Doses Of Diphtheria-tetanus-pertussis Research Articles

#91 Counting the shots

PURPOSE: Because children in poverty continue to be significantly under-immunized, WIC clinics, which are now the single largest point of access to these children, are crucial to assuring protection by vaccination. Realizing that comprehensive assessment of the immunization history of every child attending a WIC clinic exceeds the capacity of most local WIC clinics, a 7-member inter-agency collaboration led by the USDA and the CDC has proposed a simplified method in which the doses received of a single vaccine—the diphtheria-tetanus-pertussis (DTaP) series—are treated as a proxy for the entire 4-antigen 4:3:1:3 series (4 doses of DTaP, 3 of polio , 1 of measles-mumps-rubella, 3 of H influenza b). Because research has not yet shown whether children's true immunization status can be assessed accurately in this way, we evaluated the validity of DTaP as a predictor of completion status for the universally recommended 4:3:1:3 series. METHODS: We analyzed 6,277 records of WIC-enrolled children from the National Immunization Survey 2000 to index parents' reports of completion status for DTaP as shown on the hand-held household record (Method 1); parents' report of completion status for all immunizations in the 4:3:1:3 series (Method 2) based on the hand-held record; and providers' report of completion status for the 4:3:1:3 series (child's “true” immunization status). The comparative sensitivity, specificity, and overall test efficiency with which assessments based on Method 1 versus those based on Method 2 matched the provider-reported true immunization status were the main outcome measures. RESULTS: Although assessments based on the household-recorded DTaP count alone were 9% less sensitive than those based on the household-reported entire 4:3:1:3 series (74% vs. 83%, respectively), they were 6% more specific (93% vs. 87%). Overall test efficiency for the two methods (88% vs. 86%) was not significantly different. CONCLUSIONS: Results will be discussed in terms of their implications for developing achievable health objectives for this vulnerable population through the WIC-Immunization partnership.

Ibuprofen prophylaxis for adverse reactions to diphtheria-tetanus-pertussis vaccination: a randomized trial

The aim of this study was to determine the effectivenes of ibuprofen prophylaxis in reducing the adverse effects of diphtheria-tetanus-pertussis (DTP) and oral polio vaccination in children 3, 5, and 7 months of age and to compare its effects with those of the present policy of treating adverse reactions when they occur. This 12-month, multicenter, randomized, open-label trial was conducted in six ambulatory, primary care centers. A total of 256 healthy children aged 3 months (±15 days) receiving DTP vaccine were studied at that age and at 5 and 7 months (ie, at the second and third DPT doses). Adverse effects of 719 vaccine doses were studied; 219 infants received all three doses. Patients were randomized to receive either ibuprofen prophylaxis (20 mg/kg per day in three equally divided doses over 24 hours, the first dose given together with the vaccine) or treatment (ibuprofen 7.5 mg/kg) for the adverse reactions when they occurred. The same therapeutic regimen was followed after the second and third DTP doses. Adverse effects after immunization were recorded by parents or guardians in a previously validated questionnaire and included elevated rectal temparature, systemic reactions (crying, drowsiness, fretfulnees, vomiting, diarrhea, and anorexia), and local reactions (redness, edema, induration, and pain). None of the patients were withdrawn from the study because of adverse effects. The results of the study suggest that children given ibuprofen prophylaxis had temperature increases after DTP vaccination similar to those who received treatment when reactions occurred, but they had fewer systemic and local effects. No remarkable adverse effects such as seizures, collapse, or shock-like state (hypotonic-hyporesponse episodes) occurred. One sterile abscess was seen at the injection site in the prophylaxis group. Thus ibuprofen prophylaxis after DTP vaccination at 3, 5, and 7 months of age slightly decreased the occurrence of systemic and local adverse effects but did not reduce temperature.

Fragmentation of scheduled visits and missed doses among infants receiving multiple injected vaccines.

