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Childhood Immunization in the Kingdom of Saudi Arabia

1994; King Faisal Specialist Hospital and Research Centre; Volume: 14; Issue: 2 Linguagem: Inglês

10.5144/0256-4947.1994.91

0975-4466

Haysam Tufenkeji, Hoda Kattan,

Immune responses and vaccinations

EditorialChildhood Immunization in the Kingdom of Saudi Arabia Haysam Tufenkeji and FAAP Hoda KattanFRCPC Haysam Tufenkeji Search for more papers by this author and Hoda Kattan Search for more papers by this author Published Online:1 Mar 1994https://doi.org/10.5144/0256-4947.1994.91SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionVaccination is now recognized as being one of the most important and cost effective health promotion activities. The World Health Organization (WHO) estimates that current immunization programs save more than 3.2 million lives annually and that full utilization of existing vaccines could save an additional 1.7 million lives per year.1Vaccination as a deliberate attempt to protect humans against disease has a long history, although only in the 20th century has the practice flowered into routine use in large populations. In 1976G, Edward Jenner demonstrated that when a material was taken from a human pustular lesion caused by cowpox (i.e., an orthopox virus) and inoculated into the skin of another person, it produced a similar infection and that on recovery the latter individual was protected against smallpox after challenge. Jenner called the material vaccine from the Latin word vacca (cow) and the process, vaccination.During the last 200 years, and since the time of Jenner, vaccination helped control major diseases throughout the world and in 1977G, and for the first time in the history of man, resulted in the triumphant eradication of the old scorch smallpox. In 1974G, the Expanded Program on Immunization (EPI) was launched by the WHO. The goal of the EPI was global universal immunization of children against tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, and measles. By 1990G, and largely due to the EPI efforts, 80% of children born in the world receive these six vaccines.1More recently, rapid advances in molecular biology made possible the development of more sophisticated vaccines. Of particular importance was a report by Burrell in 1979G of his successful cloning of hepatitis B viral antigen,2 which opened up the possibility of producing effective and safe vaccines against a variety of diseases. Because of the large number of vaccines under development, our discussion will focus on vaccines that are commercially available.Within a relatively short period of time, the Kingdom of Saudi Arabia made great strides in its program of childhood immunization. More than 90% of school age children are completely immunized and the incidence rates of vaccine preventable diseases had decreased by more than 90% from peak levels. Conformity with the EPI program, improved standard of living and health care throughout the country, and enforcement of the Royal decree that all children must complete their immunizations before issuance of their birth certificates have resulted in the almost complete eradication of diseases that hitherto were very common. Moreover, when accumulated data showed Saudi Arabia to be endemic for hepatitis B viral (HBV) infection, health authorities acted swiftly by incorporating HBV vaccine into the routine immunization schedule of young children in 1989G. By doing this, the Kingdom became one of the very few countries in the world to have adopted universal infant HBV vaccination. The current immunization schedule that was enacted in 1991G was the product of efforts made by the Ministry of Health (MOH) in collaboration with several major hospitals in the Kingdom in order to unify this practice (Table 1). In addition to the diseases represented in this schedule, Saudi Arabia is in a unique situation whereby campaigns have to be carried out annually prior to Haj season so that high levels of immunity among residents against infections, such as meningococcal disease, are maintained.Table 1 Current recommended schedule for routine immunization of young children in Saudi Arabia.AgeVaccinesBirthHBV, BCG6 weeksDPT, OPV, HBV3 monthsDPT, OPV5 monthsDPT, OPV6 monthsHBV, Measles12 monthsMMR18 monthsDPT, OPV4–6 yearsDPT, OPVHBV=hepatitis B vaccine; BCG=bacille Calmette-Guérin; DPT=diphtheria, pertussis and tetanus toxoid; OPV=oral polio vaccine; MMR=mumps, measles and rubella vaccine.On the basis of studies performed in Saudi Arabia on measles vaccine failure3 and the increased susceptibility of infants less than nine months of age to this infection,4 measles vaccine timing for the first dose was advanced to age six months provided the immunogenicity-superior Edmonston-Zagreb5 strain was used. A second dose in the form of combination vaccine with mumps and rubella was recommended at age 12 months to optimize immunity.In this issue of the Annals of Saudi Medicine, we present two reports on the ongoing campaign to eliminate yet another serious infectious disease -- poliomyelitis.6,7 These reports are timely when considered in the context of the declared commitment