Vaccines In Special Situations Dr. A. Jaleel Ahamed Consultant Pediatrician & Neonatologist, Royal Care Super speciality Hospital, Coimbatore. Immunization is one of the most cost effective public health interventions and argely responsible for reduction of childhood diseases and one of the strong pillars of child survival. Some definitions: Vaccination- act of introducing a vaccine into the body to stimulate the immune system to induce production against infection or disease. Immunization- a process bywhich apersonbecomes protected against disease. Types of Vaccines: Broadly classified as Live attenuated vaccines like OPV, MMR, Varicella Inactivated vaccines DPT Practitioner needs to know what are the indications, contraindications, side effects , and use in special situations. In general immunocompromised are in greater need of vaccines as they are more susceptible to infection. Since immunogenicity or efficacy is lower and risk of adverse effects with live vaccines s higher all live vaccines are contraindicated. All inactivated can be given. In severe immunodeficiency all live vaccines are contraindicated. In some instances higher doses or greater number of doses should be given e.g Hepatitis B. House hold contacts of immunocompromised should not receive transmissible vaccines like OPV. 51
Other conditions that warrant holding or modifying recommendations are HIV Corticosteroids / other immunosuppressive drugs Children receiving Immunosuppressive Medications like methotrexate, Azothioprine, Biologic response modifying drugs. Cancer cases on Chemotherapy / Radiotherapy. Transplant recipients like HSCT, Solid organ transplants Asplenia / Hyposplenia Chronic Illness Congenital and Acquired Immunodeficiency Children with Allergy like egg Immunization in Health Care Personnel Immunization in relation to Anti Body containing products like whole blood, PCV, Plasma, IVIG etc. Immunization in Pregnancy / Lactation Immunization in Preterm birth / Low birth weight like administered as per chronological age irrespective of birth weight. All above situations and recommendations are guided by an International panel of experts on evidence based guidelines. Dr. A. Jaleel Ahamed FIAP FNNF, Consultant Pediatrician & Neonatologist, Coimbatore. 52
NEWER VACCINES DR. NANDHINI KUMARAN SENIOR CONSULTANT PEDIATRICIAN' MASONIC MEDICAL CENTER FOR CHILDREN, COIMBATORE, TAMILNADU. HUMAN PAPILLOMA VIRUS-HPV VACCINES. What is human papilloma virus?[HPV] 1. Human Papilloma Virus is the most common Sexually Transmitted Infection [STI] 2. Most sexually active men and women being exposed to the virus at some point during their life time. 3. Increased risk of hpv at younger age. 4. Highest prevalance occurs amongst adolescent&young adults between 15-25 years. 5. More than 200 types have been identified. 6. Arround 30-40 of them cause genital hpv infection. 7. HPV can cause several type of cancer-cervical, oral, penile, vaginal, vulval&anal. SCHEDULE OF HPV VACCINE 4v HPV(cervavac-sii) 9-14 yrs (boys&girls)- 2 doses-0 and 6 months. 15- 26yrs(males&females) - 3 doses 0, 2 and 6 months. 9v HPV Gardasil-9 - ( MSD ) 9-14 yrs (boys&girls) 2 doses-0 and 6 months. 15- 26yrs (females Only) 3 doses 0, 2 and 6 months. RECOMBINANT ZOSTER VACCINE ( RZV) Supplied as two vials gE ( active ingredient ) in a lyophilized form. Adjuvant system is liquid form. Indicated for prevention of Herpes Zoster (HZ) and Post Herpetic Neuralgia (PHN ) in adults 50 Yrs of age or older. 53
RECOMMENDATION FOR RZV All immunocompetent adults aged > 50 yrs. Given IM in 2 doses 0 and 2-6 months. Recommended to those with past history of HZ any time after clinical recovery . PNEUMOCOCCAL VACCINES Pneumococci - Strep. Pneumoniae Serious infections - Pneumonia, Septicemia & meningitis (IPD). Elderly population highly susceptible to this disease. All the following bodies recommend pneumococcal vaccines: Association of physicians of India API. Geriatric Society of India GSI. Indian Society of Nephrology ISN. Indian Medical Association IMA. Indian Chest Society National College of Chest physicians ICS. NCCP. Research Society for Diabetes. 2 types of vaccines PCV- pneumococcal conjugate vaccine PCV13. PPSV- pneumococcal polysaccharide vaccine - PPSV 23 High risk groups CSF leaks. Cochlear implants Diabetes Chronic heart disease, lung disease COPD, asthma, renalfailure, nephrotic syndrome, sickle cell Immunocompromised - HIV, malignancy, organ transplant SCHEDULE PCV 13 one dose for all above 50 years. HIGH RISK INDIVIDUALS PCV 13 one dose followed by PPSV23 one dose 8 weeks later. Additional PPSV 23 after 5 years. INFLUENZA VACCINE Quadrivalent vaccine. Influenza A 2 strains. Influenza B2 strains 0.5 ml IM , Annually DR. NANDHINI KUMARAN, 9442625267, [email protected] 54
