Principles of Vaccination
Kolářová Marie, EPI
Autumn 2017
Revised 2007
The word “vaccine” comes from the Latin word
vaccinus, which means “pertaining to cows.”
What do cows have to do with vaccines? The
first vaccine was based on the relatively mild
cowpox virus, which infected cows as well as
people.
This vaccine protected people against the
related, but much more dangerous, smallpox
virus.
More than 200 years ago (in 1789), Edward Jenner, a country
physician practicing in England, noticed that milkmaids
rarely suffered from smallpox.
The milkmaids often did get cowpox, a related but far less
serious disease, and those who did never became ill with
smallpox.
In an experiment that laid the foundation for modern
vaccines, Jenner took a few drops of fluid from a skin sore
of a woman who had cowpox and injected the fluid into
the arm of a healthy young boy who had never had
cowpox or smallpox.
Six weeks later, Jenner injected the boy with fluid from a
smallpox sore, but the boy remained free of smallpox.
Dr. Edward Jenner
Dr. Jenner had discovered one of the fundamental principles
of immunization.
He had used a relatively harmless foreign substance to
evoke an immune response that protected someone from
an infectious disease.
His discovery would ease the suffering of people around the
world and eventually lead to the elimination of smallpox, a
disease that killed a million people, mostly children, each
year in Europe.
By the beginning of the 20th century, vaccines were in use
for diseases that had nothing to do with cows—rabies,
diphtheria, typhoid fever, and plague—but the name stuck.
Graf 1. Development of immunoglobulin levels
15.12.2017
Šedivá A. Čes.-slov. Pediat., 2005, roč.60, č.11, s. 617-624
Remembering an Old Disease
Smallpox
Face lesions on boy with smallpox.
Public Health Images Library (PHIL) ID # 3.
Source: CDC/Cheryl Tyron
Smallpox recognition
card, c.1973, courtesy
Dr. Damodar Bhonsule,
Panjim, Goa, India.
Smallpox lesions on skin of trunk.
Picture taken in Bangladesh, 1973.
Public Health Images Library (PHIL) ID # 284. Source: CDC/James Hicks
Variola virus, which causes smallpox, was once the scourge of the
world.
This virus passes from person to person through the air.
A smallpox infection results in fever, severe aches and pains, scarring
sores that cover the body, blindness in many cases, and, often,
death. There is no effective treatment.
Although vaccination and outbreak control eliminated smallpox in the
United States by 1949, the disease still struck an estimated 50
million people worldwide each year during the 1950s.
In 1967, the World Health Organization (WHO)
launched a massive vaccination campaign to rid the
world of smallpox — and succeeded.
Rural vaccinator in United Provinces, British India,
c.1930, private collection of Dr. Sanjoy Bhattacharya
Eradication of smallpox - Czech experts
A key figure in the global eradication program
smallpox was prof. MUDr. Karel Raska, MD.,
who drove in the sixties division Communicative
Diseases of the WHO Secretariat in Geneva.
He promoted the establishment of a new, independent
units "Eradication of smallpox"and ensure its initial
financial and material support, not only in Geneva, but
also in regional offices of WHO.
With its support of the program also attended the 20
Czechoslovak health professionals (14 Czechs and
Slovaks 6), mainly epidemiologists.
The last natural case of smallpox
occurred in Somalia in 1977.
Ali Maow Maalin, cook twenty-three
of the hospitals in the Somali Merce.
He contracted when he showed the path of the
ambulance chauffeur who drove two sick children to
camp insulation.
Mr. John Wickett, of the World Health Organization, with the last person to
have contracted – and survived – naturally occurring smallpox in Somalia.
(1977); courtesy Mr. John Wickett.
In 1978 was ill photographer Medical School in
Birmingham, England. She was killed by a virus
that escaped from a neighboring laboratory.
This unfortunate event has led to another strong
request by the WHO to destroy the virus or transmit it
to WHO Collaborating Centers equipped with the
highest level of biological protection.
At present, viruses of smallpox are deposited into laboratories:
in Russia (Moscow)
in USA (Atlanta)
In the Czech republic began to vaccinate against smallpox in
1821 on the basis of the issue of an imperial document.
Vaccination was terminated in 1980 with eradication of
smallpox around the world.
Smallpox eradication was
officially announced
at the 33rd General Assembly WHO
8. May 1980.
Milestones in the eradication of smallpox
1789 Edward Jenner invents a smallpox vaccine.
1966 The World Health Organization (WHO) launches a massive global
campaign to eradicate smallpox.
1972 Smallpox vaccinations are discontinued in the United States.
1975 and 1977 The last cases of the two known variants of smallpox
occur in the world, in Bangladesh and Somalia.
1978 Two people are sickened in a lab accident in England; one dies.
1980 The WHO declares smallpox eradicated.
1991 Smallpox virus DNA is mapped.
1999 The WHO sets this deadline, by which remaining lab stocks of the virus are to be
destroyed. The deadline will be postponed again and again.
2003 Millions of doses of vaccine are produced to hedge against a biological attack.
2011 WHO's decision-making body will meet in May to again vote on
whether to kill the remaining live viruses.
There is a risk of variola virus abuse as
a possible biological weapon
For this reason, a certain supply of vaccines is
constantly kept on a global scale, because it is
impossible to completely exclude the
possibility that somewhere in the world is
stored this virus, which is potentionally
abusive for terrorist purposes.
At present, however, it is clear that the cognition
of this virus has reached such a level that it will
also be possible to consider its destruction.
Remembering an Old Disease
Diphtheria:
PHIL Photo ID#7323
Causes and Transmission
Diphtheria is an infection caused by the toxic Corynebacterium diphtheriae
bacterium.
Diphtheria is spread (transmitted)
from person to person,
usually through respiratory droplets, like from coughing
or sneezing.
Rarely, people can get sick from touching open sores
(skin lesions) or clothes that touched open sores of
someone sick with diphtheria.
A person also can get diphtheria by coming in contact
with an object, like a toy, that has the bacteria that
cause diphtheria on it.