A retrospective cohort study was used to determine the extent to which immunisation visits due in the first year of life are split into separate visits. A one-month birth cohort of infants registered in early childhood health centres in the former Eastern Sydney Health Area was followed up when the infants were 8 to 11 months of age. A telephone questionnaire sought documented dates of each dose in the primary series of diphtheria-tetanus-pertussis (DTP), Haemophilus influenzae type b (Hib) and hepatitis B (HBV) vaccination. Of the 141 subjects, 130 had received all due doses of DTP and Hib vaccines and 63 (45 per cent) had been enrolled in the neonatal hepatitis B program. Infants in the latter group received the first DTP-Hib dose on average one week later than did those not in the hepatitis B program (DTP, P = 0.016; Hib, P = 0.047). The greatest percentage of missed DTP or Hib doses occurred in infants not receiving HBV vaccination (7.1 per cent of doses) or those high-risk infants enrolled in the neonatal hepatitis B program (2.9 per cent). Overall, 12 infants had 28 (6.9 per cent) of the 404 possible scheduled visits fragmented into two separate visits. In all cases, parents reported that this was at the suggestion of the general practitioner. We found no greater likelihood of fragmentation for infants who had also received hepatitis B vaccine. Only 17 infants (29 per cent) had received the third hepatitis B vaccine and DTP doses at the same visit, as recommended. These findings confirm anecdotal reports of fragmentation of scheduled visits and missed doses for infants due to receive multiple injections, and some delay in uptake among those receiving hepatitis B vaccine. Universal infant hepatitis B immunisation should not be considered until combination vaccines (which should also include a Hib component) become available in Australia.

Priming with diphtheria-tetanus-pertussis vaccine enhances the response to the Haemophilus influenzae type b tetanus conjugate vaccine in infancy

Haemophilus influenzae type b (Hib) capsular polysaccharide (PS) conjugated to tetanus toxoid (PRP-T) was given at 4 and 6 months of age and anti-Hib PS antibody response to the first and second dose of PRP-T was compared in groups that received diphtheria-tetanus-pertussis (DTP) vaccine either simultaneously with PRP-T (34 infants) or separately at 3, 4 and 5 months of age (49 infants). The geometric mean anti-Hib PS antibody concentration after the first dose of PRP-T given at 4 months of age was eightfold higher if the infants primed with DTP at 3 months of age than if the first dose of DTP was given together with the first dose of PRP-T (0.81 μg ml −1 vs 0.11 μg ml −1). The positive influence of DTP priming was seen also after the second dose of PRP-T given at 6 months of age (7.55 μg ml −1 vs 3.45 μg ml −1).

Acellular Pertussis Vaccine is Licensed for Infants

AFTER 15 YEARS of development and extensive field trials in Europe and the United States, the Food and Drug Administration (FDA) has licensed an acellular pertussis vaccine for use in the primary diphtheria-tetanus-pertussis (DTP) immunization series at age 2, 4, and 6 months, when most serious complications of the disease occur. The new licensure does not require a new product to be manufactured. The acellular version has been licensed since 1992 for use in the fourth and fifth doses of DTP given to children up to 6 years of age. The vaccine, manufactured by Connaught Laboratories, Inc, Swiftwater, Pa, is available now to physicians for use in their pediatric practices. Marketed under the trade name Tripedia, the vaccine contains 2 antigens: pertussis toxin and filamentous hemagglutinin. Acellular vaccines were originally developed in Japan. The principle was further developed by several US manufacturers, including Connaught, in response to concerns over adverse

Immunizations: supporting the community's efforts.

C HILDHOOD immunization continues to be a major health care issue in this country. It is recommended that by the age of 2 years, a child should have completed three doses of DTP (diphtheria, tetanus, pertussis), TOPV (trivalent oral polio vaccine), hepatitis B vaccines, and Huemophilus influenzue vaccines. The 2-year-old child should also have received a tuberculin test as well as the first dose of MMR (measles, mumps, rubella). The issue of immunizations for two-year-olds has escalated because as few as 50% of these children have been fully immunized in some inner cities. For example, the incidence of measles has increased 1,670% in children under 1 year of age. Also, in order to treat each case, $10 will be spent, as opposed to $1 that could have been spent in immunization costs to prevent these cases (National Association of Children’s Hospitals and Related Institutions, 1991). These costs do not take into consideration the needless pain and suffering that these children will endure. The positive side to this issue is that 98% of all school-age children are now fully immunized. This high percentage has developed over the past 15 years because most states now require immunizations before children can enter school.

Response of preterm infants to diphtheria-tetanus-pertussis vaccine.

The American Academy of Pediatrics recommendation that immunization of preterm infants with diphtheria-tetanus-pertussis (DTP) vaccine should begin at 2 months after birth, regardless of gestational age, is based on limited data. A prospective study was conducted to determine the immunogenicity and safety of DTP vaccine in preterm infants. One hundred ten preterm and 146 full term infants received doses of DTP at 2, 4 and 6 months after birth. Adjusted analysis of the antibody responses indicated that after three doses mean titers among preterm infants to each vaccine component were comparable to those of full term infants. Adjusted analysis of the incidence of adverse events indicated that the risk of adverse events in preterm infants was not significantly higher than that in full term infants. DTP vaccine is immunogenic and safe in preterm infants when the series is initiated at 2 months after birth, and this study supports the current recommendation of the American Academy of Pediatrics.