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Bone marrow transplantation DR KARTTHIK SHANMUGAM MBBS, MD, DM (Clinical Haematology), MRCP (UK), DipRCPath (Haem -UK) Consultant Haematologist, Haemato Oncologist and Bone marrow transplant physician Royal care Super Specialty Hospital, Coimbatore Stem cell transplant (SCT) is the term now most commonly used terminology rather than bone marrow transplant (BMT). In the 1970s, SCT was still an experimental treatment. There have been major developments since, and now a transplant has become the treatment of choice for a wide range of blood cancers and blood disorders, with other disorders and cancers responding well to high doses of chemotherapy and/or radiotherapy, which are treatments used to kill cancer cells. High doses of chemotherapy and/or radiotherapy is given beforehand. This strong (high-intensity) treatment is called a 'conditioning therapy'. It can destroy cancer cells or change the way disease behaves, but the treatment will also damage bone marrow's ability to produce all other cells. Without a transplant of new stem cells, bone marrow might not be able to recover. Therefore, after patient have received the high-dose treatment, the stem cells are given to help them produce new blood cells by simple transfusion. The stem cells for the transplant are collected from the bone marrow or the blood. The process used to collect stem cells is called harvesting. There are two different ways that the cells can be harvested: either through a peripheral blood stem cell harvest by apheresis after stem cell mobilisation or direct bone marrow harvest under general anaesthesia. The cells are given through a central venous catheter (Hickman® or PICC line). When the stem cells are given , it's known as a 'cell infusion'. The infused stem cells received find their way to bone marrow and begin to produce new blood cells. This happens about two to three weeks after they have been infused. This process 'rescues' bone marrow from the effects of the high-dose chemotherapy or radiotherapy 81
There are two types of transplants. Autograft/autologous – where own patient bone marrow or stem cells are used Allograft/allogeneic – where the bone marrow or stem cells from a donor are used. Different types of donors. These include: an identical twin (syngeneic) , a brother or sister (sibling), a parent, cousin or child (alternative family donor or haplo-identical donor) , a matched unrelated donor or a volunteer unrelated donor (MUD or VUD) or umbilical cord and placenta. The type of stem cell transplant depends upon the type of disease being treated and the quality of the person's own bone marrow or stem cells. In case of allogeneic stem cell transplant, Immunosuppressive drugs are used to stop immune system fighting the donor stem cells, and instead allow them to grow. Stem cell transplant has risk of dangerous infection which can be tackled well with big basket of antibiotics, antifungal and antiviral medication, but still prevention is brought about by performing this procedure in a specialised unit including HEPA filtered rooms and dedicated team. Most important other risk associated with allogeneic stem cell transplant includes the risk of graft-versus-host disease (GvHD). Now a new form of engineered T cells called CAR (Chimeric antigenic receptor) T cells are making their way into resistant cancer treatment. 82
IMMUNO-ONCOLOGY -Release the immune break Introduction Immuno -Oncology is one of the recent and most promising treatment modality in managing patients suffering from cancer . Dr James P Allison and Dr Tasaku Honju were jointly awarded the Nobel prize in Physiology or Medicine during 2018 for their discovery of the immune brake proteins CTLA 4 and PD 1 on the surface of T cell respectively . Mechanism of Immune surveillance and escape Our immune system functions incredibly to protect the human body by eliminating any form of foreign threat entering the body . The T lymphocytes mainly functions to destroy the pathogens or tumour cells and later the brakes in the immune system helps to terminate the destructive process once the threat is removed . These immune brakes mediated through T cells receptor proteins also play a role in preventing the autoimmune response against the self antigens over the normal cells .The cell surface of the tumour cells express some of the self antigen and hence evades from the immune destruction causing immune escape . So immunotherapy or immune check point inhibitors are the drugs that inhibits the immune brakes through which the tumour cells escape from T cell mediated killing . Dr.Narmadha Rathinasamy MD(R.T),DM(Medical Oncology) 83
Immune check point inhibitors There are several tumour biomarkers available to predict the response to immunotherapy including PDL1 , Microsatellite Instability MSI and TMB but are less robust . Currently available immunotherapy drugs are PD 1 inhibitor , PDL1 inhibitors , CTLA4 inhibitor and LAG3 inhibitors. Immunotherapy has been approved for various solid tumours and some of the hematological malignancies. Initially these were approved in palliative setting to control the disease and improve survival outcomes. Recently immunotherapy has been approved in the curative setting as neoadjuvant and adjuvant therapy . Immunotherapy is used in combination with chemotherapy and also as monotherapy in those in higher PDL1 expression and chemo ineligible /intolerant and chemo resistance tumours . Guidelines recommend that steroid administration during immunotherapy should be avoided or kept less than or equal to Prednisone 10 mg equivalent for better efficacy of the treatment. Outcomes About 30 % of patients on immunotherapy achieve response to therapy and these patients usually have durable response even after stopping the drug likely due to the long lasting immune memory .The response to immunotherapy is assessed by PETCT scan using the iRECIST criteria . The toxicity outcomes mimicks an autoimmune process commonly affecting the thyroid , pituitary ,colon , lung and skin . Majority of the toxicity are of lesser grade and can be continued or rechallanged on immunotherapy whereas 1-5 % may experience grade 3 or 4 complications requiring administration of iv or oral steroids at the earliest and tapered over 4-8 weeks of duration . 84
