IAP recommendations 2012: Major Changes

Contents

• Polio• Hepatitis B• Influenza• Other changes

Polio

Polio: Important developments

• India has not reported a single case of wild Polio since January 2011

• 7 VDPV cases reported in 2011 and 1 iVDPV reported in 2012 (West Bengal)

• WHO declared India non-endemic in Feb 2012• To reduce incidence of VAPP and VDPV (especially

type 2), in April 2012, WHO recommended introduction of bOPV inplace of tOPV as well as IPV in all countries currently using OPV in their routine immunization programme

Polio: Important developments (cont)

• India Expert Advisory Group (IEAG) has also recently recommended bOPV and IPV

• In light of these developments IAP has decided to endorse gradual shift from tOPV to bOPV in the national immunization programme and to introduce a sequential schedule of IPV and OPV rather than a combined schedule for private practice

Polio: IAP recommendations

• Phased OPV removal : switching from tOPV to bOPV1&3 for routine EPI & campaigns.

• Retained the birth dose of OPV (necessary where the risk of poliovirus transmission is high).

• Sequential immunization schedules starting with IPV & then OPV induce protective immunological responses to all 3 serotypes in ≥ 90% & ↓ risk of VAPP

Polio: IAP Time Table

Age Vaccine

Birth OPV

6 weeks IPV

10 weeks IPV

14 weeks IPV

6 months OPV

9 months OPV

16 - 18 months IPV

4½ - 5 years OPV

Polio: Catch-up schedule and Travellers

Catch-up schedule (< 5yrs of age) 3 doses of IPV; 2 doses at 2 months interval followed by a 3rd dose after 6

months.

Travelers•Immunized individual (previously received ≥3 doses of OPV or IPV) should

be offered another dose of polio vaccine as a once-only dose before

departure.

•Non-immunized individuals should complete a primary schedule of polio

vaccine, using either IPV or OPV ( at least 3 doses of either vaccine).

Hepatitis B

IAP Recommendations

• IAPCOI has now recommended a 0–6 week–6 month schedule for routine Hepatitis-B vaccination in office practice for children: – the first dose at birth– second dose at 6 weeks– and third dose at 6 months

• Administering Birth dose to all infants before hospital discharge critical

• Final dose not to be administered before 6m of age

Rationale

• This schedule is not only closer to immunologically ideal and most widely used 0-1-6 months schedule

• Confirms to latest ACIP recommendations wherein the final (third or fourth) dose in the Hepatitis-B vaccine series should be administered no earlier than age 24 weeks and at least 16 weeks after the first dose.

• 0-1-6 is the only schedule widely followed across the world and for which there is abundant evidence of effectiveness (Taiwan, Thailand and USA)

Rationale (cont)

• Birth dose extremely important to protect against chronic infection and possibly Hepatocellular carcinoma

• The GMTs with 0, 1, and 6 months schedule are upto 10 times higher than 6,10,14 wk schedule.

• Infants who achieve higher Anti HBs titers may be protected better in later years.

• The seroprotection rates are found to be highest when the interval between the second and third dose is longer.

• The classic 0, 1, and 6 months schedule yields a high seroconversion rate and relatively high titers of anti-HBs that will persist for an extended period of time.

Influenza

IAP recommendations

• Data since 2004 suggests a clear peaking of circulation during the rainy season across the country- ‘June to August’ in North (Delhi), west (Pune) and East (Kolkata), and ‘October to December’ in South (Chennai)

• This data is also consistent with the WHO circulation patterns for 2010 and 2011 for India which also shows a clear peak coinciding with the rainy season across the country.

• Vaccination should be with the latest strains available and before the peak of Influenza circulation in the rainy season

IAP recommendations (cont)• In addition to this, WHO classifies India under the

‘South Asia’ transmission zone of Influenza circulation.

• This along with summary review of the 2011 southern hemisphere winter influenza season strongly points towards India’s alignment with the availability of Southern hemisphere vaccine (available in March-April)

• This will ensure that we have the latest available strains for early vaccination to prevent the peak of circulation of Influenza in the rainy season across the country.

Other changes

• Rota virus vaccination: History of intussusception in the past is added as an absolute contraindication to rotavirus vaccine administration.

• Pneumococcal vaccination: Prematurity and very-low birth weight are added as another high risk category for pneumococcal vaccine administration

IAP Immunization Calendar at a glance Age ►

Vaccine ▼Birth 6 wk 10 wk 14 wk 18 wk 6 mo 9 mo 12 mo

15 mo

18 mo

2-3 Yr

4-6 Yr

BCG BCGHep B Hep B1 Hep B2 Hep B3Polio vaccines

OPV0 IPV1 IPV2 IPV3 OPV1 OPV2 IPV B1OPV

3DTP

DTP 1 DTP 2 DTP 3 DTP B1DTP B2

Hib Hib 1 Hib 2 Hib 3 Hib-boosterPneumococcal PCV 1 PCV 2 PCV 3 PCV -booster PPSVRotavirus* RV 1 RV 2 RV* 3Measles MeaslesMMR

MMR 1MMR 2

VaricellaVaricella 1

Varicella 2

Hep AHep A 1

Hep A 2

Typhoid TyphoidInfluenza Influenza (yearly)Meningococcal Mening

ococcalCholera Cholera 1 & 2JE JE

9th July 2012

Conclusions

• Polio: Sequential IPV-OPV schedule in place of combined OPV+IPV schedule.

• Hepatitis-B: ‘Birth-6 weeks-6 months’ instead of earlier ‘0- 6 weeks-14 weeks’ schedule.

• Influenza: Southern Hemisphere vaccine to provide earliest and most accurate protection against the circulating strains of Influenza virus.