12. DR. Dr. Iris Rengganis SpPD KAI, FINASIM Vaccinology Workshop Sept 2017

Cur ric ulum V it a e Cur ric ulum V it a e

  Nama : Dr. dr. Iris Rengganis, SpPD, K-AI, FINASIM TTL : Jakarta, 29 June 1958 Pendidikan:

• DU/S1 : FKUI 1983 DU/S1 : FKUI 1983
• Internis/S2: FKUI 1994
• Konsultan Alergi Imunologi: FKUI 2000
• Doctor/S3: IPB 2009 Riwayat Pekerjaan: Riwayat Pekerjaan:
• Puskesmas Kel. Cikoko, Kec.Mampang Prapatan, DKI,1984-1988
• Jakarta Hajj Hospital, Pondok Gede, DKI, 1995-1997
• FKUI/RSCM, DKI, 1998-sekarang
• Ketua Divisi Alergi dan Imunologi Klinik, Dept. Ilmu Penyakit Dalam, g g , p y ,

  FKUI/RSCM, September 2014-sekarang Organisasi:

• Pengurus Besar IDI (Ikatan Dokter Indonesia)
• Pengurus Besar PAPDI (Perhimpunan Spesialis Penyakit Dalam Indonesia) g ( p p y )
• Ketua Pengurus Besar PERALMUNI (Perhimpunan Alergi Imunologi Indonesia)
• Anggota PERALMUNI JAYA
• Pengurus IIF (Indonesian Influenza Foundation)
• Anggota WAO (World Allergy Organization) gg ( gy g )
• Board Member of APAAACI (Asia Pacific Association of Allergy, Asthma and Clinical Immunology)

  

Vaccinology Vaccinology Workshop Workshop

Wh Ad lt V i Wh Ad lt V i Why Adult Vaccines are Why Adult Vaccines are

Important Important Important Important

Iris Rengganis

  

Division of Allergy and Clinical Immunology

Department of Internal Medicine

Faculty of Medicine, University of Indonesia

Dr.Cipto Mangunkusumo Hospital

  

A History of Vaccine Development A History of Vaccine Development

Vaksinasi V ksi Vaksinasi pada V ksi si si pada Dewasa d D d D Dewasa s s Pierce G dan Schaffner

  Kurangnya perhatian imunisasi usia dewasa karena: Kurangnya perhatian imunisasi usia dewasa karena: Keraguan keamanan vaksin

  Ganti rugi yang tidak memadai /asuransi G ti i tid k d i / i Belum berkembang sistem imunisasi dewasa

Vaksinasi Vaksinasi

  Adalah suatu cara untuk meningkatkan kekebalan seseorang secara aktif terhadap suatu antigen, sehingga bila kelak terpajan pada antigen yang serupa, tidak terjadi penyakit. pada antigen yang serupa, tidak terjadi penyakit.

Tujuan Vaksinasi Tujuan Vaksinasi

  Untuk mencegah terjadinya penyakit tertentu pada seseorang, masyarakat/populasi atau bahkan melenyapkan penyakit tertentu dari y p p y dunia seperti cacar.

  Antigen B-cell CD4 CD4 Extra cellular Extra cellular Antibody pathogens production T-helper cell _CD4 Activated T-Helper 2-cell Memory _CD4 B-cell B ll

  A ti Antigen- Intra presenting cellular Activated cell T-Helper 1-cell pathogens Memory _{TCR CD 8}

  T cell T-cell Vaccine Vaccine Cytotoxic Cytotoxic Activated Antigen T-cell Virus-infected Cytotoxic T-cell Immunogenic Immunogenic Target-cell

  Antigen B-cell Extra cellular CD4 Antibody pathogens production p T-helper cell _CD4 Activated T-Helper 2-cell Memory _{CD4 CD4} B-cell

  Antigen- Intra presenting cellular Activated Activated cell T-Helper 1-cell pathogens Memory _{TCR CD 8}

  T-cell Vaccine Cytotoxic Activated Antigen T-cell Virus-infected Cytotoxic T-cell y Immunogenic Immunogenic Immunogenic Immunogenic Target-cell

  Antigen Adjuvant Preservative St bili

  Bahan ACTIVE Bahan

  INACTIVE Antigen Adjuvant pengawet Stabilizer

• Mikroorganisme yang dilemahkan atau dimatikan

  Memperkuat vaksin- imunitas

  Mencegah pertumbuhan bakteri atau

  Menjaga efektifitas vaksin selama

• Komponen antigen dari mikroorganisme terinduksi bakteri atau fungi penyimpanan

  Adapted from: Plotkin SA,Orenstein WA, _eds.

