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Immunisation

Asst Prof Dr Syed Abdul Khaliq


Paediatrics Department
Kulliyyah of Medicine, IIUM
Our brave new world????
Our brave new world????
SMALLPOX
Among the
The Few Last
Children in
Malaysia
Receiving
Smallpox
vaccine
Before smallpox vacination

Smallpox
•Caused by variola virus
•20-50% mortality
•Most survivors scarred with residual facial
marks, some left blind
Faces of the last cases of Smallpox**

Rahima Banu Ali Maow Maalin


16 Oct 1975 26 Oct 1977
Bangladesh Somalia
** Two laboratory acquired cases occurred in UK in 1978
Smallpox
9 Dec 1979 – WHO – Smallpox
eradicated
1980 – WHO – All countries cease
routine vaccination

1980
WHO, Peter
CDC/Barbara Rice
Davies
Videos
• Smallpox will kill you
• Smallpox patients
POLIO
POLIO 1919 ----------2000

12
Polio

13
Videos
• Growing up with Polio
• The Polio Story
• The Iron Lungs
PERTUSSIS
Videos
• The 100-day cough
• Elijah
• Pertussis
• Pertussis
DIPHTHERIA
DIPHTHERIA

Slide Prof Zabidi Azhar


Soal-jawab Vaksinasi | www.suhazeli.com 20
Videos
• The Strangling angel
HISTORY
Smallpox variolation – China
~ 3rd century A.D

Mortality rate of this technique: 0.5-2%


Mortality from Smallpox disease: 20-30%
Edward Jenner (1749–1823). Photo courtesy
of the National Library of Medicine
1796

Edward Jenner (1749–1823). Photo courtesy The hand of Sarah Nelms


of the National Library of Medicine
5 7 10 15 17 20

Jenner 1749-1823
DARK AGE OF EUROPE 5-15 RENNAISANCE AND AGE OF SCIENTIFIC GLORY

Vaksin diTurki 1000


Ibn AlHaytham 965-1040-mikroskop
Universiti diBaghdad 1004
ArRazi Paeds/imunologi /smallpox/measles 865-925
GOLDEN AGE ISLAM OTOMAN EMPIRE
8-13th 1453-1919
Ibn Sina 1030
AlGhazali
History of Immunisation
1796 Smallpox Jenner
1885 Rabies Pasteur
1892 Cholera Haffkine
1896 Typhoid Wright
1913 Diphtheria Behring
1921 Tuberculosis Calmette
1923 Diphtheria toxoid Ramon & Glenny
1923 Pertussis Madseu
1927 Tetanus) Ramon & Zoeller
1932 Yellow Fever Sellard & Laigret
1949 Mumps Smorodintsev
1954 Polio Salk
1957 Polio Sabin
1960 Measles Edmonston
1962 Rubella Weller, Neva & Parkmann
Vaccination Policies
WHO recommends vaccination against:
Diphtheria
Tetanus
Pertussis
In all countries
Polio
Measles
Hepatitis B
Hib disease
where it is a substantial burden
Tuberculosis
where TB is prevalent
Yellow fever
where the disease is endemic
Source: WHO Fact Sheet 288; Immunisation against diseases of public health importance. March 2005
HPV
Year Vaccine Introduction in Malaysia 2010
2010 DTaP-IPV-Hib
DTP-HB+Hib 2009
MMR & Hib 2006
2002
2000

1990
Hepatitis B
Rubella 1989
Measles 1986
1982
1980
Polio
1972
1970 Others to come:
DTP BCG • PCV ?
1960 1961 • RV ?
1960 • Meningococcal ?
Smallpox • Dengue ?
1950
1950
2009 Malaysian Immunisation Schedule
Birth 1mth 2mth 3mth 5mth 6mth 12mth 18mth 7yrs 15yrs

BCG

Hep B

DTaP

IPV

Hib

MMR
Sabah
Measles only

DT

JE Sarawak only 9 mo 10 mo 18 mo 4-5 yr

Tetanus
Latest MoH
Immunisation
Schedule
Vaccine successes
Polio - worldwide Measles - US
60
Reported cases (000s)

40

EPI implemented
20 Vaccine introduced

1980 1990 2000 1950 1960 1970 1980 1990 2000


Source: WHO Database 2007. Poliomyelitis global annual reported incidence and Pol3 Source: Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-
coverage, 1980-2006. Preventable Diseases.