The incubation period of diphtheria is 2–5 days (range: 1–10
days).
After:
 the provisional clinical diagnosis is made
 and appropriate cultures are obtained,
persons with suspected diphtheria should be given:
1. - antitoxin and
2. - antibiotics in adequate dosage and
3. - placed in isolation.
Respiratory support and airway maintenance should also be
administered as needed.
Symptoms
When the bacteria get into and attach to the lining of the respiratory system, they
produce a poison (toxin) that can cause:
 Weakness
 Sore throat
 Fever
 Swollen glands in the neck (sometimes referred to as „bull neck“)
The poison destroys healthy tissues in the respiratory system. PHIL Photo ID#5325
Within two to three days, the dead tissue forms a thick, gray coating that can build up
in the throat or nose. This thick gray coating is called a "pseudomembrane."
It can cover tissues in the nose, tonsils, voice box, and throat, making it very hard to
breathe and swallow.
The poison may also get into the blood stream and cause damage to the heart,
kidneys, and nerves.
EU case definition of diphteria
2.11. DIPHTHERIA (Corynebacterium diphtheriae, Corynebacterium ulcerans and Corynebacterium pseudotuberculosis)
Clinical Criteria
• Any person with at least one of the following
clinical forms:
Classic Respiratory Diphtheria:
• An upper respiratory tract illness with laryngitis or
nasopharyngitis or tonsillitis
• AND
• an adherent membrane/pseudomembrane
Mild Respiratory Diphtheria:
• An upper respiratory tract illness with laryngitis or
nasopharyngitis or tonsillitis
• WITHOUT
• an adherent membrane/pseudomembrane.
Cutaneous Diphtheria:
• Skin lesion
Diphtheria of other sites:
• Lesion of conjunctiva or mucous membranes
Laboratory Criteria
• Isolation of toxin-producing Corynebacterium diphtheriae,
Corynebacterium ulcerans or Corynebacterium
pseudotuberculosis from a clinical specimen.
Epidemiological Criteria
• At least one of the following epidemiological links:
• — Human to human transmission
• — Animal to human transmission
Case Classification
• A. Possible case
• Any person meeting the clinical criteria for classical
respiratory diphtheria
• B. Probable case
• Any person meeting the clinical criteria for diphtheria
(Classic Respiratory Diphtheria, Mild Respiratory
Diphtheria, Cutaneous Diphtheria, Diphtheria of other sites)
with an epidemiological link to a human confirmed case or
with an epidemiological link to animal to human
transmission
• C. Confirmed case
• Any person meeting the laboratory criteria AND at least
one of the clinical forms
In the United States is diphtheria now reported only
infrequently. In the prevaccine era, the disease was one of the
most common causes of illness and death among children.
Since the introduction and widespread use of vaccines
containing diphtheria toxoid (formalin-inactivated diphtheria
toxin) beginning in the 1920s and 1930s and universal childhood
immunization in the late 1940s, diphtheria has been well
controlled in the United States.
 In the 1970s, diphtheria was endemic in the Southwest, the
Northern Plains, and the Pacific Northwest. The last major
outbreak was in Seattle, Washington, in the 1970s.
In recent years, some cases in the United States have been
related to importation. From 1980 to 2010, 55 cases of
diphtheria were reported to CDC’s National Notifiable Diseases
Surveillance Systém.
 Diphtheria remains endemic in many parts of the developing
world, including some countries of the Caribbean and Latin
America, Eastern Europe, Southeast Asia, and Africa.
In the 1990s, a large epidemic of diphtheria occurred in the
former Soviet Union where diphtheria had previously been well
controlled and this renewed interest in the factors associated
with persistent circulation of toxigenic C. diphtheria.

In the EU/EEA.
The reported number of cases of diphtheria remains low.
During 2009–2013, 102 cases of diphtheria were reported in the EU/EEA with 55
cases of C. diphtheriae. There has been an increase in the number of C.
diphtheriae cases reported at EU level since 2011.
Latvia is the only EU Member State that reports indigenous transmission.
In a recent European study, ten European countries each screened between 968
and 8551 throat swabs from patients with upper respiratory tract infections for C.
diphtheriae during 2007–2008.
Six toxigenic strains of C. diphtheriae were identified: two from symptomatic
patients in Latvia and four from Lithuania (two cases, two carriers).
Among the toxigenic isolates, the Sankt Petersburg epidemic clone that caused
large diphtheria outbreaks in Russia countries in the 1990s was still in circulation
.
Carriage rates among household contacts of a laboratory-confirmed case may
be as high as 25% .
In 2014 --- 7 321 cases of diphtheria were reported worldwide
to the World Health Organization, but many more cases likely
go unreported.
The case-fatality rate for diphtheria has changed very little
during the last 50 years.
The overall case-fatality rate for diphtheria is 5%–10%,
with higher death rates (up to 20%) among persons younger
than 5 years and older than 40 years of age.
Before there was treatment for diphtheria, the disease was
fatal in up to half of cases.
15.12.2017
A case of diphtheria in Spain
15 June 2015
The detection, management and public health response to the first case of
diphtheria in Spain in nearly 30 years has highlighted challenges for
preparedness against diphtheria in the European Union.
The case is a 6-year-old unvaccinated child. A case of diphtheria in an
unvaccinated individual within a highly protected population is not unexpected,
because vaccinated people can be asymptomatic carriers of toxigenic C.
diphtheriae.
The challenges for diphtheria case management, preparedness and public
health response experienced in Spain are shared by many EU Member States.
The most urgent critical issue is the shortage of diphtheria antitoxin (DAT) for
immediate use when clinicians suspect diphtheria.
DAT must be given as early as possible to be effective, often on the suspicion of
diphtheria before a laboratory confirmation.
EU Member States have for a number of years reported difficulties with sourcing
and maintaining adequate stockpiles of DAT for emergency use, a problem they
share with many countries around the world. EU Member States have on
occasion been forced to arrange emergency deliveries of DAT for patients with
diphtheria.
