m.r ashrafi professor of pediatric neurology children’s medical center tehran university of...
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M.R AshrafiProfessor Of Pediatric Neurology
Children’s Medical CenterTehran university Of Medical Sciences
Neurologic Complications of Immunization
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Adverse Events Following Immunization / AEFI
Vaccine Reaction
Program Error
Coincidental
Injection Reaction
Unknown
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AEFI / Neurologic Complications Vaccine Reaction
Hypotonic-Hyporesponsive Episode
Persistent Crying Seizure Encephalopathy Paralytic poliomyelitisGuillaine-Barre Syndrome
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Hypotonic-Hyporesponsive Episode
Worrisome uncommon shock-like reaction to DTP
Occurs within 24 hours with a mean interval of 12 hoursIncidence of 0.06 % of DPT-immunized infants
Approximately one-half of infants are febrile
The episode subsides in minutes to at most 4 hours
Leaving no apparent residua
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AEFI / Neurologic Complications Vaccine Reaction
Persistent or high pitched crying of 1 hour or more was seen in 3.5 % of DPT-immunized infants .
Drowsiness was seen in approximately 32-62 % of DPT-immunized infants .
A transient increase in ICP , manifested by a bulging fontanel , has been encountered after DPT immunization .
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AEFI / Neurologic Complications Vaccine Reaction
The use of whole-cell pertussis vaccine has been associated with febrile and afebrile seizures , which are generalized and typically occur within 72 hours after immunization .
FS occur in 1 : 1750 immunization
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Acute Encephalopathy
Generalized febrile or nonfebrile convulsions , altered consciousness and serious neurologic or psychologic residua can occur within 72 hours of DPT immunization .
Incidence of 1 : 165000 immunization
The prognosis for survival is good
Major neurologic residua in 77 % of cases such as MR and epilepsy .
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Acute EncephalopathyAcute encephalopathy can follow
immunization with measles or MMR vaccine .Occur between 2 – 15 days after
immunization , and peak onset of encephalopathy on days 8 or 9 .
Seizures , altered behavior or consciousness and ataxia .
Death or mental regression is common No cases of encephalopathy have been
identified after administration of monovalent mumps or rubella vaccines .
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AEFI / Neurologic Complications Vaccine Reaction
Hypotonic-Hyporesponsive Episode
Persistent Crying Seizure Encephalopathy Paralytic poliomyelitisGuillaine-Barre Syndrome
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Vaccine Associated Paralytic Poliomyelitis / VAPP
Any case of AFP with onset of paralysis 4-30 days following receipt of OPV and the presence of neurological sequelae compatible with poliomyelities 60 days following paralysis onset and isolation of vaccine-derived poliovirus from the stools .
Serotype 3 is most frequently isolated poliovirus from patients with VAPP (60-90%)
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The following criteria must be fulfilled before diagnosis of VAPP
Paralysis should be clinically compatible with poliomyelitis (residual paralysis at 60 days )
Adequate stool negative for wild polioRuled out other illnesses Evaluation by expert committee
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Contact VAPP
Known contact with a vaccinee that received OPV 7-70 days before onset of paralysis of
the patient and the contact between the patient and vaccinee should have occurred 4-30 days before paralysis onset.
Half of the cases of VAPP reported from America are among contacts of vaccinated children
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VDPV (Vaccine-derived poliovirus )
Usually 1-15% differences from parent OPV strains
Classified as wild.Extensive period of virus excretion or
transmission.
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AEFI / Neurologic Complications Vaccine Reaction
Hypotonic-Hyporesponsive Episode
Persistent Crying Seizure Encephalopathy Paralytic poliomyelitisGuillaine-Barre Syndrome
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GBS study group diagnostic criteria
Required for diagnosis :
Progressive motor weakness involving
more than one extremity
Areflexia or marked hyporeflexia
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GBS study group diagnostic criteriaStrongly supportive of diagnosis :
Initial absence of fever
Progressive over days to a few weeks
Onset of recovery 2-4 weeks after cessation
of progression
Relatively symmetric weakness
Mild sensory sign and symptoms
Cranial nerve palsies
Autonomic dysfunction
Elevation of CSF protein after one week of symptoms
Slowed NCV
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GBS / Etiology
Two-thirds of patients report an antecedent , acute
infectious illness , most commonly a respiratory tract
infection or gastroenteritis .
The interval between the prodromal infection and the
onset of GBS symptoms varies between 1-3 weeks .