Diphtheria – England & Wales


60
Reported cases (000s)

40
Vaccine introduced
20

1940 1960 1980 2000


Source: Dept of Health. Immunisation against infectious disease (The Green Book) 2006 edition.
Chapter 15
BASICS OF VACCINOLOGY
Definitions
• Adjuvant • Immunoglobulin e.g.,
• Adverse reaction – Human Normal
Immunoglobulin [HNIG]
• Antitoxin
– Human Specific
Immunoglobulin /
• Immunization Hyperimmune globulin
– Active • Toxoid
– Passive – modified bacterial toxin
Definitions
• Vaccine
• a suspension of live attenuated or inactivated
microorganisms or fractions thereof administered
to induce immunity and thereby prevent infectious
disease
• Vaccination
• the term used to refer to the administration of any
vaccine or toxin
Principles of Immunization

• Immunization denotes the process of inducing or


providing immunity artificially

• Protection from infectious disease

• Usually indicated by the presence of antibody


• Very specific to a single antigen
Principles of Immunization
Antigen
• A live or inactivated substance (e.g., protein,
polysaccharide) capable of producing an
immune response

Antibody
• Protein molecules (immunoglobulin) produced
by B lymphocytes to help eliminate an antigen
Principles of Immunization
Active
• Protection produced by the person's own immune
system, “usually” permanent
• Immunity and immunologic memory produced,
similar to the natural infection but without the risk of
disease
Passive
• Protection transferred from another person or animal
as antibody
• This will afford temporary protection
• In infancy, transplacental transfer is the most
important source
Active

39
Passive

40
Cara Bertindak
Serangan 2 Organisma

41
Sources of Passive Immunity
• Almost all blood or blood products

• Homologous pooled human antibody (immune


globulin)

• Homologous human hyperimmune globulin

• Heterologous hyperimmune serum (antitoxin)


Example: Antibody for Prevention of Respiratory
Syncytial Virus infection

• RSV-IGIV
– Human hyperimmune globulin
– Contains other antibodies

• Palivizumab (“Synagis”)
– Mouse monoclonal
– Contains only RSV antibody
Classification of Vaccines
viral or bacterial
• Live attenuated
• single dose e.g., BCG (related org, shared antigens)
• two doses if immunity likely to wane over time, e.g.,
rubella, measles
• three doses for a different reason: oral polio in
primary schedule because there are 3 serotypes of
poliovirus

• Inactivated
• multiple doses; a course typically consists of 3 doses,
+/- a subsequent booster
• primary response, secondary response
Live vaccine
• Attenuated agent (unstable)
• Amplification of response - gradual rise to peak response
then decline
• Variable but “long” duration of immunity -the immune
response produced is similar to that produced by the
natural infection

• There will be a booster effect with subsequent exposure


• There is a possibility of generalised /severe infection in
an immunocompromised individual
• There may be interference from circulating antibody with
the “take” of the vaccine
Inactivated Vaccines
Whole
• virus
• bacteria

• protein-based
– subunit
– toxoid
• polysaccharide-based
– pure
– conjugate
Inactivated Vaccines
• Cannot replicate
• There will be minimal interference from circulating
antibody
• In general they are not as effective as live vaccines

