0011 0010 1010 1101 0001 0100 1011

• Isolation of mumps virus • Serologic testing

2

1

4

– positive IgM antibody – significant increase in IgG antibody between acute and convalescent specimens

Mumps Epidemiology 0011 0010 1010 1101 0001 0100 1011

• Reservoir

Human

• Transmission

Respiratory drop nuclei Subclinical infections may transmit

• Temporal pattern

Peak in late winter and spring

• Communicability

Three days before to four days after onset of active disease

2

1

4

Mumps Clinical Case Definition 0011 0010 1010 1101 0001 0100 1011

• Acute onset of unilateral or bilateral tender, self-limited swelling of the parotid or other salivary gland lasting >2 days without other apparent cause.

2

1

4

0011 0010 1010 1101 0001 0100 1011

2

1

4

Mumps 0011 0010 1010 1101 0001 0100 1011

2

1

4

0011 0010 1010 1101 0001 0100 1011

2

1

4

Rubella

• From Latin meaning "little red"

0011 0010 1010 1101 0001 0100 1011

• Discovered in 18th century - thought to be variant of measles

2

1

4

• First described as distinct clinical entity in German literature

• Congenital rubella syndrome described by Gregg in 1941

Rubella Virus 0011 0010 1010 1101 0001 0100 1011

• Togavirus • RNA virus • One antigenic type

2

1

4

• Rapidly inactivated by chemical agents, low pH, heat and ultraviolet light

Rubella Pathogenesis 0011 0010 1010 1101 0001 0100 1011

• Respiratory transmission of virus

2

1

• Replication in nasopharynx and regional lymph nodes

4

• Viremia 5-7 days after exposure with spread to tissues • Placenta and fetus infected during viremia

Rubella Clinical Features

• Incubation period 14 days (range 12-23 days)

0011 0010 1010 1101 0001 0100 1011

• Prodrome of low grade fever • Lymphadenopathy in second week

2

1

4

• Maculopapular rash 14-17 days after exposure

0011 0010 1010 1101 0001 0100 1011

2

1

Forchheimer spots

4

Discreet maculopapular rashes 0011 0010 1010 1101 0001 0100 1011

2

1

4

Rubella Complications Arthralgia or arthritis children adult female

0011 0010 1010 1101 0001 0100 1011

rare up to 70%

2

1

4

Thrombocytopenic purpura 1/3000 cases Encephalitis 1/6,000 cases Neuritis rare Orchitis rare

Congenital Rubella Syndrome 0011 0010 1010 1101 0001 0100 1011

• Infection may affect all organs

2

1

• May lead to fetal death or premature delivery

4

• Severity of damage to fetus depends on gestational age

• Up to 85% of infants affected if infected during first trimester

Congenital Rubella Syndrome 0011 0010 1010 1101 0001 0100 1011

• • • • • • •

Deafness Cataracts Heart defects Microcephaly Mental retardation Bone alterations Liver and spleen damage

2

1

4

Rubella Laboratory Diagnosis 0011 0010 1010 1101 0001 0100 1011

• Isolation of rubella virus from clinical specimen (e.g., nasopharynx, urine)

2

1

4

• Significant rise in rubella IgG by any standard serologic assay (e.g., enzyme immunoassay)

• Positive serologic test for rubella IgM antibody

Rubella Epidemiology 0011 0010 1010 1101 0001 0100 1011 • Reservoir

Human

• Transmission

Respiratory Subclinical cases may transmit

• Temporal pattern

Peak in late winter and spring

• Communicability

7 days before to 5-7 days after rash onset Infants with CRS may shed virus for a year or more

2

1

4

Rubella Case Definition 0011 0010 1010 1101 0001 0100 1011

• Acute onset of generalized maculopapular rash, and

2

1

4

• Temperature of >37.2 C (>99 F), if measured, and • Arthralgia or arthritis, or lymphadenopathy, or conjunctivitis

Rubella Vaccine Arthropathy

• Acute joint symptoms in about 25% of susceptible adult women

0011 0010 1010 1101 0001 0100 1011

• Frank arthritis occurs in about 10%

2

1

4

• Rare reports of chronic or persistent symptoms • Population-based studies have not confirmed association

0011 0010 1010 1101 0001 0100 1011

2

1

4

Varicella 0011 0010 1010 1101 0001 0100 1011

• Acute viral illness • Zoster described in premedieval times

2

1

4

• Varicella not differentiated from smallpox until end of 19th century • Infectious nature demonstrated in 1875

Varicella Zoster Virus 0011 0010 1010 1101 0001 0100 1011

• Herpes virus (DNA) • Primary infection results in varicella (chickenpox)

4

• Recurrent infection results in herpes zoster (shingles) • Short survival in environment

2

1

Varicella Pathogenesis 0011 0010 1010 1101 0001 0100 1011

• Respiratory transmission of virus

2

1

• Replication in nasopharynx and regional lymph nodes • Repeated episodes of viremia

4

• Multiple tissues, including sensory ganglia, infected during viremia

Varicella Clinical Features 0011 0010 1010 1101 0001 0100 1011

• Incubation period 14-16 days (range 10-21 days) • Mild prodrome for 1-2 days

2

1

4

• Generally appear first on head; most concentrated on trunk • Successive crops (2-4 days) of pruritic vesicles

Varicella 0011 0010 1010 1101 0001 0100 1011

• Generally, a mild infection • In normal children, generalized vesicular rash with very few systemic effects • Virtually, NO PRODROME • The first manifestation is the EXANTHEM