CMV is the most common viral trigger of GBS .
C.Jejuni is recognized as the most frequent antecedent
pathogen for GBS .
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Preceding Events
Infection
Campylobacter Jejuni
Cytomegalovirus
EBV / HIV / VZV / Lyme Disease
Vaccination
Rabies / Swine Flu / Tetanus / OPV / Meningococcus
Neoplasia
Lymphoma / Hodgkin Disease
Drug
Captopril / Danazole / Penicillamine /Amitriptyline
Heavy metals / Nitrofurantoin / Hydralazine
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Adverse Events Following Immunization / AEFI
Vaccine Reaction
Program Error
Coincidental
Injection Reaction
Unknown
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AEFI / Neurologic Complications injection Reaction / Faint
Syncope is defined as a sudden loss of consciousness and postural tone , because of transient cerebral hypoperfusion , followed by spontaneous recovery .
Syncope is rare in childhood and more common in adolescence particularly in girls .
Syncope is seen in about 15 % of individuals under the age of 18 years.
30 to 50 % of children have at least one episode of syncope by adolescence .
Vasovagal (75 % )ReflexDecreased venous returnCardiac
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Syncope & Faint Vasovagal ( Neurocardiogenic Syncope ) Triggered by pain & emotional upset .
Reflex Hyperventilation , violent coughing , hot bath , defecation and micturition .
Reduced venous return Valsalva maneuver
Cardiac syncope Cardiac asystole ( Stokes-Adams Syndrome)ArrhythmiaLeft ventricular outflow obstructionAnemiaProlonged QT interval : Romano-Ward syndrome ( AD) Jervell-Lange-Nielsen Syndrome ( AR )
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Syncope & Faint Prodromal phase or presyncope
Light-headedness , blurred vision , epigastric discomfort , nausea , pallor , diaphoresis .
Loss of consciousness
Is usually brief ( few seconds to 1-2 minutes ) followed by rapid spontaneous recovery without persistent neurologic deficits .In 40 % of cases syncopal attacks are accompanied by a convulsion. ( usually tonic spasm , less often clonic or TC )
Postictal period
May be accompanied by nausea , pallor and diaphoresis .
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Adverse Events By DPT Vaccine
Event Conclusion Evidence indicates causation Anaphylaxis prolonged crying Febrile SeizureEvidence consistent with causation Acute
encephalopathy HHEEvidence does not indicate causation Afebrile Seizure Infantile Spasm SIDS Reye Syndrome
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Adverse Events By DPT Vaccine
Event Conclusion Insufficient evidence to Aseptic meningitis draw a conclusion Chronic neurological
damage
Epilepsy GBS Peripheral mononeuropathy Hemolytic anemia Thrombocytopenia Juvenile Diabetes Learning or attention
disorders Erythema multiform
No evidence available either way Autism
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AEFI / Neurologic Complications Sudden Infant Death Syndrome
SIDS is defined as the sudden death of an infant that is unexpected by history and unexplained by a thorough postmortem examination , which include a complete autopsy , investigation of the scene of death , and review of the medical history .
Infants are at greatest risk of SIDS at 2-4 months of age , with most deaths having occurred by 6 months .
Male infants are 30-50 % more likely to be affected than females .
The actual risk for SIDS in individual infants is determined by complex interactions between genetic and environmental risk factors .
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AEFI / Neurologic Complications Sudden Infant Death Syndrome
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AEFI / Neurologic Complications Sudden Infant Death Syndrome
No association between
immunization and SIDS
has been found .
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Diazepam IV / PR / IO IV : 0.1 to 0.3 mg/kg /dose every 10-15 min
PR : 0.2 to 0.5 mg/kg/dose
Maximum dose of DZP is 10 -20 mg/dose .
DZP should be administered at a rate of 1-2 mg/min .
DZP stops seizure within 5 to 10 min in 80 % of status .
Median time to stop seizure : 2 min
Peak effect : 1 to 5 min
Duration of action : 20 to 30 min
A longer acting AED should be given if DZP
successfully stops the status .
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Rectal DiazepamRectal diazepam is an effective and safe treatment for
prolonged seizures outside the hospital .
It achieves blood levels adequate for seizure treatment
more rapidly than any route except for IV one .
It has FDA approval for acute repetitive seizures
but not for Status .
Reports mention its successful use in status .
•Buccal and intranasal midazolam are other treatment options .
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