• Generally require 3-5 doses


• The immune response produced is mostly humoral
• Antibody titer falls over time
Examples of live and inactivated vaccines
Live Inactivated
• Viral • Viral
measles, mumps, rubella, polio, hepatitis A,
vaccinia, varicella, yellow
rabies, influenza
fever, oral polio, rotavirus,
(influenza “Flumist”,
not available outside • Bacterial (whole cell)
USA at present) pertussis, typhoid,
(cholera), (plague)
• Bacterial
BCG (oral typhoid)
Inactivated Vaccines
Fractional vaccines
• Subunit hepatitis B, influenza,
acellular pertussis,
(typhoid Vi), (Lyme)

• Toxoid diphtheria, tetanus


Polysaccharide Vaccines:
Derived from bacterial capsule

• pneumococcal
• meningococcal
• Haemophilus influenzae type b

(“New”) Conjugate polysaccharide vaccines


• Haemophilus influenzae type b
• meningococcal
• pneumococcal
Pure Polysaccharide Vaccines

• Not consistently immunogenic in children <2


years of age

• No booster response

• Produce antibody with less functional activity


than that produced by the infection

• Immunogenicity is greatly improved by


conjugation
Addition of 7-valent pneumococcal vaccine
to routine schedule of immunisations
• Children who attended hopitals in the greater Dublin area,
2002-2004
• Incidence of invasive pneumococcal disease: 10.6/100,000 -
2 deaths
• 61.4% <2 years; 76% < 5 years
• Reduced penicillin susceptibility in 15% - all were vaccine
serotypes
• Based on serotype data, in paediatric patients PCV7 would
prevent <90% of cases of sepsis, <82.5% meningitis, <59%
pneumonia

A safe and effective vaccine to be added to the infant schedule

Fitzsimons JJ, Chong AL, Cafferkey MT, Butler K.


Ir J Med Sci 2008;177:225-31
PCV7 would be cost effective
• Implementing a PCV7 vaccine programme with a
birth cohort of 61,000, would be expected to prevent
7703 cases of pneumococcal infection over 5 years –
costs avoided €2.05mi rising to €4.6mi allowing for
the effect of herd immunity

Economic evaluation of a universal childhood pneumococcal conjugate vaccination


strategy in Ireland
Tilson L, Usher C, Butler K, Fitzsimons J, O’Hare F, Cotter S, O’Flanagan D, Johnson H,
Barry M
Value Health 2008;May 16 [Epub ahead of print]
The need for a vaccine is determined by
the morbidity and mortality from the
natural infection

e.g., Contrast measles, rubella & hepatitis B


Measles: Morbidity & Mortality
Morbidity in 10% Mortality

• Otitis Media 5% • Notifications 2,161,542


• RTI 4%
• Deaths 365
• Convulsions 0.5%
• Other neurological
0.1% • Mortality Rate per 100,000
• Hospital Admission notified cases 16.9
1.4%
• Very small risk of SSPE
1 in 300,000 cases England & Wales, 1970 to 1988
Rubella: Morbidity & Mortality
Morbidity “benign illness”
• children Mortality
– thrombotic thrombocytopenic • due to the neurologic
purpura 1 in 500 manifestations [20-
• Adults: 50% of patients with these]
– acute polyarticular arthropathy
women > men
– chronic arthritis may
occasionally develop
Principal morbidity:
• Neurological
Congenital Rubella
– postinfectious encephalopathy
and encephalitis 1 in 4,700 to Syndrome
1 in 6,000
Hepatitis B: Morbidity & Mortality
Morbidity Mortality
• Up to 90% of vertically • approximately 1% of
infected infants may those hospitalised with
become chronic carriers acute HBV infection die
• Between 2-20% of • superinfection with delta
infected adults become agent [hepatitis D] may
chronic carriers lead to fulminant liver
• Carriers may develop failure
chronic hepatitis,
cirrhosis or HBV infection is a major
hepatocellular carcinoma economic burden
worldwide
Immunization: Protection of
• infants against the important infectious
diseases of childhood (early)
• adults and children against the
infectious hazards of travel (timely)
• susceptible or “at risk” adults and
children
• adults against certain infections that
may be acquired at work
HERD IMMUNITY
• When most people in community are immune
to a particular infection that is spread from
person to person, the natural transmission of
the infection is effectively inhibited
• Vaccine uptake rates >90% (measles 95%)
• Not tetanus!
MYTHS AND CONTROVERSIES
“I prefer to let my kids ‘build up’ their
immune system rather than get vaccines”
“Natural immunity is better than immunity
from vaccination”
INFECTION COMPLICATIONS
Diphtheria Myocarditis, Neuritis, Death 5-20%
Haemophilus Meningitis, Deafness, Death 2-5%
Influenzae
Mumps Meningitis, Encephalitis, Deafness,
Orchitis, Oophoritis, Pancreatitis
Polio Meningitis, Paralysis, Death 2-5%
Whooping Cough Encephalopathy, Fits, Pneumonia, Death
(Pertusis) 0.2%
Long Term Sequelae of
Natural Infections
SYNDROME LONG TERM COMPLICATIONS
Subacute Sclerosing Pan Encephalitis Fatal, late complication of natural
measles NOT caused by vaccine
Post Polio Syndrome New symptoms of pain, fatigue, and
weakness in 25 -40% of people who
survived polio. NO polio with vaccine
Shingles Late complication of natural chicken pox.
Less common after chicken pox vaccine