15.12.2017
A fatal case of diphtheria in Belgium, March 2016
On 17 March, Belgian authorities reported a case of toxigenic respiratory diphtheria.
The case had been confirmed on 15 March in Antwerp in a 3-year-old unvaccinated
child of Chechnyan origin, born in Belgium.
The case had onset of symptoms on 6 March. On 10 March, the child was transferred
to the University Hospital in Antwerp and admitted to a special intensive care unit with
severe tonsillitis. Diphtheria was included in the differential diagnosis and a search
for DAT was started the same day. Since no DAT was readily available in Belgium, the
search was extended but not expedited as the girl’s clinical condition improved. At this
point, no formal microbiological diagnosis had been made. On 11 March, the girl was
transferred to the ward in an isolator. Later on, she developed an AV block and
myocarditis. An external pacemaker was used.
Despite administration of DAT, the child died on 17 March.
Upon confirmation of the case, Belgian regional authorities implemented prevention
and control measures according to regional regulations (The family of the child received prophylactic
antibiotic treatment and were swabbed to determine the presence of the bacterium. The medical personnel and caregivers – who
could have been exposed to droplets during the admission process in the first hospital – were swabbed and received antibiotics.
The doctor at the day-care centre verified the vaccination status of all children in the child’s group and another two groups in
adjacent rooms. One child needed a supplementary vaccination).
Remembering an Old Disease
Tetanus:
Tetanus is an acute, potentially fatal disease that is
characterized by generalized increased rigidity and convulsive
spasms of skeletal muscles.
Tetanus is caused by the spore-forming bacterium Clostridium
tetani. C. tetani spores (the dormant form of the organism) are
found in soil and in animal and human feces.
The spores enter the body through breaks in the skin, and germinate under low-oxygen
conditions. Puncture wounds and wounds with a significant amount of tissue injury are
more likely to promote germination. The organisms produce a potent toxin
tetanospasmin which is absorbed into the bloodstream. The toxin then reaches the
nervous system, causing painful and often violent muscular contractions. The muscle
stiffness usually first involves the jaw (lockjaw) and neck, and later becomes
generalized.
Tetanus is a noncommunicable disease — it is not transmitted from
one person to another.
The spores can get into the body through broken skin, usually through injuries from
contaminated objects. Certain breaks in the skin are more likely to get infected with
tetanus bacteria. These include:
 Wounds contaminated with dirt, poop (feces), or spit (saliva)
 Wounds caused by an object puncturing the skin (puncture wounds), like a nail or needle
 Burns
 Crush injuries
 Injuries with dead tissue
Rarely, tetanus has also been linked to breaks in the skin caused by:
 Clean superficial wounds (when only the topmost layer of skin is scraped off)
 Surgical procedures
 Dental infections
 Compound fractures (a break in the bone where it is exposed)
 Chronic sores and infections
 Intravenous (IV) drug use
 Intramuscular injections (shots given in a muscle)
 Time from Exposure to Illness
 The incubation period is usually between 3 and 21 days
(average 10 days), although it may range from one day to
several months, depending on the kind of wound. Most
cases occur within 14 days.
 In general, shorter incubation periods are seen with more
heavily contaminated wounds, more serious disease, and a
worse outcome (prognosis).
Tetanus is often called “lockjaw” because one of the most common
signs of this infection is tightening of the jaw muscles. Tetanus infection
can lead to serious health problems, including being unable to open the
mouth and having trouble swallowing and breathing.
Symptoms of tetanus include:
 Jaw cramping
 Sudden, involuntary muscle tightening (muscle spasms) — often in
the stomach
 Painful muscle stiffness all over the body
 Trouble swallowing
 Headache
 Fever and sweating
 Changes in blood pressure and a fast heart rate
EU case definitions - Tetanus
2.43. TETANUS (Clostridium tetani)
• Clinical Criteria
• Any person with at least two of the following
three:
• — Painful muscular contractions primarily of the
masseter and neck muscles leading to facial
spasms known as trismus and ‘risus sardonicus’
• — Painful muscular contractions of trunk muscles
• — Generalised spasms, frequently position of
opisthotonus
• Laboratory Criteria
• At least one of the following two:
• — Isolation of Clostridium tetani from an infection
site
• — Detection of tetanus toxin in a serum sample
• Epidemiological Criteria NA
• Case Classification
• A. Possible case NA
• B. Probable case
• Any person meeting the clinical criteria
• C. Confirmed case
• Any person meeting the clinical and the
laboratory criteria
TETANUS DISEASE
 TETANUS VACCINE: The most common reactions
reported to occur following DT vaccine include
swelling and pain at the injection site; sleepiness;
irritability; vomiting; loss of appetite; persistent
crying; and fever.
 Paleness, cold skin, collapse, rash, and joint pain
have also been reported.
 In 1994 the Institute of Medicine concluded that
there is compelling scientific evidence to conclude
that tetanus, DT and Td vaccines can cause
Guillain-Barre syndrome including death; brachial
neuritis; and death from anaphylaxis (shock).
Tetanus – United States 1947 2014
Vaccination against rabies or tetanus in the case of injuries,
injuries, non-healing wounds and some cures
Tetanus prophylaxis is performed:
when injuries,
injuries
non-healing wounds,
in indicated cases in pre-operative preparation, especially before
surgery on the rectum or colon.
Vaccination is performed
Remembering an Old Disease
Poliomyelitis:
The highly infectious poliovirus, the cause of polio,
once crippled 13,000 to 20,000 people every year in
the United States. In 1 out of 200 cases, this virus
attacks the spinal cord, paralyzing limbs or leaving
victims unable to breathe on their own. In 1954, the
year before the first polio vaccine was introduced,
doctors reported more than 18,000 cases of
paralyzing polio in the United States. Just 3 years
later, vaccination brought that figure down to about
2,500. Today, the disease has been eliminated from
the Western Hemisphere, and public health officials
hope to soon eradicate it from the globe. In 2001,
only 537 cases of polio were reported worldwide,
according to WHO.
