Highlghts in Pediatric

Infectious Diseases
Lester A. Deniega M.D.
Associate Professor III
UST Faculty of Medicine and Surgery
 Disclaimer:
 The Childhood Immunization Schedule
present recommendations for immunization
for children and adolescents based on the
knowledge, experience and premises current
at the time of publication.
 No claim is made for infallibility, and the PPS,
PIDSP and PFV acknowledge that individual
circumstances may warrant decisions
differing from recommendations given here.
 Disclaimer:
 The recommendations are not absolute.
Physicians must regularly update their
knowledge about specific vaccines and their
use because information about safety and
efficacy of vaccines and recommendations
relative to their administration continue to
develop after a vaccine is licensed.
 Childhood Immunization
Schedule 2012
Revised as of November 14, 2011
 PHILIPPINE EPI VACCINES:
Vaccines in the pink area, are vaccines given in the
Philippine Expanded Program of Immunization (EPI) of
the Department of Health. Vaccines in the EPI include:
• BCG
• DTwP
• Hepatitis B
• Hib
• Measles
• MMR
• OPV
 Other Recommended Vaccines
Not part of the Philippine EPI but because of merit
are advocated by the PPS, PIDSP and the
Philippine Foundation for Vaccination
These vaccines include:
•DTaP •MMRV
•Hepatitis A •Pneumococcal
•Human Papilloma virus •Rotavirus
(HPV) •Tdap
•IPV •Varicella
•Influenza
 BCG
 Given intradermally (ID)
 BCG - given at the earliest possible age after birth
preferably within the first 2 months of life. For healthy
infants and children > 2 months who are not given BCG
at birth, PPD prior to BCG vaccination is not necessary.
However, PPD is recommended prior to BCG vaccination
if any of the following are present:
• suspected congenital TB,
• history of close contact to known or suspected infectious
cases of TB,
• clinical findings suggestive of TB and/or chest x-ray
suggestive of TB.
In the presence of any of these conditions, an induration of > 5
mm is considered positive.
 The dose of BCG is 0.05 ml for infants < 12 months of
age and 0.1 ml for children > 12 months of age.
 DIPHTHERIA AND TETANUS TOXOIDS AND
ACELLULAR PERTUSSIS VACCINE (DTaP)/DTwP:

 Given intramuscularly (IM)

 Given at a minimum age of 6 weeks with a
minimum interval of 4 weeks
 The fourth dose may be given as early as 12
months provided there is a minimum interval
of 6 months from the third dose. The fifth
dose may not be given if the fourth dose was
administered at age 4 years or older.
 Hepatitis B
 Given intramuscularly (IM).
 1st dose within the 1st 12 hours of life, and may be counted as
part of the 3-dose primary series. Subsequent doses are given at
least 4 weeks apart, with the 3rd dose preferably given not earlier
than 24 weeks of age.
 A 4th dose is needed for the following: (to be administered not
earlier than 24 weeks of age):
• If the 3rd dose is given at age < 24 weeks.
• For patients using the EPI schedule of birth, 6 and 14 weeks.
• For preterms < 2 kgs whose 1st dose was given at birth
o Preterm infants born to HBsAg(-) mothers who are
medically stable may be given the 1st dose of HBV at 30
days of chronological age regardless of weight, and this can
be counted as part of the 3-dose primary series.
 If mother is HBsAg (+), administer HBV and HBIg
(0.5mL) within 12 hours of life.
 If HBsAg status is unknown, administer HBV within
12 hours of birth and determine mother’s HBsAg
 ASAP if HBsAg (+), administer HBIg no later than 7
days of life.
 HAEMOPHILUS INFLUENZAE TYPE B
CONJUGATES VACCINE
 Given intramuscularly (IM)
 Given at a minimum age of 6 weeks with a minimum
interval of 4 weeks
 If the first dose was given between 7 through 11
months of age, the second dose should be given at
least 4 weeks later and the third dose at least 8
weeks from the second dose.
 A booster dose should be given between 12-15
months with an interval of 6 months from the 3rd
dose.
 One dose of Hib vaccine should be considered for
unimmunized children age 5 years or older who have
sickle cell disease, leukemia, HIV infection, or who
had splenectomy.
 MEASLES

