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1
4
0011 0010 1010 1101 0001 0100 1011
Type of
Hepatitis
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A B C D E
1
2
Source of feces blood/ blood/ blood/ feces
virus blood-derived blood-derived blood-derived
4
body fluids body fluids body fluids
2
1
4
Hepatitis A - Clinical
Features
0011 0010 1010 1101 0001 0100 1011
2
Range 15-50 days
1
Jaundice by <6 yrs, <10%
4
age group: 6-14 yrs, 40%-50%
>14 yrs, 70%-80%
Complications: Fulminant hepatitis
Cholestatic
hepatitis
Relapsing hepatitis
Chronic sequelae: None
Hepatitis A Virus Transmission
0011 0010 1010 1101 0001 0100 1011
2
(e.g., household contact, sex contact, child
1
day care centers)
4
• Contaminated food, water
(e.g., infected food handlers, raw shellfish)
• Blood exposure (rare)
(e.g., injecting drug use, transfusion)
0011 0010 1010 1101 0001 0100 1011
2
1
4
Laboratory Diagnosis
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1
2
detection of HAV-IgM in serum by EIA.
4
• Past Infection i.e. immunity is determined
by the detection of HAV-IgG by EIA.
Hepatitis A Vaccination
Strategies
Epidemiologic
0011 0010 1010 1101 0001 0100 1011
Considerations
• Many cases occur in community-wide outbreaks
2
– no risk factor identified for most cases
1
– highest attack rates in 5-14 year olds
4
– children serve as reservoir of infection
2
1
4
Hepatitis B - Clinical
Features
0011 0010 1010 1101 0001 0100 1011
2
Range 45-180 days
1
Clinical illness (jaundice): <5 yrs, <10%
4
5 yrs, 30%-50%
Acute case-fatality rate: 0.5%-1%
Chronic infection: <5 yrs, 30%-90%
5 yrs, 2%-10%
Premature mortality from
chronic liver disease: 15%-25%
Spectrum of Chronic Hepatitis B
0011 0010 1010 1101 0001 0100 1011
Diseases
1
2
asymptomatic
4
2. Chronic Active Hepatitis -
symptomatic exacerbations of hepatitis
3. Cirrhosis of Liver
4. Hepatocellular Carcinoma
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2
1
4
Concentration of Hepatitis B
Virus in Various Body Fluids
0011 0010 1010 1101 0001 0100 1011
Low/Not
2
High Moderate Detectable
1
4
blood semen urine
serum vaginal fluid feces
wound exudates saliva sweat
tears
breastmilk
Hepatitis B Virus
Modes of Transmission
0011 0010 1010 1101 0001 0100 1011
2
particular at risk.
1
Parenteral - IVDA, Health Workers are at
4
increased risk.
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.
2
• HBsAg - used as a general marker of infection.
1
• HBsAb - used to document recovery and/or immunity to HBV
infection.
4
• 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.
Treatment
0011 0010 1010 1101 0001 0100 1011
2
hepatitis. Response rate is 30 to 40%.
1
• Lamivudine - a nucleoside analogue reverse transcriptase
inhibitor. Well tolerated, most patients will respond favorably.
4
However, tendency to relapse on cessation of treatment.
Another problem is the rapid emergence of drug resistance.
• 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
2
available. Vaccine can be given to those who are at increased risk of
1
HBV infection such as health care workers. It is also given routinely
to neonates as universal vaccination in many countries.
4
• 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
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2
1
4
Hepatitis B Infection in Children
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• About 40% of infants born to HBsAg-carrier mothers will be infected at birth
– if mothers HBeAg + transmission rate about 90%
2
– risk of chronic carrier at least 90%
1
• Contribute as reservoir, source of transmission to others
4
(Euler, Gary et al., PIDJ Feb. 2003)
1
2
– Prevent vertical and diminish horizontal transmission
4
– Safety net to infants born to mothers with unknown status
2
Range 2-26 wks
Clinical illness (jaundice):
1
30-40% (20-30%)
4
Chronic hepatitis: 70%
Persistent infection: 85-100%
Immunity: No protective
antibody
response
identified
Chronic Hepatitis C Infection
0011 0010 1010 1101 0001 0100 1011
1
2
essentially the same as chronic hepatitis B
infection.