  Vaccines 3 ^{rd ed.;1999: 40-46}

Imunisasi Imunisasi pasif pasif dan dan ak ak tif tif p p Imunitas alami Imunitas artifisial Aktif Pasif

  Aktif Pasif Setelah Transfer Pemaparan Injeksi Infeksi antibodi melalui placenta Pemaparan antigen Imunisasi Injeksi antibodi Imunisasi f Aktif Pasif

Imunisasi pasif Imunisasi pasif Imunisasi Imunisasi pasif pasif Kerugian :

  Proteksi jangka pendek, tidak ada sel memori Harga mahal

  di

  Efek samping Efek samping

  o o trasi antib Konsen

  4

  8

  12

  16

  20 Minggu Injeksi

  

Imunisasi Aktif Imunisasi Aktif / / Vaksinasi Vaksinasi

Keuntungan :

  Proteksi jangka panjang Murah dan efektif

   antibodi

  Aman Aman

  nsentrasi o o K

  4

  8

  12

  16

  20 Minggu Injeksi vaksin

Sifat yang Sif t Sifat Sif t yang dibutuhkan dib t hk dibutuhkan vaksin dib t hk vaksin k i k i Vaksin yang ideal :

  I Imunogenik ik i i f k i l i → meniru infeksi yang alami

  Memberikan proteksi jangka panjang Tidak memberikan efek samping yang tinggi Stabil

  Various Various Types  of Adult Vaccines Types  of Adult Vaccines

Type of Vaccines Type of Vaccines yp yp Vaksin virus

• Hidup yang dilemahkan
• Inaktif / dimatikan
• Sub unit
• Sub unit

Vaksin bakteri

• Sel utuh
• Toxoid
• Sub-unit
• Polisakarida

  Vaksin kombinasi (MMR) ( )

Klasifikasi Vaksin Klasifikasi Vaksin Vaksin Bakteri Vaksin Bakteri Vaksin Bakteri Vaksin Virus Vaksin Virus Vaksin Virus Campak Campak Campak OPV OPV OPV BCG BCG BCG

  Parotitis Parotitis Parotitis Parotitis Parotitis Parotitis Yellow Yellow Yellow Vaksin Vaksin Rubela Rubela Rubela Fever Fever Fever Varisela Varisela Varisela Hidup Hidup Influenza Influenza Influenza Influenza Influenza Influenza HPV HPV HPV Difteria Difteria Difteria Difteria Difteria Difteria Meningo Meningo Meningo Meningo Meningo Meningo Infuenza Infuenza Infuenza Vaksin Vaksin Tetanus Tetanus Tetanus Pneumo Pneumo Pneumo Hepatitis A Hepatitis A Hepatitis A Inaktif Inaktif Pertusis Pertusis Pertusis Hib Hib Hib Hepatitis B Hepatitis B Hepatitis B Kolera Kolera Kolera Typhim Vi Typhim Vi Typhim Vi yp yp yp Rabies Rabies Rabies

Adjuvants Adjuvants Adjuvants Adjuvants

  Substance added to many vaccines to S b t dd d t i t increase their immunogenicity and efficacy Aluminium salts (alum) have been widely used as adjuvants Aluminium salts (alum) have been widely used as adjuvants and are generally considered safe Aluminium salts have limitations in terms of adjuvant effect Aluminium salts have limitations in terms of adjuvant effect Wide range of novel adjuvants now being evaluated for use in new or improved vaccines: immunostimulators, p

  , microparticulate carriers and emulsions as well as various combinations of these. _{http://www.who.int/vaccine_safety/topics/adjuvants/en/index.html (Accessed Oct 2006)} WHO website. Global Advisory Committee on Vaccine Safety; Adjuvants.

Ajuvan Ajuvan jj Respon Ajuvan

  ibodi ntasi ant e e

Respon Primer

  Kons

  2

  4

  6

  8

  10 Minggu Vaksinasi V k i i

  Why Vaccinate ? Why Vaccinate ?

