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I’m not going to talk much about whole cell DTP vaccine because it’s the old vaccine. Now what’s recommended and is preferred is to use the acellular vaccine because there are less reactions to it. The whole cell vaccine contains endotoxin and does have more reaction. Given in the same series as the acellular vaccine, has the same contraindications and precautions and similar efficacy. But it does have a lot of reactions, as shown in this table. This is a study by Cody and colleagues showing really the high rates of reaction to whole cell DTP vaccine; up to 50% local reactions, half the patients with fever and then systemic reactions, such as drowsiness, irritability, persistent crying. Again, a lot of these reactions due to endotoxin. Give the acellular pertussis component vaccine, you get less reaction and that’s why it’s preferred. But because it’s so reactagenic, in the past it’s been blamed for a lot of other things. Just to clear up some misconceptions; pertussis-containing vaccines do not cause sudden infant death syndrome. Pertussis-containing vaccines do not cause brain damage. There is no causal link between any pertussis component vaccine and brain damage. In the past some practitioners have given half doses of DTP vaccine in an attempt to prevent reaction. Half doses have not been well studied. The immunogenicity and efficacy of that is not well known and therefore you should not give half doses of vaccine. Give the regular dose.
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Now polio vaccine; this is also one of these areas that is really in a state of flux, and a good portion of the polio discussion in the syllabus is about OPV, oral polio vaccine, live vaccine. And there are some changes in that regard that are coming up and therefore for Board review purposes, you have to realize it takes a while for these Board tests to catch up with what’s going on. So if you know the latest information, that’s fine. And if you know the old information, that’s fine too. You are not going to be dinked on that if it’s a transitional period and that’s where we are right now, in a transitional period. What you need to know is that the oral, live vaccine is a very good vaccine but it has a rare side effect. And that’s that the oral vaccine may mutate into a virulent form and cause vaccine-associated paralytic polio. This occurs rarely so the benefits of this vaccine outweigh the risks. However, in this day and age when we’ve done such an excellent job in eliminating polio from this country, the risks of vaccine are no longer acceptable. That’s why now we don’t recommend the oral vaccine and as of January 1st 2000, recommend that all four doses of polio vaccinations should be with the killed vaccine, the inactivated polio vaccine administered subcutaneously. The killed vaccine has no risk of reversion to the wild type, virulent strain. No risk of causing paralytic polio. The current schedule, however, – and in the syllabus and on this slide – until Y2K, is to give the first doses of IPV at two months and at four months of age. The second doses, personal choice; either OPV or IPV and I’m not going to go into the logistics of 6-18 months, 12-18 months and 4-6 years. Really what’s going to happen after January 1st is you should just give two months, four months, 6-18 months is the third dose of IPV and 4-6 years for the fourth dose of IPV. And then somebody will be up to date. Until then, the second two doses may be oral polio vaccine.
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Precautions and contraindications are specific really for the oral polio component, which again is sort of out of date. But IPV should be used only for immunocompromised subjects or household contacts. The oral vaccine may multiply and can be transmitted person to person, and so should not be given if there is anybody immunocompromised, such as with HIV infection, in the household. In pregnancy there is a theoretical risk and so one should avoid vaccination if possible.