4
• 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
Transmission
0011 0010 1010 1101 0001 0100 1011 of HCV
Transfusion or transplant from infected donor
1
2
Injecting drug use
Hemodialysis (yrs on treatment)
4
Accidental injuries with needles/sharps
Sexual/household exposure to anti-HCV-positive
contact
Multiple sex partners
Birth to HCV-infected mother
0011 0010 1010 1101 0001 0100 1011
2
1
4
Laboratory Diagnosis
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2
infection. Not useful in the acute phase as it takes at least
1
4 weeks after infection before antibody appears.
4
• 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
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2
chronic active hepatitis. The response rate is
1
around 50% but 50% of responders will relapse
4
upon withdrawal of treatment.
• 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
2
1
RNA
4
Hepatitis D - Clinical
Features
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Coinfection
1
2
– severe acute disease.
4
– low risk of chronic infection.
Superinfection
– usually develop chronic HDV infection.
– high risk of severe chronic liver disease.
– may present as an acute hepatitis.
Hepatitis D Virus
Modes of
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Transmission
2
Percutanous exposures
injecting drug use
1
4
Permucosal exposures
sex contact
0011 0010 1010 1101 0001 0100 1011
2
1
4
Hepatitis D -
0011 0010 1010 1101 0001 0100 1011
Prevention
HBV-HDV Coinfection
1
2
Pre or postexposure prophylaxis to prevent
4
HBV infection.
HBV-HDV Superinfection
Education to reduce risk behaviors among
persons with chronic HBV infection.
Hepatitis E
Virus
0011 0010 1010 1101 0001 0100 1011
2
1
4
Hepatitis E - Clinical Features
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1
2
Range 15-60 days
4
Case-fatality rate: Overall, 1%-3%
Pregnant women,
15%-25%
Illness severity: Increased with age
Chronic sequelae: None identified
Hepatitis E -
Epidemiologic
Features
0011 0010 1010 1101 0001 0100 1011
2
water.
1
Several other large epidemics have occurred since in the Indian
4
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.
0011 0010 1010 1101 0001 0100 1011
2
1
4
Prevention and Control
Measures for Travelers to HEV-
0011 0010 Endemic Regions
1010 1101 0001 0100 1011
2
unknown purity, uncooked shellfish, and
1
uncooked fruit/vegetables not peeled or prepared
by traveler.
4
IG prepared from donors in Western countries
does not prevent infection.
Unknown efficacy of IG prepared from donors in
endemic areas.
Vaccine?
Hepatitis G
0011 0010 1010 1101 0001 0100 1011
2
children, seen in about 1.5% of blood
1
donors in the US.
4
• 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
Hepatitis G
0011 0010 1010 1101 0001 0100 1011
2
illness or no disease
1
• Diagnosis
4
– 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
0011 Greek diphtheria
1010 1101 0001(leather hide)
0100 1011
2
1
• Epidemics described in 6th century
4
• C. diphtheriae described by Klebs in 1883
1
2
• Toxin production occurs only when C.