Chronic Hepatitis B 50% of children (and 90% of infants)


develop cirrhosis, liver failure, and liver
cancer. NIL with vaccine
MMR & Autism
The Truth about Dr Andrew Wakefield
Effect of Vaccine Scare
Malaysia, 2008–2012 1

350

300
Number of measles cases

250

200

150

100

50

0
Jul

Jul

Jul

Jul

Jul
Apr

Apr

Apr

Apr

Apr
Jan
Mar

Jun

Jan
Mar

Jun

Jan
Mar

Jun

Jan
Mar

Jun

Jan
Mar

Jun
Aug

Aug

Aug

Aug

Aug
Feb

Sep

Feb

Sep

Feb

Sep

Feb

Sep

Feb

Sep
Oct

Oct

Oct

Oct

Oct
Dec

Dec

Dec

Dec

Dec
Nov

Nov

Nov

Nov

Nov
May

May

May

May

May
2008 (N=332) 2009 (N=56) 2010 (N=74) 2011 (N=1573) 2012 (N=2112)
Lab & Epi=110 Lab & Epi=55 Lab & Epi=70 Lab & Epi=1530 Lab & Epi=1720
Clinically=222 Clinically=1 Clinically=4 Clinically=43 Clinically=392

Lab-confirmed Epi-linked Clinically confirmed


Source: National measles and rubella monthly country reports
1 Reports received for January toDecember 2012
Mercury Exposure
120

100
Milligrams

80

60

40

20

0
Breast Milk Vaccine Breast Milk Influenza

Source Robison et al NIC 2008


Aluminum Exposure
1st Six Months of Life
120

100
Milligrams

80

60

40

20

0
Breast Milk Formula Soy Formula Vaccines

Source Robison et al NIC 2008


Too many vaccines?
1900 1960 1980 2000
Smallpox ~200 ~200 - -
Diphtheria 1 1 1
Tetanus 1 1 1
Pertussis ~3,000 ~3,000 2-5
Polio 15 15 15
Measles 10 10
Mumps 9 9
Rubella 5 5
Hib 2
HBV 1
Varicella (69)
Pneumococcus (7)
Total ~200 ~3,217 ~3,031 46-49
Offit et al. Pediatrics 2002
Antigen overload ?
“Each infant would have the theoretical capacity to respond to
about 10,000 vaccines at any one time (107 B cells per ml
divided by 103 epitopes* per vaccine)”

Based on theoretical assumprions by


Cohn M, Langman RE. Immunol Rev. 1990;115:9-147

Therefore, if 11 vaccines were given to infants at one time, then


about 0.1% of the immune system would be “used up”