  25

  Vaccine Preventable Disease Vaccine Preventable Disease i i i i

  Hepatitis Hepatitis A  A Hepatitis  B Typhoid  Fever Varicella Influenza Meningococcal Meningococcal Pneumococcal

  26

  

Principles of Vaccination Principles of Vaccination

General General Rule  Rule

  All  vaccines can be administered at the  same same visit as all other vaccines  visit as all other vaccines

  Epidemiology  and Prevention of Vaccine‐Preventable Diseases. Chapter 2 General Recommendation.  National  Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

  Nonsimultaneous Administration of Nonsimultaneous Administration of Two Live Parenteral Two Live Parenteral Vaccines Vaccines Administration of live vaccine should be given on same time.

  Interference can occur Interference can occur between two live vaccines given less between two live vaccines given less than 28 days apart.

  If two live parenteral vaccines (MMR, MMRV, varicella, zooster, p ( yellow fever), or live intranasal influenza vaccine, are given less than 28 days apart the vaccine given second should be repeated. Exception is yellow fever vaccine given less than 4 weeks after measles vaccine.

  Epidemiology  and Prevention of Vaccine‐Preventable Diseases. Chapter 2 General Recommendation. 

  

Principles of Vaccination

Principles of Vaccination

  Increasing  the interval between doses of a multidose vaccine

   does not diminish the effectiveness of the vaccine

• Ex:  Hepatitis B vaccine 0,1,6  Æ 0, 2, 6?

  Decreasing  the interval between doses of a multidose vaccine

   may interfere with antibody response and  protection protection

  Ex:  Hepatitis B vaccine 0,1,6  Æ 0,1,2? Epidemiology  and Prevention of Vaccine‐Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization and 

  VACCINES

  VACCINES

  Prefilled Syringes Samples Prefilled Syringes Samples y g p y g p

NEEDLES

  Hub Glue Canula Disposable Needle Softpack needle _{Needles conditioned by 5 into a are used for syringe by 10} soft plastic packaging. They _{are only used for syringe by hard plastic packaging. They hard plastic packaging They Sole needle conditioned into a} Hardpack needle _packs. one packs.

NEEDLES Needle size 23G1

  Diameter : 0.6 mm ; length : 25 mm. g Usually for adults and adolescents.

  Needle size 25G5/8. Diameter : 0.5 mm ; length : 16 mm. Usually for pediatric vaccines. y p Needle size 25G1.

  Diameter : 0.5 mm ; length : 25 mm. Usually for paediatric vaccines.

  

Vials Samples Vials Samples

  Need  to be reconstituted

  Need  to be reconstituted

Screening Questions Example Screening Questions Example Screening Questions Example Screening Questions Example

  Is the child (or are you) sick today? Does the child (or are you) have an allergy to any medications, food, or any vaccine? Has the child (or are you) had a serious reaction to a vaccine in the past? Is the child/teen (or are you) pregnant or is there a chance she could become pregnant during the next month? Does the child (or are you) have cancer, leukemia, AIDS, or any other immune system problem?

  Epidemiology  and Prevention of Vaccine‐Preventable Diseases. Chapter 2 General Recommendation. 

  Berbagai cara B b Berbagai B b i i cara pemberian pemberian vaksin b i b i vaksin k i k i - Intramuskular - Subkutan S bk t - Intradermal - Intradermal - Intranasal - Oral

  

Subcutaneous injection Subcutaneous injection

Epidemiology  and Prevention of Vaccine‐Preventable Diseases. Appendix D  Vaccine Administration. 

  Intramuscular injection Intramuscular injection Intramuscular injection Intramuscular injection Epidemiology  and Prevention of Vaccine‐Preventable Diseases. Appendix D  Vaccine Administration. 