4
diphtheriae infected by virus (phage) carrying tox
gene
2
• May involve any mucous membrane
1
4
– Anterior nasal
– Tonsillar and pharyngeal
– Laryngeal
– Cutaneous
– Ocular
– Genital
Pharyngeal and Tonsillar
Diphtheria
0011 0010 1010 1101 0001 0100 1011
1
2
• Exudate spreads over 2-3 days and may form adherent
membrane
4
• Membrane may cause respiratory obstruction
2
1
4
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2
1
4
0011 0010 1010 1101 0001 0100 1011
2
1
4
0011 0010 1010 1101 0001 0100 1011
2
1
Cutaneous diptheria
4
Diphtheria Complications
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1
2
• Severity generally related to extent of local
4
disease
• Myocarditis
2
– Usually occurs during 2nd or 3rd week
– Cardiac failure may also occur
1
4
• Neuritis
Treatment
0011 0010 1010 1101 0001 0100 1011
1. antitoxin
2. antibiotics: to eradicate the organisms and halt toxin
2
production and prevent carrier state
1
• PCN G 100,000 units/kg/day IV x 14 days
4
• Erythromycin 40 mg/kg.day oral or parenteral x 14
days
3. supportive: bedrest, adequate nutrition and hydration,
tracheostomy
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
2
– All contacts irrespective of immunization
1
status should be cultured, kept under
4
surveillance for 7 days
– Antimicrobial prophylaxis: erythromycin
Diphtheria Antitoxin
0011 0010 1010 1101 0001 0100 1011
1
2
• Produced in horses
4
• Used only for treatment of diphtheria
1
2
• Transmission Respiratory
4
Skin and fomites rarely
2
1
4
Tetanus
• First described by Hippocrates
0011 0010 1010 1101 0001 0100 1011
2
and Rattone
1
4
• Passive immunity used for treatment and
prophylaxis during World War I
2
for months to years
1
4
• Multiple toxins produced with growth of bacteria
2
• Toxin binds in central nervous system
1
• Interferes with neurotransmitter release to block
4
inhibitor impulses.
2
• 1. Generalized tetanus:
1
trismus is the presenting symptom in half of
4
the cases
• 2. localized tetanus: painful spasms of the
muscles adjacent to the wound site
Generalized tetanus
0011 0010 1010 1101 0001 0100 1011
2
• A. Neonatal tetanus:
1
– Onset: between 3 and 12 days old with progressive difficulty in
feeding with associated hunger and crying
4
– 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
Generalized tetanus
0011 0010 1010 1101 0001 0100 1011
• B. in older children
2
– Progressively increasing stiffness of voluntary
1
muscles. Usual sequence of involvement:
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
2
mobement of the patient will produce the
spasm
1
4
• Fever usually absent may be high grade
• Sensorium intact
0011 0010 1010 1101 0001 0100 1011
2
1
Risus sardonicus
4
0011 0010 1010 1101 0001 0100 1011
2
1
Trismus or lock jaw
4
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2
1
4
Tetanus
0011 0010 1010 1101 0001 0100 1011
• Diagnosis : clinical
2
• Laboratory tests : normal
1
4
Tetanus Complications
0011 0010 1010 1101 0001 0100 1011
• Laryngospasm
2
• Fractures
• Hypertension
1
4
• Nosocomial infections
• Pulmonary embolism
• Aspiration
• Death
Tetanus treatment
0011 0010 1010 1101 0001 0100 1011
a. eradication of C. tetani:
2
• drug of choice: Penicillin G; metronidazole ( equally
1
effective)
b. Neutralization of toxin: antitoxin
4
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
Tetanus Wound Management
0011 0010 1010 1101 0001 0100 1011
Clean, minor All other
wounds wounds
2
Vaccination History Td TIG Td TIG
1
4
Unknown or <3 doses Yes No Yes Yes
2
period, absence of fever, localized disease
1
• Unfavorable prognosis: short Incubation
4
period ( week or less between injury and
trismus; with 3 days or less between
trismus and onset of generalized tetanic
spasm)
Tetanus Epidemiology
0011 0010 1010 1101 0001 0100 1011
• Reservoir Soil and intestine of
animals and humans
1
2
• Transmission Contaminated wounds
4
Tissue injury
2
1
4
0011 0010 1010 1101 0001 0100 1011
2
suggestive of pertussis?