Simultaneous Administration of Measles-Mumps-Rubella Vaccine With Booster Doses of Diphtheria-Tetanus-Pertussis and Poliovirus Vaccines

The safety and efficacy of simultaneous administration of measles-mumps-rubella (MMR), diphtheria-tetanus-pertussis (DTP), and trivalent oral poliovirus (OPV) vaccines in a test group of 405 children were compared with the safety and efficacy of sequential administration of the same vaccines in a control group of 410 children given MMR followed by booster doses of DTP and OPV 2 months later. The study was double blind and placebo controlled with respect to DTP and OPV. Seroconversion rates to measles, mumps, and rubella exceeded 96% in both groups. Geometric mean titers to measles (P = .05) and rubella (P = .004) were higher in the test group, and titers of antibodies to the other seven antigens were similar in both groups. Clinical reaction data were analyzed in 248 of 405 test children and 249 of 410 control children. The rates of serious vaccine-associated reactions were low and similar in the two groups. Some minor side effects were reported more frequently in the test group, but these differences were judged to be related to study design rather than to differences in the safety of the two vaccine schedules. The results indicate that the safety and serologic efficacy of administering MMR simultaneously with reinforcing doses of DTP and OPV in the second year of life is equivalent to the safety and efficacy observed after administering these antigens separately.

SYMPTOMS AFTER PRIMARY IMMUNISATION WITH DTP AND WITH DT VACCINE

Symptoms after routine primary immunisation of 6004 infants with diphtheria/tetanus/ pertussis (DTP) vaccine and 4024 infants with diphtheria/ tetanus (DT) vaccine have been compared. After each dose, crying, screaming, and feverishness were more frequent with adsorbed DTP than adsorbed DT, but the difference was small. Attacks of high-pitched screaming, episodes of pallor or cyanosis with limpness, convulsions, and local reactions occurred with similar frequency after both vaccines. There was a considerable increase in local reactions after the 3rd dose with both vaccines. Over 1000 doses of plain DTP (with no aluminium hydroxide adjuvant) were given during the study. Post-vaccination symptoms were more common after the plain than after the 2 adsorbed preparations.

Interferon as an in vitro modifier of immune responses induced by combined vaccine (DTP) in mice.

The ability of DTP (diphtheria, tetanus, pertussis) vaccine to stimulate IgG-plaque forming cells (PFC) in mice was markedly inhibited by human leukocyte and mouse fibroblast interferon (IF). This effect of IF was not dose-dependent. The maximum inhibitory effect of human IF was observed on Day 10 after the administration of the vaccine. The inhibition of IgM-PFC was more severe when human IF was used. Although IF abrogated the effect of DTP vaccine on IgG-PFC, at the same time it stimulated PFC in the control group of non-vaccinated animals. The administration of DTP vaccine decreased IgM-PFC on Day 5, the effect was enforced by the addition of both human and mouse IF. IF decreased IgM-PFC in the control group. Small and large doses of DTP suppressed the leukocyte adherance inhibition (LAI) on Day 5 after administration of the vaccine, the effect was not affected by addition of IF. The suppressive effect of DTP was lost on Day 10 when addition of IF increased the percent of LAI in all experimental groups. Thus IF appears to interfere with the effect of DTP and selectively modulate the different immune responses.

Risk Factors Associated with Failure to Receive Vaccinations

A major purpose of a state-wide survey to document the vaccination status of 1,003 2-year-old children was to identify factors associated with failure to receive the recommended vaccinations. With a basic series of immunization defined as three doses of diphtheria-tetanus-pertussis (DTP), three oral polio vaccine (OPV), one measles, and one rubella, 72.5% of the children had completed the series. When the completed series was redefined to include a fourth DTP and mumps vaccine the rate of completion dropped to 40.8%. However, 59.1% of the children who had not completed this optimal series could be brought up-to-date with a single visit to their provider of medical care. Demographic variables independently associated with completion of the basic series were increased paternal education (P less than .001), increased maternal education (P less than .02), smaller family size (P less than .01) and higher socioeconomic status, as determined by census tract or rural town of residence (P less than .02). Race was not found to be a factor associated with vaccination rates when socioeconomic status was controlled. Patients who received their vaccinations from private physicians had a better vaccination rate than those who attended health department clinics. This difference persisted even when socioeconomic status was controlled by residence (P less than .02). The simultaneous comparison of parental education and family size demonstrated that a child having one parent with less than 12 years education or having at least three siblings has a fourfold greater risk of failure to complete his immunization than children whose parents are both college graduates. By using paternal and maternal education level and family size as screening variables, children at high risk for failure to complete their immunizations could be identified prospectively and made the target of intervention programs to improve compliance.