EU case definition of poliomyelitis
2.31. POLIOMYELITIS (Polio virus)
Clinical Criteria
Any person < 15 years of age with Acute flaccid paralysis (AFP)
OR
Any person in whom polio is suspected by a physician
Laboratory Criteria
At least one of the following three:
— Isolation of a polio virus and intratypic differentiation — Wild polio virus (WPV)
— Vaccine derived poliovirus (VDPV) (for the VDPV at least 85 % similarity with vaccine virus in the nucleotide sequences in the
VP1 section)
— Sabin-like poliovirus: intratypic differentiation performed by a WHO-accredited polio laboratory (for the VDPV a > 1 % up to 15
% VP1 sequence difference compared with vaccine virus of the same serotype)
Epidemiological Criteria
At least one of the following two epidemiological links:
— Human to human transmission
— An history of travel to a polio-endemic area or an area with suspected or confirmed circulation of poliovirus
Case Classification
• A. Possible case
• Any person meeting the clinical criteria
• B. Probable case
• Any person meeting the clinical criteria and with an epidemiological link
• C. Confirmed case
• Any person meeting the clinical and the laboratory criteria
Poliomyelitis
Morbid changes occur
mainly in the gray matter of the spinal cord.
The infectious agent:
There are three types of polioviruses
-1, 2 and 3.
Virus excretion: 1 week from the nasopharynx,
6 weeks of stool.
80% of cases are asymptomatic.
 Polio Viruses, which are endemic or epidemic areas
 spreading in a population,we are known as wild polioviruses.
 Among them were for the purpose of preparing
live vaccines repeated passaging the virus in cell cultures
resulting strain called vaccinal.
Polio eradication
In 1988, the forty-first World Health Assembly adopted a resolution for the worldwide eradication of
polio, the Global Polio Eradication Initiative (GPEI). Since then, the number of cases has fallen by over
99% from an estimated 350 000 to 416 reported cases in 2013.
In 2014, only three countries in the world remained polio-endemic: Nigeria, Pakistan and Afghanistan.
In 2015 to date, two countries have together reported 37 cases: Pakistan (29 cases) and Afghanistan
(eight cases), all due to wild poliovirus type 1.
The last natural circulation of WPV2 was in India in 1999 and the last WPV3 case was detected in
Nigeria in November 2012.
 Since then, WPV1 has been the only circulating wild type virus.
The last case of endemic paralytic polio in the WHO European Region (i.e. with the source of the
infection originating in the Region) was reported in Turkey in November 1998,
and the Region was declared polio-free in June 2002.
The most recent outbreaks linked to importations into the WHO European Region occurred in 2010 in
Tajikistan and in 2013–2014 in Israel where WPV1 was circulating in the environment without causing
clinical cases .
The most recent polio outbreaks in what today constitutes EU/EEA were in the Netherlands in 1992, in
a religious community opposed to vaccination,
and in 2001, when three polio cases were reported among Roma children in Bulgaria .
On 5 May 2014, WHO declared the international spread of wild poliovirus in 2014 a Public Health
Emergency of International Concern (PHEIC) following the confirmed circulation of wild poliovirus in
several countries and the documented exportation of wild poliovirus to other countries.
The Polio Eradication and Endgame Strategic Plan 2013–2018 sets out the actions required for a poliofree
world by 2018 and beyond.
Outbreak of circulating vaccine-derived poliovirus type 1
(cVDPV1) in Ukraine
2 September 2015
Two cases of paralytic poliomyelitis caused by circulating vaccinederived
poliovirus type 1 (cVDPV1) were confirmed in Ukraine on 28
August 2015.
The cases, a 4-year-old child and a 10-month-old infant, had onset
of paralysis on 30 June and 7 July respectively and the positive stool
samples were collected from 5–10 July 2015.
The genetic similarity between the isolates indicates active
transmission of cVDPV1.
Both children are from the Zakarpatskaya oblast [region], in southwestern
Ukraine, bordering Romania, Hungary, Slovakia and
Poland.
Ukraine has been at high risk of vaccine-preventable diseases
outbreaks for several years due to persistent low routine vaccination
coverage.
Monitoring the circulation of polioviruses and other
enteroviruses in sewage waters in the Czech Republic in 2014
Petra Rainetová,
Zprávy CEM (SZÚ, Praha) 2015; 24(3): 89–90.
The National Laboratory for Enteroviry investigates environmental surveillance
waste water from treatment plants of 8 selected cities
- Prague, Rakovník, Plzeň, České Budějovice, Ústí nad Labem, Hradec Králové, Brno,
Ostrava)
- and 3 refugee camps (Zastávka at Brno, Jezová, Kostelec nad Orlicí).
In 2014, 147 samples of sewage were tested, in which non-polioenteroviruses
were found in 2 samples.
15.12.2017
In the US, the last case of uncontrolled polio occurred in 1979
and in September 1991 South America recorded the last case
across the American continent.
Similar success was achieved in 2000 in the Western Pacific
region, which includes 37 countries, including China's most
populous country.
Both WHO and ECDC draw attention to the risk of spreading wild type
1 poliomyelitis (WPV1) from Israel.
From February to early August 2013, WPV1 was detected in 85 waste
water samples from 27 sampling points in the southern and central
parts of the country.
The virus was isolated from stalk samples of 42 people in these
areas, allegedly vaccinated by IPV in accordance with Israeli national
recommendations.
There was no case of paralytic poliomyelitis.
Retrospectively, positive findings were also found in waste water
samples in the West of the country, in the Gaza Strip.
Indigenous transfer of wild poliovirus has not been recorded in Israel
since 1988. The strain is related to strains circulating in Pakistan and
strain detected in December 2012 from wastewater in Cairo, Egypt.
15.12.2017
The aggravation of poliomyelitis has been demonstrated in the 1980s when people with
persistent consequences of poliomyelitis have been deformed after many years of
stability
new nervous signs have begun to appear:
pain in muscles and joints,
reducing the strength of the affected and untreated muscles,
fasciculation and muscle cramps,
new paralysis and atrophy, and
overall impairment of movement abilities.