•
1
a. 49,000 with 30% eosinophils
4
c. 25,000 with 80% neutrophils
• b. 8,000 with 80% lymphocytes
d. 40,000 with 80% lymphocytes
0011 0010 1010 1101 0001 0100 1011
1
2
A. 4-5 days of high grade fever followed by
whooping and coughing
4
B. suddent onset of fever, cough and whooping
C. rhinitis & possibly low grade fever, followed
by gradual worsening of cough and finally
whooping
D. gradual onset of cough, followed by abrupt
onset of fever and cough
Pertussis
• Highly contagious respiratory infection caused by
0011 0010 1010 1101 0001 0100 1011
Bordetella pertussis
2
• Outbreaks first described in 16th century
1
4
• Bordetella pertussis isolated in 1906
2
• Antigenic and biologically active components:
– pertussis toxin (PT)
1
4
– filamentous hemagglutinin (FHA)
– agglutinogens
– adenylate cyclase
– pertactin
– tracheal cytotoxin
Pertussis Pathogenesis
• Attachment to cilia of ciliated epithelial cells in
0011 0010 1010 1101 0001 0100 1011
respiratory tract
2
• Pertussis antigens allow evasion of host defenses
1
(lymphocytosis but impaired chemotaxis)
4
• Local tissue damage in respiratory tract
1
2
• Insidious onset, similar to minor upper respiratory
4
infection with nonspecific cough
2
1
• Paroxysmal
4
cough stage 1-6 weeks
• Convalescence Weeks to
months
0011 0010 1010 1101 0001 0100 1011
2
1
4
Pertussis in Adults
0011 0010 1010 1101 0001 0100 1011
2
year
1
4
• Disease often milder than in infants and
children
2
1
Seizures 0.8
Encephalopathy 0.1
4
Death 0.2
Hospitalization 20
*Cases reported to CDC 1997-2000 (N=28,187)
Pertussis Complications by Age
Pneumonia Hospitalization
70
0011 60
0010 1010 1101 0001 0100 1011
50
40
Percent
2
30
1
20
4
10
0
<6 m 6-11 m 1-4 y 5-9 y 10-19 y 20+ y
Age group (yrs)
2
• Reservoir Human
1
Adolescents and adults
4
• Transmission Respiratory droplets
Airborne rare
Diagnosis:
1
2
• isolation of B. pertussis in a culture
4
medium is the gold standard
• CBC: leukemoid reaction
Pertussis
Treatment:
0011 0010 1010 1101 0001 0100 1011
2
preparoxysmal stage or catarrhal stage; if after
1
this, may prevent transmission to others but
will not alter course
4
• 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
Whole-Cell Pertussis Vaccine
0011 0010 1010 1101 0001 0100 1011
2
in mid-1940s
1
2
• Intended to reduce adverse reactions
4
• Licensed for fourth and fifth doses in 1991
2
• If documented disease, do not need additional doses of
1
pertussis vaccine
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
2
component or following prior dose
1
4
• 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
1
other identifiable cause
4
• Collapse or shock-like state (hypotonic-hyporesponsive episode)
within 48 hours
2
1
4
• Causative Agent: Ricketsia rickettsii
0011 0010 1010 1101 0001 0100 1011
1
2
• Period of Communicability: Not
communicable from person to person
4
0011 0010 1010 1101 0001 0100 1011
2
or rabbit tick
1
4
• Immunity: Rocky Mountain
spotted fever vaccine
• Seen most often during spring &
0011 0010 1010 1101 0001 0100 1011
early summer
1
2
• Signs & Symptoms:
4
• Reddened area develops on the site
of tick bite
• Typical rash (2-8 days)
0011 0010 1010 1101 0001 0100 1011
• Persistent headache
2
• High fever (104 degrees
Fahrenheit)
1
4
• Mental confusion
• Rash begins as reddened macules then
0011 0010 1010 1101 0001 0100 1011
changing to petechiae
2
• Begins on the wrists & ankles, spreads
up the arms, legs & trunk
1
4
• Cover the palm of the hand & soles of
the feet
Complications:
0011 0010 1010 1101 0001 0100 1011
2
like seizures & stiff neck
• Cardiac & pulmonary symptoms –
1
4
pneumonia & heart failure