of WHO to the global eradication of poliomyelitis by the year 2000G. Although this objective has already been achieved in developed countries, WHO estimates that approximately 250,000 paralytic cases occur each year in developing countries. The report from Kuwait7 details the history of the disease in Kuwait over 3-1/2 decades, which culminated in its eradication in 1986G. The Kuwaiti experience is a commendable one and serves as an example for many of the developing countries to follow. The report from Saudi Arabia,6 on the other hand, focuses on the immunogenicity of the currently used oral polio virus (OPV) vaccine in 209 children representing five main regions in the Kingdom. As has been reported in developing countries previously, the immunogenicity of the vaccine, particularly for Type 3, was found to be suboptimal. Presence of a vaccine virus inhibitor in infants’ saliva, interference by other enteroviruses or by the presence of antibody in the breast milk, protein and cellular immunity deficiency have all been implicated in the cause of this unusual phenomenon. Possible options to overcome this problem include the use of parenterally administered killed vaccine (IPV), particularly the more immunogenic enhanced form (IVP-Ep), using a schedule combining IPV or IPV-Ep with OPV, or changing the ratio of the three Sabin strains in the OPV, especially that of Type 3, to provide better immune response. Disadvantages of the two former options are the increased cost of the injectible form and the relative complexity of administering two different vaccines. Moreover, change from current practice in the Kingdom is probably not indicated since with increased OPV coverage, reportable cases have declined from 102 in 1984G to two in 1992G.8 With projected OPV coverage of >95% by the end of 1994G and enforcement of strict surveillance, it is hoped that the Kingdom will meet the WHO eradication goal.Hemophilus influenzae type b (Hib) vaccine appears ready to be added to the EPI. Hib causes serious disease in young children and infants, especially during the first two years of life. Studies in Saudi Arabia suggest Hib is the most common cause of bacterial meningitis in children.9–12 After years of research and development, a vaccine for this disease was licensed in the United States in April 1985G. Although there was considerable controversy about the efficacy in the earlier polysaccharide version, the new conjugate vaccines have all been shown to be highly immunogenic and in large clinical trials some have proved to be effective in preventing Hib disease in young infants and children.13,14 Thus, conjugation to certain proteins results in an improved T-cell-dependent immune response. The four currently licensed vaccines in the United States and their properties are listed in Table 2. PRP-D is recommended for infants 12 months of age or older. In a recent article in the Annals of Saudi Medicine, this vaccine was found to be safe and highly immunogenic in Saudi children 17 to 19 months of age.15 The other conjugate vaccines are recommended for infants beginning at approximately two months of age in a primary series of two or three doses, depending on the product, and a booster at 12 to 15 months. More recently, and in keeping with the trend of developing multiantigen vaccines, HbOC-DPT combination vaccine was licensed for use in infants and in the same regimen as HbOC or DPT when administered separately. Antibody responses to the combination vaccine are similar to those observed in infants given two separate injections.16 Experience with Hib in Finland has already shown that as a result of the vaccine, the previously common Hib disease has become almost extinct in that country.17 Health care providers in Saudi Arabia are eager to share in this experience and are anticipating with hope the early approval and integration of Hib conjugate vaccine into the routine immunization schedule for children.Table 2 Hemophilus influenzae type b conjugate vaccines.AbbreviationCarrier ProteinTotal No. of DosesVaccine RegimenPRP-DDiphtheria toxoid1Only for infants ≥ 12 monthsHbOCCRM 197 (a nontoxic mutant diphtheria toxin)43 doses at 2 month intervals. Fourth dose at 12–15 months of agePRP-OMPOMP (an outer membrane protein complex of Neisseria meningitidis)32 doses at 2 month intervalsPRP-TTetanus toxoid43 doses at 3 month intervals. Fourth dose at 12–15 months of ageThe whole cell pertussis vaccines currently used in Saudi Arabia are prepared from inactivated cells of Bordetella pertussis and contain multiple antigens. Since the early 1970s, there has been undue growing concern, mostly within the lay press and the media, about serious reactions to the vaccine. Although minor side effects such as fever and local swelling are common, a causative relationship between the vaccine and severe neurologic reactions has not been established.18 Nevertheless, new acellular vaccines that contain one or more immunogens derived from the B. pertussis were developed. The acellular vaccine has recently been approved in the United States for the fourth and fifth doses for children older than 15 months and younger than seven years of age.19 If