Patients complain of fatigue, sleep disturbances, breathing difficulties and cold sensitivity.
These late consequences of poliomyelitis are referred to as post-poliomyelitis syndrome.
It occurs in 40-70% of people in 25-35 years after the disease with poliomyelitis.
Excessively stressed muscles, which compensate for the function of the denerved
muscle groups, are particularly affected.
The essence of the syndrome is premature termination of long-overloaded motor units.
WHO estimates that there are over 20 million people in the world suffering from polio, and
there are about 15,000 people in the Czech Republic endangered by post-poliomyelitis
syndrome.
These patients require permanent dispensarisation, longer convalescence after injuries or
surgery, and regular rehabilitation care.
Pertussis
Pertussis is an acute bacterial infection of the respiratory tract, caused by the
bacterium Bordetella pertussis. The disease is characterised by a severe cough,
which can last two months or even longer.
Humans are the only reservoir. Infected adults usually have only mild symptoms,
but can shed bacteria for weeks. Following infection (by inhalation of droplets),
susceptible individuals develop symptoms after an incubation period of about 10
days. The typical paroxysmal cough is usually seen in young children. Babies
less than six months old may not cough, but they manifest dyspnea and
paroxysmal asphyxia and are the most likely to die of the disease unless they
receive suitable treatment.
Affected children are also exposed to complications such as pneumonia,
atelectasia, weight loss, hernia, seizures, encephalopathy (probably due to
hypoxia). Antibiotics may reduce the duration of the disease, especially if
administered in its early stages.
Bordetella pertussis
Sequencing of genomic areas ptxP, ptxA, prnA and fim3
in B. pertussis strains isolated in the Czech Republic in the period
1967-2010 changes in allelic variants were confirmed
these areas.
The occurrence of strains carrying new allelic variants has
increased since 1995 at the expense of the strains carrying the
original variants.
The results of the study can be interpreted as partial
genetic leakage of pathogenic B. pertussis strains outside
effectiveness of pertussis vaccines.
This graph shows reported pertussis incidence (per 100,000 persons) by age group in the
United States from 1990–2014. Infants aged <1 year, who are at greatest risk for serious
disease and death, continue to have the highest reported rate of pertussis. School-aged
children 7 to 10 years continue to contribute a significant proportion of reported pertussis
cases.
This graph illustrates the number of pertussis cases reported to CDC from 1922 to 2014.
Following the introduction of pertussis vaccines in the 1940s when case counts frequently
exceeded 100,000 cases per year, reports declined dramatically to fewer than 10,000 by 1965.
During the 1980s pertussis reports began increasing gradually, and by 2014 more than 32,000
cases were reported nationwide.
15.12.2017
0
500
1000
1500
2000
2500
3000
1 2 3 4 5 6 7 8 9 10
ČR Pertusse
2015/585 případů
2014/2 521 případů
2006/234 případů
 Recommendations for the vaccination of
pregnant women against pertussis.
15.12.2017
Measles
During the 12-month period from July 2014 to June 2015, a total of 4 224 cases was reported by
30 EU/EEA countries. Twenty-three countries reported consistently throughout this period.
 • Germany accounted for 58.2% of the cases reported during this period.
In 10 of the countries reporting consistently, the measles notification rate was less than one case
per million population, including six countries which reported zero cases during the 12-month
period.
The diagnosis of measles was confirmed by positive laboratory results (serology, virus detection
or isolation) in 63.4% of all cases.
Of all cases, 89.2% had a known vaccination status and of these, 83.8% were unvaccinated.
In the target group for routine childhood MMR vaccination (1–4-year-old children), 76.9% of the
cases were unvaccinated.
One measles-related death was reported during the period July 2014–June 2015, and eight
cases were complicated by acute measles encephalitis.
Since the previous report, outbreaks of measles have been detected in several countries in the
WHO European Region: Austria, Belarus, Lithuania, Denmark, Norway, the United Kingdom,
France, Sweden and Belgium.
Outside of Europe, measles outbreaks are reported from the Democratic Republic of Congo,
Guinea, Sudan, South Sudan, Brazil, Australia, Mali, Algeria, Chile, Peru, Cameroon, Taiwan,
Iraq and Malaysia.
Measles
High incidence in developing countries and in
Europe (2015: 15 months of death in Berlin)
In the Czech Republic, measles are virtually
absent, in the case of isolated diseases, they are
mostly imported diseases.
CR - there are no conditions for epidemics
But 20% of people aged 35-44 do not have
antibodies
Threats: health professionals, young adults,
children of non-immature mothers, rarely even
immunized children
15.12.2017
0
50
100
150
200
250
1 2 3 4 5 6 7 8 9 10
ČR Spalničky
2006/7 případů
2014/ 221 případů
Rel. 2,1/100 000 obyvatel
2015/ 9 případů
Rubella
• Twenty-eight EU/EEA countries reported a total of 2 808 rubella
cases during the period July 2014 to June 2015.
• In 18 of the countries reporting consistently, the rubella
notification rate was less than one case per million population,
including 11 countries reporting zero cases during the 12-month
period.
• Poland accounted for 93.9% of all reported rubella cases in the
12-month period.
The highest number of cases was observed in 5–9- and 1–4-yearolds.
28.5% of the cases were unvaccinated.
However, this figure needs to be interpreted with caution as only 37
cases were confirmed through laboratory testing.
• No outbreaks of rubella have been detected by epidemic
intelligence since the last report.
15.12.2017
15.12.2017
0
5
10
15
20
25
30
1 2 3 4 5 6 7 8 9 10
ČR Zarděnky
2006/8 případů
2011 /208 případů
2015/ 0
MUMPS
Mumps is an acute illness caused by the mumps virus. It is characterised by fever
and swelling of one or more salivary glands (mumps is the only cause of epidemic
infectious parotitis).