• Treatment: Tetracycline (7-10 days)
0011 0010 1010 1101 0001 0100 1011
2
1
4
Poliomyelitis
• First
0011 0010 1010 described by Michael
1101 0001 0100 1011 Underwood in 1789
1
2
• 21,000 paralytic cases reported in the United States
4
in 1952
• Three serotypes: 1, 2, 3
1
2
• 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
1
2
• Hematologic spread to lymphatics and central nervous
4
system
2
1
4
0 20 40 60 80 100
Percent
0011 0010 1010 1101 0001 0100 1011
2
1
Paralytic polio
4
Poliovirus Epidemiology
0011 0010 1010 1101 0001 0100 1011
• Reservoir Human
1
2
• Transmission Fecal-oral
Oral-oral possible
4
• Communicability 7-10 days before onset
Virus present in stool
3-6 weeks
Polio Vaccination of Adults
0011 0010 1010 1101 0001 0100 1011
1
2
years of age not necessary or recommended
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
1
2
• Use standard IPV schedule if possible (0, 1-2
4
months, 6-12 months)
2
– administer one dose of IPV
1
4
• Incomplete series
– administer remaining doses in series
– no need to restart series
Polio Vaccine Adverse Reactions
0011 0010 1010 1101 0001 0100 1011
1
2
• No serious reactions to IPV have been
4
documented
1
2
• No procedure available for identifying persons at risk of paralytic
disease
4
• 5-10 cases per year with exclusive use of OPV
2
1
4
Measles
0011 0010 1010 1101 0001 0100 1011
1
2
• First described in 7th century
4
• Near universal infection of childhood in
prevaccination era
2
• Hemagglutinin important surface antigen
1
4
• One antigenic type
1
2
• Replication in nasopharynx and regional lymph
4
nodes
1
2
• Stepwise increase in fever to 103 F or
4
higher
• Cough, coryza, conjunctivitis
• Koplik spots
Measles Clinical Features
Rash
0011 0010 1010 1101 0001 0100 1011
2
14 days after exposure
1
• Maculopapular, becomes
confluent
4
• Begins on face and head
• Persists 5-6 days
• Fades in order of
appearance
0011 0010 1010 1101 0001 0100 1011
2
Enanthem:
Koplik’s Spots
1
4
•Appear 1-2
days after
onset of
symptoms
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
1
2
4
0011 0010 1010 1101 0001 0100 1011
2
1
4
Measles Complications
0011 0010 1010 1101 0001 0100 1011
Percent reported
Condition 8
2
Diarrhea 7
1
Otitis media 6
4
Pneumonia
0.1
Encephalitis
Death 0.2
Hospitalization 18
1
2
4
Measles pneumonia
Measles Complications by Age Group
0011 0010
30 1010Pneumonia
1101 0001Hospitalization
0100 1011
25
2
20
Percent
1
15
10
4
5
0
<5 5-19 20+
Age group (yrs)
Measles Laboratory Diagnosis
0011 0010 1010 1101 0001 0100 1011
1
2
(e.g., nasopharynx, urine)
4
• Significant rise in measles IgG by any standard
serologic assay (e.g., EIA, HA)
• Reservoir Human
1
2
• Transmission Respiratory
Airborne
4
• Temporal pattern Peak in late winter and spring
2
1
• Temperature >38.3 C (101 F), and
4
• Cough or coryza or conjunctivitis
Measles Vaccines
0011 0010 1010 1101 0001 0100 1011
1963 Live attenuated and killed vaccines
1965 Live further attenuated vaccine
1
2
1967 Killed vaccine withdrawn
4
1968 Live further attenuated vaccine
(Edmonston-Enders strain)
1971 Licensure of combined measles-
mumps-rubella vaccine
1989 Two dose schedule
Measles Vaccine
• Composition
0011 0010 Live1011
1010 1101 0001 0100 virus
1
2
• Duration of
4
Immunity Lifelong
• Schedule 2 doses
2
• Second dose of MMR at 4-6 years
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
2
minimum age
1
4
• MMR given before 12 months should not
be counted as a valid dose
2
persons who failed to respond to the first
dose (primary vaccine failure)
1
4
• May boost antibody titers in some persons
ACIP Recommendations
0011 0010 1010 1101 0001 0100 1011
2
required for school entry
