Issues in pediatric vaccine-preventable diseases in low- to middle-income countries

Figures & data

Table 1. Summary of current booster recommendations for pertussis-containing vaccines in Europe⁴ and the US.^5,6

	ACIP recommendations (US)
COPE recommendations (Europe)	Cocooning	Children	Adolescents	Adults	Pregnant women
Adolescents (10–17 y) should receive a single dose of combined reduced-antigen-content tetanus-diphtheria-acellular pertussis (dTap) vaccine instead of dT, irrespective of a complete primary vaccination schedule #The cocooning strategy (vaccinating close contacts of newborns with dTap) should continue until immunization coverage in adults is sufficient for herd protection	Adolescents and adults who have or anticipate having close contact with an infant aged <12 m should receive a single dose of Tdap to protect against pertussis if they have not received Tdap previously	Children aged 7–10 y who are not fully vaccinated against pertussis* and for whom no contraindication to pertussis vaccine exists should receive a single dose of Tdap. Those never vaccinated against tetanus, diphtheria, or pertussis or who have unknown vaccination status should receive a series of 3 vaccinations containing tetanus and diphtheria toxoids. The first of these 3 doses should be Tdap	Adolescents aged 11–18 y who have completed the recommended childhood DTP/DTaP vaccination series and adults aged 19 through 64 y should receive a single dose of Tdap. Adolescents should preferably receive Tdap at the 11 to 12 y old preventive health-care visit.	Adults aged 19 through 64 y who have completed the recommended childhood DTP/DTaP vaccination series should receive a single dose of TdapAdults aged 65 y and older who have or anticipate having close contact with an infant aged less than 12 m should receive a single dose of Tdap. #Other adults ages 65 y and older may be given a single dose of Tdap.	During pregnancy, optimal timing for Tdap administration is between 27 and 36 wks gestation, although Tdap may be given at any time during pregnancy. For women not previously vaccinated with Tdap, if Tdap is not administered during pregnancy, it should be administered immediately postpartum.

COPE, Consensus on Pertussis Booster Vaccination in Europe; ACIP, Advisory Committee on Immunization Practices. General guidance relating to booster vaccination only is shown. For the full recommendations refer to Zepp 2011, CDC 2011 and CDC 2013b.

Table 2. Barriers and enablers of effective pertussis diagnosis and surveillance.

Region	Barriers	Enablers
Russia/CIS	• Lab diagnosis limited by technical complexity of bacteriological tests and high cost of PCR • Administrative barriers • Atypical cases not being diagnosed reducing accuracy of surveillance	• Use a standard case definition • Educate immunizing physicians • Increase implementation of PCR • Make use of IT for surveillance
MENA	• Lack of awareness of doctors leading to an underestimation of cases • Lack of a standard case definition • Lack of facilities for lab diagnosis • Not recognized as a public health problem due to a lack of local epidemiological studies	• Establishing a national case definition • Set up a regional surveillance network • Include vaccine preventable diseases in national reports • Identify and engage stakeholders
Africa	• Inadequate budget • Very limited facilities for laboratory diagnosis • A clinical case definition which is not pathogen specific • The possibility of atypical presentation • Inadequate reporting and feedback from the Ministry of Health	• Reduce the costs of diagnosis • Provide clinical guidance for diagnosis • Establish a reference laboratory • Improve the Ministry of Health Bulletin reporting and feedback process
South East Asia	• Difficulty of culturing the pathogen • Lack of lab infrastructure • Lack of awareness and political will • Costs of surveillance • Other healthcare priorities	• Establish national and regional reference laboratories • Conduct active surveillance • Make pertussis notifiable and enforce notification • Increase awareness and training

Table 3. Regional status of MMR and varicella vaccination (November 2012).