  

VACCINE STORAGE &

HANDLING HANDLING

  

VACCINE STORAGE &

Storing the Vaccines Storing the Vaccines

  th CDC: Oct  Vaccine Storage and Handling Toolkit. Accessed 14  2009: 

Managing Vaccine Storage Managing Vaccine Storage

  CDC:  Vaccine Storage and Handling Toolkit. Accessed 14 ^th Oct  2009: 

Expiration Date (1) Expiration Date (1) Expiration Date (1) Expiration Date (1)

  Vaccine may be used Vaccine may be used up to and including the expiration date up to and including the expiration date

_{http://www2a.cdc.gov/vaccines/ed/shtoolkit/pages/inventory_management.htm ( Accessed 10 Nov 2009)}

_{Inventory Management. Centers for Disease Control and Prevention. Downloaded at:}

Vaccine storage and handling toolkit. National Centre for Immunization and Respiratory Diseases. Vaccine

  Expiration Date (2) Expiration Date (2) p

( ) p

( ) EXP: 10/2010 EXP BY: 10/2010 EXP BEFORE: 10/2010 E i ld b E i ld b E i ld b E i ld b E i ld b Expiry would be Expiry would be 31/10/2010 31/10/2010 Expiry would be Expiry would be 30/9/2010 30/9/2010 Expiry would be 30/9/2010 Use through 31/10/2010 DO NOT

  Use through 30/9/2010 DO NOT ft 1/10/2010 DO NOT use on or after 1/11/2010 DO NOT use on or after 1/10/2010

NHS. Vaccine Handling Recommendations for Clinics, Hospitals, Community Pharmacies and GP Practices July 2007.

Vaccine Transport Vaccine Transport p p

  y

  Be sure to place an insulating barrier between the refrigerated/ frozen packs and the vaccines to prevent accidental freezing.

  y

  Th l The layer should be as follows h ld b f ll refrigerated/frozen packs-barrier- vaccine-thermometer-barrier- additional refrigerated/frozen packs. additional refrigerated/frozen packs

  y

  Pack vaccines in their original packing on top of the barrier. on top of the barrier

  y

  Do not remove vaccine vials from boxes.

  Vaccine Storage Practice in Vaccine Storage and Handling Tool Kit by NCIRD

Disposal Disposal

  y y Dispose of sharps immediately Dispose of sharps immediately after use at the point of care. after use at the point of care. y y

  Needles and syringes must be Needles and syringes must be disposed of as a single unit. disposed of as a single unit. disposed of as a single unit. disposed of as a single unit. y y

  Do not over fill the sharps bin or Do not over fill the sharps bin or fill beyond the fill line. fill beyond the fill line. y y

  L Lock and tag the bin to identify Lock and tag the bin to identify L k d k d h h bi bi id id if if the clinic source when full for the clinic source when full for disposal. disposal. p p y y

  Full sharps bins must be stored in Full sharps bins must be stored in a secure locked area away from a secure locked area away from the public the public the public the public

  Unsafe Immunization Practices Unsafe Immunization Practices

Vaccine Adverse Reactions

• extraneous effect caused by vaccine

  Adverse Adverse Ad Ad

• side effect

• • reactogenicity g y

  reaction reaction reaction reaction

• any event following vaccination
• may be true adverse reaction

  Adverse Adverse

• may be only coincidental b l i id l

  event event

• KIPI

  Epidemiology  and Prevention of Vaccine‐Preventable Diseases. Chapter 2 General Recommendation. National Center 

Vaccine Adverse Reactions Vaccine Adverse Reactions Vaccine Adverse Reactions Vaccine Adverse Reactions Allergic Allergic

  Due to vaccine or vaccine component ◦

  Rare ◦

  Risk minimized by screening y g ◦

  Epidemiology  and Prevention of Vaccine‐Preventable Diseases. Chapter 2 General Recommendation.  National  Center for Immunization and Respiratory Diseases. CDC. Revised April 2009.

Vaccine Adverse Events Vaccine Adverse Events Systemic Systemic Local Local

  pain, swelling, fever, malaise, redness at site headache of injection of injection common with nonspecific nonspecific inactivated vaccines may be usually mild unrelated to and self- vaccine limited

  Epidemiology Epidemiology Preventable _{and and}  and Prevention of Vaccine‐‐Preventable Diseases. Chapter 2 General Recommendation. National Center for Immunization   and Prevention of Vaccine  Diseases. Chapter 2 General Recommendation. National Center for Immunization   Respiratory Diseases. CDC. Revised April 2009.  Respiratory Diseases. CDC. Revised April 2009.