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
2
attenuated measles vaccine
– DOH, EPI : 9 months of age
1
4
– Measles epidemic: early 2 dose measles
• 6 months: 1 dose; 12 months : booster dose
st
2
immunoglobulin
a. Susceptible child with definite
1
4
exposure to measles
given within 6 days of exposure
– Dose: 0.25 ml/kg ( normal child)
0.5 ml /kg ( immunocompromised)
Measles prevention
0011 0010 1010 1101 0001 0100 1011
2
immunoglobulin
1
b. Children with contraindication to
4
vaccination when there is an
outbreak of measles
dose: 0.5 ml/kg ( max. 15 ml)
Measles prevention
0011 0010 1010 1101 0001 0100 1011
2
immunoglobulin
1
c. Infants younger than 5 months of
4
age whose mothers develop measles
also should receive IG
Measles Immunity
0011 0010 1010 1101 0001 0100 1011
1
2
• Documentation of physician-diagnosed
4
measles
1
2
• Joint symptoms 25%
• Thrombocytopenia
4
<1/30,000 doses
• Parotitis rare
• Deafness rare
• Encephalopathy <1/1,000,000 doses
MMR Vaccine and Autism
0011 0010 1010 1101 0001 0100 1011
2
by British gastroenterologist
1
• Diagnosis of autism often made in second
4
year of life
2
1
component or following prior dose
4
• Pregnancy
• Immunosuppression
• Moderate or severe acute illness
• Recent blood product
Measles Vaccine and HIV Infection
0011 0010 1010 1101 0001 0100 1011
• MMR recommended for persons with
asymptomatic and mildly symptomatic HIV
2
infection
1
4
• NOT recommended for those with evidence of
severe immuno- suppression
1
2
• 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
1
2
• Parotitis and orchitis described by Hippocrates in
5th century B.C.
4
• Viral etiology described by Johnson and
Goodpasture in 1934
• Paramyxovirus
1
2
• RNA virus
4
• One antigenic type
1
2
• Replication in nasopharynx and regional lymph
4
nodes
2
malaise, myalgias
• Parotitis in 30%-40%
1
4
• Up to 20% of infections asymptomatic
2
Orchitis 20%-50% in post-
1
pubertal males
4
Pancreatitis 2%-5%
Deafness 1/20,000
Death 1-3/10,000
Mumps Laboratory Diagnosis
0011 0010 1010 1101 0001 0100 1011
• Serologic testing
1
2
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
1
2
• Transmission Respiratory drop nuclei
Subclinical infections
4
may transmit
• Acute onset of
2
unilateral or bilateral
1
tender, self-limited
4
swelling of the parotid
or other salivary gland
lasting >2 days
without other apparent
cause.
0011 0010 1010 1101 0001 0100 1011
2
1
4
Mumps
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
1
2
of measles
4
• First described as distinct clinical entity in
German literature
• Togavirus
1
2
• RNA virus
4
• One antigenic type
1
2
• Replication in nasopharynx and regional lymph nodes
4
• Viremia 5-7 days after exposure with spread to tissues
2
• Prodrome of low grade fever
1
4
• Lymphadenopathy in second week
2
1
Forchheimer spots
4
Discreet
maculopapular
0011 0010 rashes
1010 1101 0001 0100 1011
2
1
4
Rubella Complications
Arthralgia or arthritis
0011 0010 1010 1101 0001 0100 1011
children rare
2
adult female up to 70%
1
4
Thrombocytopenic purpura 1/3000 cases
Encephalitis
Neuritis 1/6,000 cases
Orchitis rare
rare
Congenital Rubella Syndrome
0011 0010 1010 1101 0001 0100 1011
1
2
• May lead to fetal death or premature delivery
4
• Severity of damage to fetus depends on
gestational age
• Deafness
2
• Cataracts
1
• Heart defects
4
• Microcephaly
• Mental retardation
• Bone alterations
• Liver and spleen
damage
Rubella Laboratory Diagnosis
0011 0010 1010 1101 0001 0100 1011
2
(e.g., nasopharynx, urine)
1
4
• Significant rise in rubella IgG by any standard
serologic assay (e.g., enzyme immunoassay)
• Transmission Respiratory