Region	Country	Public sector	Private sector
Russia		MMR: available as MM + R on a 12 m, 6 y schedule	Varicella vaccines are available in regional programmes and in the private sector
		Varicella: regional immunization is increasing
CIS	Ukraine	MMR: available since 2007 using 12 m, 6 y schedule Catch-up up to 18 years since 2008 Varicella: vaccine available to high-risk groups and military recruits	Varicella vaccine available in private market
	Kazakhstan	MMR: since 2007 using 12 m, 6 y schedule
		Varicella: not available
MENA		MMR: All GCC countries have MMR at 12 m and pre-school. MMRV is not available in any country Varicella: Most GCC countries have a 2-dose schedule In Bahrain the vaccine is available in high schools and to HCPs	Varicella: Most countries have a 2-dose schedule except Oman
South East Asia	India/Pakistan	MMR: Measles vaccine at 9, 15 months	MMR+V at 15 m, 4–6 y (India)
			MMR+V at 13–15 m, MMRV at 4–6 y (Pakistan)
	Bangladesh	MMR: Measles and rubella vaccines at 9, 15 months	MMR
			Varicella single dose at 1–12 y
Africa	Tunisia	MMR: Measles at 15 months, 6 y, 12 y	MMR and varicella available
		Rubella exclusively for girls at 12 years	Varicella uptake very low
	Ivory Coast	MMR: Measles at 9 months	MMR available at 15 m, 4.5 y
			Rubella at 12 y
			Varicella uptake very low

CIS, Commonwealth of Independent States; GCC, Gulf Cooperation Council; MENA. Middle East and North Africa; MMR, measles-mumps-rubella; V, varicella

Table 4. Recommendations for the use of varicella-containing quadrivalent vaccines.

American Academy of Pediatrics (AAP) 2011^49

STIKO 2012^50

• AAP recommends that the timing of vaccine doses remains the same (12–15 m for Dose 1 and 4 to 6 yrs for Dose 2) • The first dose administered at 12–47 m can include either MMR and varicella vaccines administered separately or MMRV vaccine • Because the risk of febrile convulsions is not increased in older children who receive the second dose of MMRV, the use of MMRV is generally preferred for the first dose of vaccine administered at 48 months and older, and for Dose 2 at any age (15 m to 12 years) • It is recommended that children with a personal or family history of febrile convulsions generally should be vaccinated with separate MMR and varicella vaccines, because the risks of using MMRV in this group generally outweigh the benefits

• STIKO recommend that first dose is administered at 11–14 months and the second at 15–23 m • Separate first-dose vaccinations with MMR and monovalent varicella vaccine are recommended, due to a slightly increased risk of febrile convulsions after first-dose application of the combined MMRV vaccine

For the full recommendations refer to American Academy of Pediatrics 2011⁴⁹ and STIKO 2012⁵⁰

Table 5. Meningococcal serotype distribution and epidemiology.^85,96-98

Serogroup	Key geographical and epidemiological characteristics
A	• Responsible for the largest and most devastating meningococcal outbreak in sub-Saharan Africa in 1996–1997 • Now rare in the US and Europe
B	• Associated with a lower incidence of disease compared to serogroup A or C • Prolonged outbreaks of disease cause significant morbidity and mortality • The most important cause of endemic disease in developed countries, causing:o 20–40% of disease in the USo up to 80% in Europe
C	• Responsible for part of the reported endemic disease and localized epidemic outbreaks in developed countries • Accounts for 30% of disease in the US and Europe
Y	• Emerged in the US and also seen recently in South Africa, South America, and Israel • Caused >25% of the disease due to meningococci in the US in the last decade • Causes meningococcal pneumonia in older adults • Responsible for a large proportion of meningococcaemia and meningitis among infants less than 6 months of age
W-135	• Emerged in the last 20 y as a cause of epidemic disease including in South America and Africa • Particularly important in relationship to the Hajj pilgrimage
X	• Recently found to be responsible for meningococcal cases and outbreaks in certain African countries such as Kenya, Niger, and Ghana

Zepp F, Heininger U, Mertsola J, Bernatowska E, Guiso N, Roord J, Tozzi AE, Van Damme P. Rationale for pertussis booster vaccination throughout life in Europe. Lancet Infect Dis 2011; 11:557-70; PMID:21600850; http://dx.doi.org/10.1016/S1473-3099(11)70007-X

 PubMed Web of Science ®Google Scholar

American Academy of Pediatrics. Policy statement-Prevention of varicella: update of recommendations for use of quadrivalent and monovalent varicella vaccines in children. Pediatrics 2011; 128:630-2; PMID:21873692; http://dx.doi.org/10.1542/peds.2011-1968

 PubMed Web of Science ®Google Scholar

STIKO. Empfehlungen der Ständigen Impfkommission (STIKO) am Robert Koch Institut. Epidemiol Bull 2012; 30:283-310.

 Google Scholar