Humans are the only reservoirs of the virus, which is transmitted from person to
person via droplets and/or saliva. Following infection, the incubation period lasts on
average 16–18 days. Salivary glands apart, other organs may be involved and
symptoms might include infection in the testicles (in post-pubertal males), prostate
gland, thyroid gland, and pancreas. Brain involvement is frequent, but mostly
without symptoms. Brain infection is believed to occur in only one in 10 000 cases,
but it often leads to death.
Mumps is preventable by a vaccine, which is most often administered in association
with anti-rubella and anti-measles vaccines (MMR).
MUMPS - NORWAY: INCREASED INCIDENCE
Date: Fri 6 Nov 2015
Around 80 cases of the mumps (called kusma in Norwegian) have been recorded in Norway
recently, mostly among college students. The outbreak began in Trondheim, but residents of
Oslo, Bergen and elsewhere along the west coast have also fallen ill.
Doctors in Trondheim alerted state officials at the Institute for Public Health (Folkehelseinstituttet)
late last week. By then, cases were spreading beyond Trondheim. All students suffering
symptoms that can be confused with flu were urged to undergo testing. Dr Karin Ronning of the
health institute said the outbreak is believed to have been brought in by foreign students.
"Since 1969, all children in Norway have been offered vaccination against
measles via the Childhood Immunisation Programme. The measles vaccine is
given in the form of 2 doses of MMR vaccine at 15 months and at 11 years
(Grade 6). If there is an increased risk of infection, the vaccine may be given as
early as 9 months, but a booster dose at
 15 months of age is recommended.„
15.12.2017
0
1000
2000
3000
4000
5000
6000
1 2 3 4 5 6 7 8 9 10
ČR Parotitis
2006/5172 případů
2012/3902 případů
2015/1616 případů
Leden – březen 2016/1089 případů
Haemophilus influenzae type b (Hib).
Other familiar diseases that vaccines protect against
include chickenpox, hepatitis A and B, and
Haemophilus influenzae type b (Hib). Hib causes
meningitis, an inflammation of the fluid-filled
membranes that surround the brain and spinal cord.
Meningitis can be fatal, or it can cause severe
disabilities such as deafness or mental retardation.
This disease has nearly disappeared among babies
and children in the United States since the Hib
vaccine became widely used in 1989.
Invasive Haemophilus influenzae disease
Invasive Haemophilus influenzae disease has become rare; the notification rate in Europe was
0.49 per
100 000 population, with a slightly ascending trend which may be attributed to improved
surveillance in most countries.
Country-specific rates were highest in northern Europe and in the United Kingdom;
age-specific rates were highest in children under one year and adults aged 65 years or over.
The national immunisation schedules of all EU/EEA countries include the Hib vaccine, which
has led to a
 progressive reduction of type b serotype infections.
Even though there appears to be a trend towards an increase in disease due to noncapsulated
(nontypeable) strains, European data is too scarce to draw conclusions on serotype
replacement.
Continued monitoring of strains, together with their associated clinical syndromes, is essential
for assessing the effect of interventions.
In 2012, 2 545 confirmed cases of invasive Haemophilus influenzae disease (all serotypes)
were reported by 27 countries, 24 of which have surveillance systems with national coverage.
Belgium, France and Spain reported data from sentinel surveillance and therefore had to be
excluded from the notification rates analysis, while no confirmed cases were reported from
Malta for 2012.
15.12.2017
 As from 1 November 2010,
 On vaccination against infectious diseases, according to which vaccination is
obligatory for children with the following indications, is valid:
 one or both of the parents or sibling or member of the household in which the
child lives has an active tuberculosis,
 one or both of the parents or siblings of the child or member of the household
in which the child is living was born or continuously resident for more than 3
months in a State with a higher incidence of TB than 40 cases per 100
thousand. of population (Minor healthcare annually publishes list of countries
with higher incidence of tuberculosis within 30 days of WHO update), list of
countries on www.mzcr.cz
 the child was in contact with sick tuberculosis.
Očkování proti TBC
TB notifications by countryIn 2013, 64 844 TB cases were reported in the EU/EEA.
The notification rate was 12.7 per 100 000 population (range 3.4–83.5).
85
Figure 1: TB
notification rate
per 100 000
population by
country, EU/EEA,
2013
Not included or not
reporting
20 to 49 per 100 000
10 to 19 per 100 000
5 to 9 per 100 000
< 5 per 100 000
≥ 50 per 100 000
WHO beats the alarm: 4400 people die daily for tuberculosis
The World Health Organization (WHO) on Wednesday (28.10.2015) called
for a further fight against tuberculosis (TB), which is still one of the leading
causes of death in the world, and dying 4400 people every day.
This figure is "unacceptable" by the authors of the WHO report, and more
sadly, that almost all TB patients can now be diagnosed and cured.
Efforts against TB have so far halved worldwide mortality from 1990
onwards. The situation has improved especially since 2000. New diagnostic
and treatment methods have saved 43 million lives. According to the WHO,
however, it is necessary to continue and intensify the fight against TB, which
is mainly hampered by a lack of money.
Last year, 9.6 million new cases of disease occurred. More than half of the
current cases of TB fall on China, India, Indonesia, Nigeria and Pakistan,
the WHO said.
The numbers of diseases in the Czech Republic are constantly decreasing,
512 cases were reported last year. The Czech Republic thus has 4.8 cases
per 100,000 inhabitants to the lowest TB countries in the world.
15.12.2017
Zdroj: www.czso.cz
TBC – in Slovakia - 2013
number of cases/100 000 residents
16,15
8,06
4,81
4,79
4,89
4,31
5,71
BA TT
TN
NI
ZA
BB
5,62
PO
KE
Source: Doc. MUDr. Ivan Solovič, CSc.