 Given subcutaneously (SC)

 Children who received a dose of a measles-
containing vaccine at less than 12 months of age
should be given 2 additional doses beginning at 12
through 15 months of age and separated by at least
4 weeks, the latter two preferably as MMR.
 Measles vaccine may be given as early as 6 months
of age in cases of outbreaks as declared by public
health officials.
 MEASLES, MUMPS, RUBELLA (MMR)
 Given subcutaneously (SC)
 Minimum age of MMR is administered at age 12 months. The
second dose is administered at age 4 through 6 years but may
be administered at an earlier age provided the interval
between the first and second dose is at least 4 weeks.
 Children < 12 months of age given any measles-containing
vaccine (measles, MR, MMR) should be given 2 additional
doses of MMR. The first dose is given at 12 to 15 months of
age and should be separated by at least 4 weeks from measles
containing vaccine. The second dose is administered at age 4
through 6 years, but may be given at an earlier age provided
the interval between the first and second dose is at least 4
weeks.
 Children 12 months or older given any measles-containing
vaccine (measles, MR, MMR) should be given one dose of
MMR vaccine, separated by at least 4 weeks from the first
measles-containing vaccine.
 POLIOVIRUS VACCINE (IPV/OPV)
 IPV given intramuscularly (IM) / OPV given per orem
 Given at a minimum age of 6 weeks with a minimum
interval of 4 weeks
 The final dose in the series should be given on or
after the 4th birthday and at least 6 months after the
previous dose. If 4 or more doses have been given
prior to age 4 years an additional dose should be
administered at age 4 through 6 years.
 If a combination of OPV and IPV are given as
part of a series, a total of 4 doses should be
administered, regardless of the child’s current
age.
 If available, IPV is preferred.
 TETANUS AND DIPTHERIA TOXOID (Td)/
TETANUS AND DIPTHERIA TOXOIDS AND
ACELLULAR PERTUSSIS (Tdap)
 Given intramuscularly (IM).
 In children who are fully immunized*, Td booster doses should be given
every 10 years. A single dose of Tdap can be given in place of the due Td
dose, and can be administered regardless of the interval since the last
tetanus and diphtheria toxoid–containing vaccine
 Children and adolescents 7 to18 years of age who are not fully immunized
with DPT vaccine should be given a single dose of Tdap. The remaining doses
are given as Td.
 Children and adolescents 7 to18 years of age who have never been
immunized with DPT vaccine should receive the 3-dose series of tetanus-
containing vaccine using the 0-1-6 months schedule. A single dose of Tdap is
given, preferably as the 1st dose. The remaining doses are given as Td.

* Fully
immunized is defined as 5 doses of DTaP or 4 doses of DTaP if the fourth dose was
administered on or after the fourth birthday.
 HEPATITIS A

 Given intramuscularly (IM)

 Hepatitis A vaccine is recommended for all
children age >12 months. A second dose of
the vaccine is given 6 to 12 months after the
first dose.
HUMAN PAPILLOMAVIRUS VACCINE (HPV)
 Given intramuscularly (IM)
 Primary vaccination consists of a 3-dose series administered
to females 10-18 years of age. The recommended schedule is
as follows:
• Bivalent HPV at 0, 1 and 6 months; Quadrivalent HPV*
at 0, 2, and 6 months.
 The minimum interval between the first and second dose is at
least one month and the minimum interval between the
second and third dose is at least 3 months.