2

1

4

Varicella Hallmark of the rash : vesicular lesions Maculesmaculopapular vesicular crusting scab formation Intensely pruritic Lesions often appear first on the scalp, face or trunk At any point in time, lesions in various stages are observed

• 1010 1101 0001 0100 1011 0011 0010 • • • •

2

1

4

0011 0010 1010 1101 0001 0100 1011

2

1

Tear-dropped shape lesion

4

Varicella 0011 0010 1010 1101 0001 0100 1011

• Period of communicability:

2

– Transmission: airborne, contact – Most contagious 1-2 days before and shortly after onset of rash; – Airborne and contact precautions : minimum of five days after onset of rash and as long as the rash remains vesicular

1

4

Herpes Zoster 0011 0010 1010 1101 0001 0100 1011

• Reactivation of varicella zoster virus • Associated with: – – – –

aging immunosuppression intrauterine exposure varicella at <18 month of age

2

1

4

Varicella Complications 0011 0010 1010 1101 0001 0100 1011

• Bacterial infection of lesions • CNS manifestations • Pneumonia (rare in children) • Hospitalization ~3 per 1000 cases • Death ~ 1 per 60,000 cases

2

1

4

Groups at Increased Risk of Complications of Varicella 0011 0010 1010 1101 0001 0100 1011

• Normal adults • Immunocompromised persons

2

1

4

• Newborns with maternal rash onset within 5 days before to 48 hours after delivery

Varicella Fatality Rate in Healthy Persons 30 0011 0010 1010 1101 0001 0100 1011 25

Rate

20 15 10 5 0 <1

1-14

15-19 Age group (yrs)

*Deaths per 100,000 cases

20-29

30+

2

1

4

Congenital Varicella Syndrome 0011 0010 1010 1101 0001 0100 1011

• Results from maternal infection during pregnancy • Period of risk may extend through first 20 weeks of pregnancy • Atrophy of extremity with skin scarring, low birth weight, eye and neurologic abnormalities • Risk appears to be small (<2%)

2

1

4

Varicella Laboratory Diagnosis 0011 0010 1010 1101 0001 0100 1011

• Isolation of varicella virus from clinical specimen

2

1

• Rapid varicella virus identification using direct fluorescent antibody (DFA) testing

4

• Significant rise in varicella IgG by any standard serologic assay (e.g., enzyme immunoassay)

Varicella Epidemiology 0011 0010 1010 1101 0001 0100 1011

• Reservoir

Human

• Transmission

Airborne droplet Direct contact with lesions

• Temporal pattern

Peak in winter and early spring (U.S.)

• Communicability

2

1

4

1-2 days before to 4-5 days after onset of rash May be longer in immunocompromised

Breakthrough Infection

• Immunity appears to be long-lasting for most recipients

0011 0010 1010 1101 0001 0100 1011

2

1

• Breakthrough disease much milder than in unvaccinated persons

4

• No consistent evidence that risk of breakthrough infection increases with time since vaccination

Varicella Vaccine Recommendations Children 0011 0010 1010 1101 0001 0100 1011

• Routine vaccination at 12 months of age

2

1

• Recommended for all susceptible children by the 13th birthday

4

Varicella Vaccine Recommendations Adolescents and Adults 0011 0010 1010 1101 0001 0100 1011

• Persons >13 years of age without history of varicella • Two doses separated by 4 - 8 weeks • Up to 90% of adults immune

2

1

4

• Serologic testing may be cost effective

Varicella Vaccine Recommendations Adolescents and Adults 0011 0010 1010 1101 0001 0100 1011

• Susceptible persons at high risk of exposure or severe illness – – – – –

Teachers of young children Institutional settings Military Women of childbearing age International travelers

2

1

4

Varicella Vaccine Recommendations Adolescents and Adults 0011 0010 1010 1101 0001 0100 1011

• Susceptible persons likely to expose persons at high-risk for severe illness – Healthcare workers – Family members of immunocompromised persons

2

1

4

Varicella Vaccine Postexposure Prophylaxis 0011 0010 1010 1101 0001 0100 1011

• Varicella vaccine is recommended for use in susceptible person after exposure to varicella

2

1

– 70%-100% effective if given within 72 hours of exposure – not effective if >5 days but will produce immunity if not infected

4

Varicella Vaccine Use in Immunocompromised Persons 0011 0010 1010 1101 0001 0100 1011

• Most immunocompromised persons should not be vaccinated • Vaccinate persons with isolated humoral immunodeficiency

2

1

4

• Consider varicella vaccination for asymptomatic HIV-infected children with CD4% >25% (CDC class A1 and N1)

Varicella Zoster Immune Globulin (VZIG) 0011 0010 1010 1101 0001 0100 1011

• May modify or prevent disease if given <96 hours after exposure • Indications – – – –

2

1

4

immunocompromised persons newborn of mothers with onset 5 days before to 2 days after birth premature infants with postnatal exposure susceptible adults and pregnant women

Varicella Antiviral Therapy 0011 0010 1010 1101 0001 0100 1011

• Not recommended for routine use among otherwise healthy infants and children with varicella • Consider for persons age >13 years • Consider for persons with chronic cutaneous or pulmonary disorders, long-term salicylate therapy, or steroid therapy • IV in immunocompromised children and adults with viral-mediated complications • Not recommended for post-exposure prophylaxis

2

1

2003 AAP Red Book

4