Immunity
 Self vs. nonself
 Protection from infectious disease
 Usually indicated by the presence of antibody
 Very specific to a single organism
Immunity
Principles of Vaccination
 Protection produced by the person's own immune
system
 Usually permanent
 Protection transferred from another person or animal
 Temporary protection that wanes with time
Active Immunity
Active Immunisation
 A live or inactivated substance (e.g., protein,
polysaccharide) capable of producing an immune
response
 Protein molecules (immunoglobulin) produced by
B lymphocytes to help eliminate an antigen
Types of vaccines
monovalent - against one agent
polyvalent - against several types of origin of the same species
examples: divalent - meningococcal A + C
trivalent - 3 types of polio virus -OPV, IPV
polyvalent - 23 polysaccharide antigens
Pneumo 23
combined - 2 or more antigens of different agents
examples: VH A + VH B div
tetravachin D + T + Per + Hib
hexavacine D + T + Per + Hib + IPV + VH B
Composition of vaccines
 antigens (the immune response inducing component)
 adjuvants (depot effect, immunomodulators)
 antibiotics (suppressing the growth of contaminants
 microorganisms - for example neomycin, kanamycin)
 preservatives (secondary prevention
 contamination - multivariate packaging - eg thiomersal)
 stabilizers (support for the stability of vaccines - at
different vaccines - magnesium sulphate, sucrose,
albumin
General contraindications to vaccination
Temporary contraindications - (absolute, relative) nursing doctor evaluates
for each exercise
 the child is acutely ill or has a temperature, more attention should be
paid to the current state of health of the child when vaccinated with "live"
vaccines (eg measles)
 the child was in contact with the patient and is in the so-called incubation
period (which usually lasts 1-3 weeks depending on the type of illness);
 the child is weakened after illness (it is in convalescence), for common
childhood illnesses it is usually 1 - 2 weeks,
 the child has a serious long-term illness (most often neurological or
oncological)
 the child uses corticosteroids or immunosuppressive drugs.
 Other reasons to prevent vaccination (mostly persistent) may be severe
post-vaccination or severe chronic disease (most commonly
neurological or immune defects).
permanent contraindications - specialist (record of the opinion of the
specialist is obligatorily stored in the documentation)
Contraindications
 Specific
 Depends on the types of vaccine (exampl.- alergic
reaction on the some substances
Apliccation
 Under aseptic conditions !
 i.m.
 s.c.
 intradermal (epidermis)
 p.o.
 scarification
 …..
After aplication - 30 min - under oversight !
Reaction after apliccation
 Fysiolocal reaction
 Local
– erythema, swelling, soreness …
 Generally
- higher temperature, fever, tiredness, hedeache,
- pain of the muscles, joints,
- Indigestion
 Alergic reaction
Vaccination
 Active immunity produced by vaccine
 Immunity and immunologic memory similar to
natural infection but without risk of disease
Division of vaccines according to mechanism of action
Live vaccines contain their own infectious agents in attenuated form. It's for example vaccines against certain
viral diseases (measles, mumps, rubella).
Inactivated vaccines also contain their own infectious agents, but this time in the killed form. These include,
for example, vaccines against certain viruses (influenza, tick encephalitis or rabies).
Subunit vaccines contain only certain components of the pathogen against which they are newly exposed
The emerging immunity of the organism to focus. They are used, for example, against encapsulated bacteria such
as are H. influenzae or meningococci; the individual components of their polysaccharide capsule are used in the
vaccines.
Recombinant vaccines for the production of vaccines are involved in genetic engineering methods. Specific
protein antigens of a particular pathogen (typically, for example, hepatitis B virus) are artificially synthesized, for
example, in yeast, and subsequently forms an essential part of the recombinant vaccine.
Toxoids (anatoxins) are a specific type of vaccine where the main objective of the immune response is
inactivated pathogenic toxin. Typically, these vaccines are used to prevent tetanus or diphtheria.
DNA vaccines: Although they have not been used in practice for a long time, DNA vaccines are promising
promise for the future. Their principle is to some extent similar to that of recombinant vaccines, but vector with the
appropriate DNA sequence is administered directly to the vaccinated individual, which is subsequently made
immunogenic antigens in your body itself. In addition, persistent stimulation can provide real long-term immunity.
Live Attenuated Vaccines
 Attenuated (weakened) form of the "wild"
virus or bacterium
 Must replicate to be effective
 Immune response similar to natural infection
 Usually effective with one dose*
*except those administered orally
Live Attenuated Vaccines
 Severe reactions possible
 Interference from circulating antibody
 Fragile – must be stored and handled
carefully
Live Attenuated Vaccines
 Viral measles, mumps,
rubella, vaccinia,
varicella, yellow fever,
intranasal influenza,
(oral polio)
(rotavirus)
 Bacterial BCG, oral typhoid
Vaccines in (parenthesis) are not available in the United States.
Inactivated Vaccines
 Cannot replicate
 Less interference from circulating antibody than
live vaccines
 Generally require 3-5 doses
 Immune response mostly humoral
 Antibody titer diminishes with time
Inactivated Vaccines
 Viral polio, hepatitis A,
rabies (influenza)
 Bacterial (pertussis) (typhoid)
(cholera) (plague)
Whole-cell vaccines
Inactivated Vaccines
 Subunit hepatitis B, influenza,
acellular pertussis,
(Lyme) (HPV)
 Toxoid diphtheria, tetanus
Fractional vaccines
Polysaccharide Vaccines
 pneumococcal
 meningococcal
 Salmonella Typhi (Vi)
 Haemophilus influenzae type b
 pneumococcal
 meningococcal
Pure polysaccharide
Pure Polysaccharide Vaccines
 Not consistently immunogenic in children <2
years of age
 No booster response
 Antibody with less functional activity
 Immunogenicity improved by conjugation
Passive Immunisation
 Transfer of antibody produced by one human
or other animal to another
 Temporary protection
 Transplacental most important source in
infancy
Sources of Passive Immunity
 Almost all blood or blood products
 Homologous pooled human antibody
(immune globulin)
 Homologous human hyperimmune globulin
 Heterologous hyperimmune serum (antitoxin)
Passive immunization
P (1) Human hyperimmune antitetanic globulin is administered:
to unvaccinated people at all after the prescribed interval for revaccination
(persons over 60 years of age after 10 years)
without proof of vaccination against tetanus
(2) hyperimmune anti-rabies globulin:
in the case of bite or injury by an animal suspected of rape infection.