results in young children were substantiated in infants and if the cost was reasonable, consideration should be given to replacement of current vaccine with an acellular one in the immunization schedule.A new hepatitis A vaccine was found to be highly immunogenic and safe in healthy children.20 The vaccine may be administered to all children in endemic areas and may replace immunoglobulin as an effective method of prophylaxis. Since Saudi Arabia is endemic for hepatitis A, this vaccine needs to be evaluated for use in this country.The ultimate goal of the Children’s Vaccine Initiative that was prepared for the 1990 Summit of World Leaders on Children is to realize a single “supervaccine”.21 This vaccine could be given once at or near birth, provide immunity for life, require no boosters, permit storage without refrigeration, obviate needles and syringes and protect against as many as 20 diseases at once. While this seems to be a far away dream, each little step taken in vaccine development will bring this goal closer to reality.ARTICLE REFERENCES:1. UNICEF. State of the World’s Children 1992. New York: Oxford University Press; 1992;14. Google Scholar2. Burrell CJ, Mackay P, Greenway PJ, et al. "Expression in Escherichia coli of hepatitis B virus DNA sequences cloned in plasmid pBR322" . Nature. 1979; 279:43-47. Google Scholar3. Abanamy A, Khalil M, Salman H, Abdulazeem M. "Measles vaccine failure" . Ann Saudi Med. 1991; 11(3):311-3. Google Scholar4. Abanamy A, Khalil M, Salman H, Abdulazeem M. "Follow-up study for measles maternal antibodies and seroconversion after measles vaccination" . Ann Saudi Med. 1991; 11(1):51-3. Google Scholar5. Markowitz L, Sepulveda J, Diaz-Ortega JL, et al. "Immunization of six-month-old infants with different doses of Edmonston-Zagreb and Swartz measles vaccines" . N Engl J Med. 1990; 322:580-7. Google Scholar6. Khalil M, Al-Mazrou Y, Abanamy A, Abdel-Azeem M. "National serosurvey of postvaccination poliovirus antibody in Saudi Arabia" . Ann Saudi Med. 1994; 14(2):111-3. Google Scholar7. Al-Kandari S, Zaidi AHS. "Control of poliomyelitis in Kuwait" . Ann Saudi Med. 1994; 14(2):94-6. Google Scholar8. Ministry of Health. Saudi Epidemiology Bulletin. 1993; 1(8). Google Scholar9. Abomelha A, Uduman SA, Saleh MF, et al. "Childhood bacterial meningitis" . Ann Saudi Med. 1988; 8(4):274-8. Google Scholar10. Azubuike JC. "Childhood bacterial meningitis in Tabouk, Saudi Arabia" . Ann Saudi Med. 1990; 10(2):145-8. Google Scholar11. Abanamy A, Shuja M, Khaleel M, et al. "Childhood bacterial meningitis in Riyadh" . Ann Saudi Med. 1991; 11(6):628-32. Google Scholar12. Al-Jurayyan NAM, Al-Mazyad A, Al-Nasser M, et al. "Childhood bacterial meningitis in Al-Baha Province, Saudi Arabia" . 6th Annual Pediatric SymposiumRiyadh, Saudi Arabia1992. Google Scholar13. Black SB, Shinefield HR, Lampert D, et al. "Efficacy in infancy of oligosaccharide conjugate Hemophilus influenzae type b (HbOC) vaccine in a United States population of 61,080 children" . Pediatr Infect Dis J. 1991; 10:97-104. Google Scholar14. Santosham M, Wolff M, Reid R, et al. "The efficacy of Navajo infants of conjugate vaccine consisting of Hemophilus influenzae type b polysaccharide and Neisseria meningitidis outer membrane protein complex" . N Engl J Med. 1991; 324:1767-72. Google Scholar15. Frayha H, Shaheen H, Ganelin R, et al. "Clinical and serologic responses of Saudi children to Hemophilus influenzae type b capsular polysaccharide diphtheria toxoid conjugate vaccine" . Ann Saudi Med. 1993; 13(3):215-21. Google Scholar16. Paradiso P, Hogerman D, Madore D, et al. "Safety and immunogenicity in infants of a tetravalent vaccine composed of HbOC (HibTITER) and DPT (TRI-IMMUNOL) (abstract)" . Pediatr Res. 1992; 31(174A). Google Scholar17. Peltola H, Kilpi T, Antilla M. "Rapid disappearance of Haemophilus influenzae type B meningitis after routine childhood immunization with conjugate vaccines" . Lancet. 1992; 340:592-4. Google Scholar18. Wentz KR, Marcuse EK. "Diphtheria-pertussis-tetanus vaccine and serious neurologic illness: an updated review of the epidemiologic evidence" . Pediatrics. 1991; 87:287-97. Google Scholar19. Bernstein D, Smith V, Schiff G, et al. "Comparison of acellular pertussis vaccine as a booster in children 15 to 18 months and four to six years of age" . Pediatr Infect Dis J. 1993; 12:131-5. Google Scholar20. Horng YC, Chang MH, Lee CY, et al. "Safety and immunogenicity of hepatitis A vaccine in healthy children" . Pediatr Infect Dis J. 1993; 12:359-62. Google Scholar21. Robbins A, Freeman P, Powell K. "International childhood vaccine initiative" . Pediatr Infect Dis J. 1993; 12:523-7. Google Scholar Next article FiguresReferencesRelatedDetailsCited byAl Arishi H, Frayha H, Qari H, Al Rayes H, Tufenkeji H and Harfi H (1996) Clinical Features and Outcome of Eleven Patients with Disseminated Bacille Calmette-Guérin (BCG) Infection, Annals of Saudi Medicine, 16:5, (512-516), Online publication date: 1-Sep-1996. Volume 14, Issue 2March-April 1994 Metrics History Published online1 March 1994 InformationCopyright © 1994, Annals of Saudi MedicineThis work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.PDF download