*Epitope – immunologically distinct regions of a protein


or polysaccharide
Are vaccines safe?
• Bath – 350 drown/year
• Breakfast – 200 choke & die/year
• Playing in the rain – 100 struck by
lightning/year
• Benefit-to-Risk ratio favours Vaccination
• Small risk for huge benefit!
Four Phases of Human Clinical Trials of
Vaccines

• Phase I: 20-100 people vaccinated


• Phase II: Hundreds studied. Establish
SAFETY & EFFICACY. Dose & Dosing
schedule
• Phase III: Randomised Double Blind
Control Trial involving thousands
• Phase IV: Establish SAFETY &
EFFECTIVENESS after general use
• Vaccine Adverse Event Reporting System (VAERS)
• Clinical Immunization Safety Assessment Centers
(CISA)
Immunisation in Malaysia
Threats
• Efforts to achieve good immunisation coverage will increasingly be
undermined by anti-vaccine activists who, operating mainly through the
internet, seek to cast doubts about vaccine safety and thus reduce
vaccine uptake.

80
Example of content in vaccine insert
• Active ingredient:
– A weakened form of chickenpox virus
• Inactive ingredient:
– Sucrose, hydrolysed gelatine, sodium chloride,
monosodium L-glutamate, sodium phosphate
dibasic, potassium phosphate monobasic,
potassium chloride, residual components of MRC-
5 cells including DNA and protein, sodium
phosphate monobasic, EDTA, neomycin, fetal
bovine serum.
Medical Research Council (MRC)-5
• Lung fibroblasts, taken from a 14-week old foetus. Aborted
due to serious maternal indication. Harvested in September
1966, in National Institute for Biological Standards and
Control, Hampstead Laboratories, Holly Hill, London, England
(Jacobs, J.P., Journal of Biological Standardisation, 1976, 4, 97-99)
• Foetal cells are used as they are able to replicate much more,
42-48 times before senescence
• Foetal cells are used for viral replication, unlike bacterias,
viruses are more difficult to culture, and some virus only
replicates in human cells.
• Now, no more foetal cells used, as the foetal cells harvested in
1960s are still kept and still duplicating
• It is not used as an ingredient, but used as a culture media
IMPORTANT ISLAMIC CONCEPTS
Concept of Dhorar (harm)
• Quranic Verses:
– Allah wants for mankind ease, and not difficulties
(Al-Baqarah)
– Don’t throw yourselves into disasters and
difficulties
• Purpose of sharia: to promote goodness and
prevent badness and difficulties (jalb al-
masalih wa dar’u al-mafasid)
Concept of Dhorar (harm)
• Fiqh Concepts and application
– Do not harm, or cause harm (la dhoror wa la
dhiror)
– Harm, permits the unlawful (adh-dhroruratu tubih
al-mahzurah)
– Harm (and the things it permits) are limited to its
limts (adh-dhoruratu tuqaddaru biqadariha)
Concept of origins
• The original rulings for anything is
‘permissible’ (al-aslu fi-l-ashya’ al-ibahah)
• The original rulings of anything related to
prayer and submission (to God) is not
permitted (Al-aslu fi-l-ibadah al-mamnu’)
• The original rulings of anything that gives
benefit is permissible (al-aslu fi-l-manafi’ al-
ibahah)
Concept of origins
• Everything is related to it’s initial intention (al-
umuur bi maqaasidiha)
Istihalah
• Literal = transformation and conversion of one material to other
material
• transformation of materials to other materials (non-reversible
transformation) (Qal’ahji, 1996).
• Zuhayli (1997) also defines Istihalah as transformation or conversion
of material to other material which involves conversion of the
composition and properties includes the conversion of filthy (najs)
materials into pure (thahir) materials.
• Hammad (2004) add that Istihalah is a transformation of filthy or
haram materials to other materials which include physical
appearance and its properties such as name, odor, taste, color and
nature.
• Therefore, Istihalah can be defined as a complete transformation
occurred physically and chemically (Aizat & Radzi, 2009).
Jamaludin, M. A., et al, 2011 2nd International Conference on Humanities, Historical and Social