(3) hyperimmune globulin against viral hepatitis B:
newborn mothers of HBsAg positive mothers
Botulism immune globulin (BIG)
Antidifteric serum.
Passive immunization
botulism immune globulin (BIG) is indicated in infants
with clinically diagnosed infant botulism, before
diagnostic confirmation. The prompt use of this specific
immunoglobulin leads to a significant decrease in both
ICU and total hospital stay.
Immunisation in Czech Republic
Regulary vaccination – (refunding the state)
 (TBC) form 2010 only by indicated group
 Diphteria, Tetanus, Pertussis, Hemophillus
influenzae B, Poliomyelitis, Viral hepatitis B (VHB),
 Morbilli, Rubeola, Parotitis epidemica
 Inluenza, Pneumoccus
(for specific groups – by low )
 VHB (healths workers )
TBC only - indication
Di,Te,P(a), from 13th week 3 times in 1 year (each after 1 months)
Hib, VHB,IPV 4th dosis 6th months after 3th dosis
MMR 1st dosis from 15th months
2nd dosis from 6th to 10th months after 1st dosis
Di,Te,P(a) 5 years
Di,Te,P(a),IPV 10 years
VHB 12 years
Te 25 years, revaccination each after 10 - 15 years
Poznámka: TBC , Di (Diphteria), Tetanus (Te), P (Pertussis), Hib (Haemophilus influenzae b), HB (VHB),
IPV (poliomyelitis), MMR (measles, mumps, Rubella).
Zákon č. 267/2015 Sb., kterým se mění zákon č. 258/2000 Sb., o ochraně veřejného
zdraví a o změně některých souvisejících zákonů, ve znění pozdějších předpisů, a další související zákony
§ 46
• (1) Fyzická osoba, která má na území České
republiky trvalý pobyt, cizinec, jemuž byl povolen
trvalý pobyt, cizinec, který je oprávněn k trvalému
pobytu na území České republiky, a dále cizinec,
jemuž byl povolen přechodný pobyt na území České
republiky na dobu delší než 90 dnů nebo je oprávněn
na území České republiky pobývat po dobu delší než
90 dnů, jsou povinni podrobit se, v prováděcím
právním předpisu upravených případech a
termínech, stanovenému druhu pravidelného
očkování.
• ...ze zákona lze za nedodržení očkovací povinnosti uložit pokutu až 10 tisíc korun. Důvodem
pro odmítnutí očkování může být nejen náboženství, což soud uznal již v minulosti, ale v
mimořádných případech i svoboda svědomí v širším, sekulárním smyslu. Jde například o
situaci, kdy rodiče zaznamenali negativní účinky u jednoho potomka a poté by měli umožnit
očkovaní druhého. V podobných spíše výjimečných případech může stát upustit od
vynucovaní vakcíny a peněžní sankce. Podle názoru US je nutné posuzovat naléhavost
důvodů a sílu přesvědčení rodičů, stejně jako společenské dopady jejich rozhodnutí.
• Rodiče v nyní řešené ústavní stížnosti tvrdili, že očkováni odmítli kvůli svému svědomí i s
ohledem na zájmy dítěte. Obávali se například autismu jako následku vakcinace. Nejlepší je
podle nich přirozená imunita, kterou by očkování mohlo narušit.
Právní úprava povinného očkování se po tomto rozhodnutí US nijak nemění. Rozšiřil se ale
prostor pro výjimky. Nemění se např. to, že očkování je podmínkou pro přijetí dítěte to školky.
• Na druhé straně se US vyslovil pro to, aby stát nesl odpovědnost za připadné poškození
zdraví následkem očkování, což dikce zákona o ochraně veřejného zdraví (zak. č. 258/2000 Sb.,
ve zněni pozdějších předpisů) nestanoví.
15.12.2017
Očkování lze odmítnout z důvodu svobody svědomí
Ústavní soud (ÚS) se rozhodnutím z 20. ledna zastal rodičů z Brněnska pokutovaných
za to, že nenechali naočkovat dítě povinnou hexavakcínou.
Vaccination before going abroad.
Obligatory vaccination against:
 yellow fever when traveling to countries of Africa and
Central and South America and
 meningococcal meningitis (A, C, Y, W - 135) when
traveling to Saudi Arabia.
15.12.2017
Typhus abdominalis
TYPHIM Vi is a vaccine prepared from the purified Vi capsular
polysaccharide obtained by extraction from Salmonella typhi.
Preventing typhoid fever in adults and children over 2 years of
age, especially people traveling to endemic areas, migrants,
health workers and soldiers.
Protection is provided by one dose of the vaccine.
The vaccination is done every three years if the risk of infection
with the typhoid persists.
15.12.2017
New HPV vaccine - Gardasil 9,
Clostridium difficile vaccine
Vaccine against Autism?
Philippines - Sanofi's Dengvaxia vaccine is the first
ever authorized dengue fever vaccine.
Last week, however, the company admitted that
long-term studies have shown that the vaccine is
effective for people who have been infected in the
past but are at risk for those who become infected
for the first time. The illness may be more severe in
them.
15.12.2017
Anthrax Pertussis (Whooping Cough)
Cervical Cancer Pneumococcal
Diphtheria Poliomyelitis (Polio)
Hepatitis A Rabies
Hepatitis B Rotavirus
Haemophilus influenzae type b Rubella (German Measles)
Human Papillomavirus (HPV) Shingles (Herpes Zoster)
H1N1 Flu (Swine Flu) Smallpox
Influenza (Seasonal Flu) Tetanus
Japanese Encephalitis (JE) Tuberculosis
Measles Typhoid Fever
Meningococcal Varicella (Chickenpox)
Mumps Yellow Fever
Future vaccines may be squirted up the nose,
worn as a patch, or eaten at the dinner table.