2
Subclinical cases may
1
transmit
4
• Temporal pattern Peak in late winter and spring
2
rash, and
1
4
• Temperature of >37.2 C (>99 F), if
measured, and
1
2
• Frank arthritis occurs in about 10%
4
• Rare reports of chronic or persistent symptoms
2
1
4
Varicella
0011 0010 1010 1101 0001 0100 1011
• Acute viral illness
1
2
• Zoster described in premedieval times
4
• Varicella not differentiated from smallpox until end
of 19th century
1
2
• Primary infection results in varicella
(chickenpox)
4
• Recurrent infection results in herpes zoster
(shingles)
1
2
• Replication in nasopharynx and regional lymph
4
nodes
1
2
• Mild prodrome for 1-2 days
4
• Generally appear first on head; most concentrated
on trunk
2
• In normal children, generalized
vesicular rash with very few
1
4
systemic effects
• Virtually, NO PRODROME
• The first manifestation is the
EXANTHEM
Varicella
Hallmark of the rash :
• 1010 1101 0001 0100 1011
0011 0010
vesicular lesions
• Maculesmaculopapular
vesicular crusting scab
2
formation
1
• Intensely pruritic
4
• Lesions often appear first
on the scalp, face or trunk
• At any point in time, lesions
in various stages are
observed
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
1
– Most contagious 1-2 days before and
4
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
Herpes Zoster
0011 0010 1010 1101 0001 0100 1011
1
2
• Associated with:
4
– aging
– immunosuppression
– intrauterine exposure
– varicella at <18 month of age
Varicella Complications
0011 0010 1010 1101 0001 0100 1011
2
• CNS manifestations
1
4
• Pneumonia (rare in children)
• Normal adults
1
2
• Immunocompromised persons
4
• Newborns with maternal rash onset within
5 days before to 48 hours after delivery
Varicella Fatality Rate in Healthy
Persons
0011 0010
30 1010 1101 0001 0100 1011
25
20
2
Rate
15
1
10
4
5
0
<1 1-14 15-19 20-29 30+
Age group (yrs)
2
1
• Period of risk may extend
through first 20 weeks of
4
pregnancy
1
2
• Rapid varicella virus identification using direct
4
fluorescent antibody (DFA) testing
2
• Transmission Airborne droplet
1
Direct contact with lesions
4
• Temporal pattern Peak in winter and early
spring (U.S.)
1
2
• 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
1
2
• Recommended for all susceptible children by
4
the 13th birthday
Varicella Vaccine Recommendations
Adolescents and Adults
0011 0010 1010 1101 0001 0100 1011
1
2
• Two doses separated by 4 - 8 weeks
4
• Up to 90% of adults immune
2
severe illness
1
4
– Teachers of young children
– Institutional settings
– Military
– Women of childbearing age
– International travelers
Varicella Vaccine Recommendations
Adolescents and Adults
0011 0010 1010 1101 0001 0100 1011
2
persons at high-risk for severe illness
1
4
– Healthcare workers
– Family members of immuno-
compromised persons
Varicella Vaccine
Postexposure Prophylaxis
0011 0010 1010 1101 0001 0100 1011
1
2
susceptible person after exposure to varicella
– 70%-100% effective if given within 72 hours of
4
exposure
– not effective if >5 days but will produce immunity
if not infected
Varicella Vaccine
Use in Immunocompromised Persons
0011 0010 1010 1101 0001 0100 1011
• Most immunocompromised persons should not be
vaccinated
2
1
• Vaccinate persons with isolated humoral
4
immunodeficiency
1
2
• Indications
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
2
• Consider for persons age >13 years
1
• Consider for persons with chronic cutaneous or
pulmonary disorders, long-term salicylate therapy, or
4
steroid therapy
• IV in immunocompromised children and adults with
viral-mediated complications
• Not recommended for post-exposure prophylaxis