Oncoplasty- The New Age Breast Cancer Surgery In India, breast cancer often affects women at a younger age compared to Western countries. Therefore emphasizing the importance of early detection, promoting self-examinations, and providing support for comprehensive breast cancer care is essential. Traditionally Breast Cancer Surgery involves complete removal of the affected breast called as Mastectomy. Advances in understanding Breast Cancer and availability of advanced facilities allow us to preserve Breast while doing optimal surgery for Breast Cancer. Breast Conservation Surgery (BCS), is a vital aspect of breast cancer treatment. BCS involves removing the tumor while preserving the breast, promoting a more natural appearance. BCS often leads to equivalent cure rates compared to more extensive procedures like Mastectomy. BCS minimizes physical and emotional impacts, promoting improved body image and psychological well-being. Oncoplasty is a new surgical approach that combines cancer removal with plastic surgery techniques, benefiting breast cancer patients. Advantages, including improved cosmetic outcomes, preserving a natural breast appearance, and enhancing patients' psychological well-being. Oncoplasty yields favorable outcomes, including lower rates of re-operation, improved symmetry, and patient satisfaction compared to conventional breast cancer surgery. Studies show reduced psychological distress, better body image, and enhanced quality of life post-treatment. Awareness of Oncoplasty is limited in India, however Oncoplasty awareness in India is gradually increasing among healthcare professionals and patients. Efforts by medical societies, educational institutions, and advocacy groups have led to greater dissemination of information through conferences, workshops, and online resources. However, there's still a need for widespread education to ensure all breast cancer patients have access to this advanced surgical option. 85
The future of Oncoplasty in India looks promising with growing awareness, advancements in surgical techniques, and increasing adoption by healthcare providers. As technology improves and skills develop further, Oncoplasty will likely become more accessible across the country, enhancing the quality of care for breast cancer patients and improving cosmetic outcomes. However, challenges such as resource constraints and disparities in healthcare access must be addressed to ensure equitable distribution and utilization of Oncoplasty services. We have been providing quality Oncoplasty care for our patients. Most of our patients are from Coimbatore district, however some do come from far of regions because the do not have Oncoplasty facilities in their vicinity. Most of the breast cancer patients are presently being managed by Mastectomy, in many places, the numbers may be as high as 90%. If provided properly more than 60% of patients can be managed effectively with Breast Conservation and Oncoplasty. By raising awareness and enhancing access to Oncoplasty services, we strive to empower breast cancer patients with options for personalized, holistic care, thus contributing to overall community well-being. Dr. Shiva Kumar Kuppuswamy, Consultant Surgical Oncologist, Royal Care Super Speciality Hospital, Neelambur, Coimbatore-641062. Ph No: 9844127862 86
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World glaucoma awareness week is celebrated In the second week of March, with World glaucoma day on 7th March this year. This year the theme of glaucoma week is “ Uniting for a Glaucoma-Free Week” by the World Glaucoma Association and The Global Glaucoma Network. Glaucoma is the second leading cause of blindness, worldwide, second only to cataract. It is the first irreversible cause of blindness. The global prevalence is 3.54 % between 40 -80 years . This is estimated to increase 111.8 million by 2040. Glaucoma is known as a “silent thief of Sight” because it is an a symptomatic painless condition, Comprising a group of diseases that lead to the damage of Optic Nerve. The major respect to noted to be the increasing interocular pressures. Glaucoma is classified as Open angle , angle closure, secondary glaucoma. There are multiple risk factors for glaucoma , mosy important, modifiable risk factor is increased Intra ocular pressures. The pathophysiology of glaucoma is related to Retinal ganglion cell death related to increased resistance across the trabecular meshwork or to the pathways to aqueous outflow. Diagnosis of glaucoma can be done by various screening by tonometry, dilated fundus examination, and diagnostic tests like Pachymetry, Visual fields analysis and OCT RNFL etc. Treatment in early stages is with topical medication such as Topical Beta blockers, Prostaglandin analogos , Carbonic Anhydrase Inhibitors etc. Surgical treatment is reserved for patients with poor compliance, disease progression despite maximal medical therapy or disease resistant to medical management. Surgical management includes Filtering procedures such as Trabeculoplasty with or without use of chemotherapeutics. Filtering procedures with valves are being increasingly used now to avoid the adverse effects of hypotony and resulting complications, post filtering surgeries. It is imperative for all individuals to be aware about Glaucoma, its course of disease, leading to tunnel vision and functional blindness and the subsequent disease burden and reduction in quality of life. This making Glaucoma awareness and screening mandatory for those belonging to the high risk category and the general population, at large. Dr.Suhasini Consultant Ophthalmologist MGM Healthcare, Chennai 88
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