Keuntungan Vaksinasi Keuntungan Keuntungan Vaksinasi Keuntungan Vaksinasi Vaksinasi

  Melindungi individu Melindungi komunitas – herd immunity (80%

  yang divaksinasi dari populasi) yang divaksinasi dari populasi)

  Menurunkan angka kesakitan dan kematian

  

Herd Immunity (1) Herd Immunity (1) y ( ) y ( )

  

Herd Immunity (2) Herd Immunity (2) Herd Immunity (2) Herd Immunity (2)

  

Herd Immunity (3) Herd Immunity (3) Vaccines don't just protect yourself. Vaccines don't just protect yourself. Most vaccine Most vaccine--preventable diseases are spread from person to person. If one preventable diseases are spread from person to person. If one

person in a community gets an infectious disease, he can spread it to others who person in a community gets an infectious disease, he can spread it to others who person in a community gets an infectious disease, he can spread it to others who person in a community gets an infectious disease, he can spread it to others who

are not immune. are not immune.

  But a person who is immune to a disease because she has been vaccinated can’t get that disease and can’t spread it to others. The more people who are vaccinated, the fewer opportunities a disease has to spread. vaccinated the fewer opportunities a disease has to spread

  If one or two cases of disease are introduced into a community where most people are not vaccinated, outbreaks will occur. During a sneeze, millions of tiny droplets of During a sneeze, millions of tiny droplets of g g , , y y p p water and mucus are expelled at about 200 water and mucus are expelled at about 200 miles per hour (100 metres miles per hour (100 metres per second). The per second). The droplets initially are about 10 droplets initially are about 10--100 100 micrometres micrometres diameter, but they dry rapidly to droplet nuclei of diameter, but they dry rapidly to droplet nuclei of diameter but they dry rapidly to droplet nuclei of diameter but they dry rapidly to droplet nuclei of 1--4 1 4 micrometres micrometres, containing virus particles or , containing virus particles or bacteria. This is a major means of transmission bacteria. This is a major means of transmission of several diseases of humans of several diseases of humans

  Influenza IS NOT Influenza IS NOT !!! !!!

  Common cold Common cold _{1 2} Common cold Presentation Influenza

  Clinical spectrum p Systemic y Local (only on the ( y

  respiratory tract)

  Onset Sudden Gradual Fever Usually high Usually mild

  Clinical manifestation Fever, chill, myalgia, Sneezing, nose or presentation t ti malaise, cough, sore throat l i h th t blockage, sinusitis bl k i iti Course of disease May be continuous Usually rapid and mild

  Complications Complications May be severe, e.g. May be severe e g Usually no or mild Usually no or mild

  pneumonia, exacerbation complications of chronic disease _{1. Dolin R. Influenza. In: Kasper L et al, eds. Harrison Principles of Internal Medicine 16th Ed. McGraw-Hill 2000; 137: 1066-71 Adapted from:} Severity of illness Tends to be more severe Usually mild _{Medicine 16th Ed. McGraw-Hill 2000; 170: 1059-65}

  

VACCINATION

  

VACCINATION

  

INFORMATION

  

INFORMATION

  

INFORMATION

  

INFORMATION

  Kongres PAPDI di Manado 2003: Konsensus Imunisasi Dewasa Establishment of Adult Immunization Task Force

Vaccinology Training untuk dokter umum dan

  spesialis spesialis Buku panduan vaksinasi dewasa

Upaya Upaya meningkatkan meningkatkan vaksinasi vaksinasi

  ƒ Meningkatkan kepedulian petugas

ƒ Meningkatkan kemampuan dan penyediaan vaksin

ƒ Vaksin murah, mudah dijangkau

  P d i t h i ƒ Pendanaan pemerintah - asuransi

  ƒ Acara khusus ƒ Memantau Program Imunisasi Nasional (PIN) ƒ Memantau Program Imunisasi Nasional (PIN) ƒ

  Penelitian dalam bidang pelaksanaan vaksin

  asi Agar dampak imunisasi besar → pemutusan rantai penularan → perlu vaksinasi massal

  

Klinik Imunisasi Dewasa Klinik Imunisasi Dewasa

Varisela

  

Gedung IRM, Ruang Prosedur Alergi Imunologi, RSCM

Jl. Diponegoro No. 71, Jakarta Pusat

Ph / Fax 021 3904546 Ph / Fax 021- 3904546

e-mail : alergi@centrin.net.id