*Use of Quadrivalent HPV in males 10-18 years of age for the

prevention of anogenital warts is optional.
 INFLUENZA VACCINE
 Given intramuscularly or subcutaneously (IM/SC)
 All children from 6 months to 18 years should receive
influenza vaccine.
 Children 6 months to 8 years receiving influenza
vaccine for the first time should receive 2 doses of the
vaccine separated by at least 4 weeks. If only one dose
was administered during the previous influenza season,
administer 2 doses of the vaccine then one dose yearly
thereafter.
 In October 3, 2011 WHO recommended using the same
3 influenza strains in next year’s Southern Hemisphere
vaccine. These are the current strains as in the
Northern Hemisphere vaccine.
 INFLUENZA VACCINE
 Because the strains in the 2012 influenza vaccine
have not changed from the previous season, it is
recommended that children age 6 months to 8 years
who received at least one dose of the 2011 vaccine
will require only one dose of the 2012 vaccine.
 Children who received a single dose of influenza
vaccine for 2 consecutive years should continue
receiving single annual doses.
 Annual vaccination should preferably be given
between February to June, but maybe given
throughout the year.
 MEASLES, MUMPS, RUBELLA, VARICELLA
(MMRV)
 Given subcutaneously (SC)
 Combination MMRV may be given as an
alternative to separately administered MMR
and Varicella vaccine for healthy children 12
months to 12 years of age. A second dose of
MMRV is administered at 4-6 years or at an
earlier age provided the interval between the
first and the second dose is at least 3 months.
PNEUMOCOCCAL VACCINES (PCV/PPV)
 Given intramuscularly (IM)
 The minimum age for Pneumococcal Conjugate
Vaccine (PCV) is 6 weeks and for Pneumococcal
Polysaccharide Vaccine (PPV) is 2 years.
 A single dose of PCV is recommended for all healthy
children ages 2 to 5 years with any incomplete PCV
schedule.
 For healthy children, no additional doses of PPV are
needed if the PCV series is completed. PPV is
recommended for high risk children >2 years of age
in addition to PCV. PPV should be administered at
least 8 weeks after PCV.
 ROTAVIRUS VACCINE (RV)
 Given per orem (po)
 The monovalent human rotavirus vaccine (RV1) is given as a
two-dose series with the first dose administered beginning at
6 weeks of age and the second dose administered not later
than 24 weeks of age.
 The pentavalent human bovine rotavirus vaccine (RV5) is
given as a three-dose series with the first dose given between
6 weeks to 14 weeks of age and the third dose administered
not later than 32 weeks of age.
 The minimum interval between doses is 4 weeks.
 There is insufficient data on efficacy and safety of rotavirus
vaccines given in older age groups.
 January 10, 2012
 The Philippines will begin vaccinating children against rotavirus in
2012
 First Southeast Asian nation to implement WHO 2009
recommendation.
 Another rotavirus vaccine milestone was reached today, as the
Philippines became the first country in SEA to implement the WHO
recommendation to introduce life-saving rotavirus vaccines through
its NIP for Filipino children and the nation’s healthcare resources
 During the 13th Asian Conference on Diarrheal Disease and
Nutrition (ASCODD) in Manila, Health Secretary Enrique T. Ona
announced that the Philippines will introduce rotavirus vaccines with
an initial focus on children living in the poorest communities, which
have the highest child morbidity and mortality rates from diarrheal
diseases
 VARICELLA VACCINE
 Given subcutaneously (SC)
 The first dose of the vaccine is administered from age 12-15
months. The second dose of the varicella vaccine is
administered at 4-6 years or at an earlier age provided the
interval between the first and the second dose is at least 3
months. A second dose of the vaccine is recommended for
children, adolescents, and adults who previously received
only one dose of the vaccine.
 All individuals age >13 years and without previous evidence of
immunity should receive 2 doses of varicella vaccine given at
least 4 weeks apart.
 VACCINES FOR SPECIAL GROUPS:

 These are vaccines which are not part of the

Philippine EPI or Other Recommended
Vaccines but available data support its use in
certain conditions or in selected populations.
Vaccines for Special Groups include:
 Meningococcal
 Rabies
 Typhoid
 Philippines: Policymakers’ views on
Dengue fever/DHF and the need for a
dengue vaccine
• National Health Priority
 Top health priorities in the Philippines
• Tuberculosis
• Pneumonia
• Diarrhea
• Rabies
 Dengue
• Considerable media attention given to Dengue outbreaks
• Disease strikes urban areas
• Public and Media view Dengue as a government problem and
responsibility -> political issue
Lyndon L. Lee Suy, MD, MPH
National Program Manager
Source: Vaccine 22 (2003) 121-129. Emerging and Re-emerging Infectious Diseases
National Center for Disease Prevention and Control
Department of Health
 Challenges for Dengue Vaccine
R & D: why it has been so difficult?
 4 different serotypes
• Technical difficulties
• Inter-serotype competition
• Need for balanced protection against all four
serotypes
 There is no animal model for the disease
 Theoretical risk of immunopotentiation after
sequential infections (antibody-dependent
enhancement - ADE) : need for a combined
tetravalent vaccine
 Dengue Vaccine

• Clinical Development: Sp Dengue candidate vaccine first one to enter

Phase III clinical trial
– High seroconversion rate against all 4 sero-types
– Good safety profile
– Phase IIb study ongoing in Thailand
– Other ongoing trials in endemic regions in all age groups

• Availability of the vaccine

foreseen in next 3 to 5 years
• New production facility
– 100m + dose capacity
– Bulk facility planned to be
on line by 2014
Dengue Facility Under Construction
in Neuville, France
 Clinical development plan

• Phase I clinical results

• Phase II clinical results to date
• Phase III studies
 Sanofi Pasteur Tetravalent Dengue
Vaccine Candidate
 Molecular biology- based technology
(ChimerivaxTM ) licensed-in from former
Acambis, Cambridge, USA in 1998*

 Four live attenuated Dengue viruses

with genes encoding for envelope
protein of dengue (Pr-M and E) and the
non structural and capsid protein of the
17D Yellow Fever vaccine strain.
Dengue Vaccine Candidate’s Current
Company Target
Product Profile
Description:
Live attenuated virus, tetravalent
(4 vaccinal strains cultured in serum free Vero cells)

Pharmaceutical form:
Powder and solvent for suspension for injection (0.5 ml)

Route of administration:
Sub-cutaneous

Schedule:
3 injections 0 - 6 - 12 months
Dengue Vaccine Candidate’s Current
Company Target Product Profile
Indication:
Prevention of symptomatic dengue disease
- covering the spectrum from Dengue Fever to
severe Dengue cases due to serotypes 1, 2, 3 or 4.

Populations:
Children - 9 months of age and adults living in endemic areas,
people working in (traveling to) endemic areas

Priority:
Endemic countries (Asia/Pacific, Latin America, Caribbean)
 Completed clinical trials
Code dengue vaccine Population country Status
Monovalent Den-2 Adults (18-40 yo)
CYD01 USA Completed
(3&5 log10 PFU) n=56
Tetravalent Adults (18-40 yo)
CYD02 (4 log10 TCID50/ USA Completed
serotype) n=99
Tetravalent
Adults (18-45 yo)
CYD04 (5 log10 TCID50/ USA Completed
n=66
serotype)
Tetravalent Adults (18-45 yo)
Adolescents (12-17 yo), Long term follow-up
CYD05 (5 log10 TCID50/ Philippines
Children (2-11 yo) on-going
serotype) n=126
Tetravalent Adults (18-45 yo)
Adolescents (12-17 yo),
CYD06 (5 log10 TCID50/ Mexico Completed
Children (2-11 yo)
serotype) n=126
Tetravalent Adults (18-40 yo)
(DIV12 Trial subjects, VDV1,
CYD10 (5 log10 TCID50/ Australia Completed
VDV2 or YF primed)
serotype) Max n=48
 Summary of Results :
Phase II Clinical trials
• Immunogenicity
 Balanced immune response against all 4 serotypes after 3 doses
of tetravalent Dengue vaccine

 Higher immune responses observed in children

 Previous flavivirus vaccination has a priming potential

 Booster effect in people previously exposed to wild type

dengue

 Stepwise increase of seropositivity rates against each serotype

with 3 dose
 Summary of Results :
Phase II Clinical trials
o Safety
 Reactogenicity profile comparable to control vaccines
 No safety signal with the ongoing Phase II studies, including CYD 23
and CYD 28:
• >5,000 subjects have received ≥ 1 dose (half 2-11 years in
endemic countries)
• and > 3,000 subjects have received 2nd dose.

 …largely confirming Phase I findings