Sciences IPEDR vol.17 (2011)
Istihalah
• Istihalah can be applied into various situations as agreed by
Hanafi, Maliki, Ibn al-’Arabi, Ibn Taimiyyah, Ibn al-Qayyim,
al-Syawkani and Ibn Hazm al-Zahiri school of thoughts.
They widely applied Istihalah method in natural and
synthetics transformation (Ibn Taymiyyah, 2005).
• As an example, the fermentation of wine to vinegar is
considered halal whether it undergoes natural or synthetic
process.
• Syafii and Hanbali school of thoughts tended to limit the
application of Istihalah in certain issues only. They only
accepted natural process of transformation without any
intervention of synthetic process. i.e. natural
transformation of wine to vinegar (al-Syarbini, 1994).
Istihlak
• The concept hyperdilution; when a ‘dirty’
material in small amount is mixed into a large
amount of ‘clean’ material. As such makes the
final material as ‘clean”.
Fatwa
• European Fatwa Council, and Islamic
Organisation of Medical Sciences ruled use of
porcine gelatine as permissible as it has
undergone istihalah.
• Majma’ fiqh (Saudi) allows istihalah, but has
reserves for gelatine, as they considers it as
incomplete transformation
European Fatwa Council - Gelatine
Q) The ingredients of some foods contain items which are denoted by the
letter “E” and a string of numbers. We were told that this denotes items
manufactured from Lard or Pork bone and marrow. If this is true, what is
the Shari’a ruling on such foods?
A) The items which carry the letter “E” and a string of numbers are additives.
Additives are more than 350 compounds, and could be either
preservatives, colouring, flavourings, sweeteners, etc. These are divided
into four groups according to their origin:
First: compounds of artificial chemical origin.
Second: compounds of vegetal origin
Third: compounds of animal origin
Fourth: compounds dissolved in Alcohol
• The ruling on all these compounds is that they do not affect the status of
these foods being Halal, due to the following:
The first and second groups are Halal because they originate from a
permissible origin and no harm comes from using these items.
European Fatwa Council - Gelatine
(Continued…)
• The third group is also Halal, because the animal origin does not remain the same
during the process of manufacturing. In fact it is transformed radically from its
original form to a new clean and pure form through a process called “chemical
transformation”. This transformation also affects the legal ruling on such
ingredients. Therefore, if the original form was unclean or Haram, the chemical
transformation changed it to another ingredient which requires a new ruling. For
instance, if alcohol changed and was transformed to vinegar, then it does not
remain Haram, but carries a new ruling according to the nature of the new
product, which is Halal.
• As for the fourth group, these items are usually colourings and are normally used in
extremely small quantities which dissolves in the final product form, which deems
it an excused matter.
• Therefore, any foods or drinks that contain any of these ingredients remains Halal
and permissible for the Muslim’s consumption. We must also remember that our
religion is a religion of ease and that we have been forbidden from making matters
inconvenient and hard. Moreover, searching and investigating into such matters is
not what Allah (swt) or His Messenger (ppbuh) ordered us to do.

European Fatwa Council - members
1. Professor Yusuf Al-Qaradawi, President of
ECFR (Egypt, Qatar) 17. Sheikh Dr. Ajeel Al-Nashmi (Kuwait)
2. Judge Sheikh Faisal Maulawi, Vice-President 18. Sheikh Al-Arabi Al-Bichri (France)
(Lebanon) 19. Sheikh Dr. Issam Al-Bashir (Sudan)
3. Sheikh Hussein Mohammed Halawa, General 20. Sheikh Ali Qaradaghi (Qatar)
Secretary (Ireland) 21. Sheikh Dr. Suhaib Hasan Ahmed (UK)
4. Sheikh Dr. Ahmad Jaballah (France) 22. Sheikh Tahir Mahdi (France)
5. Sheikh Dr. Ahmed Ali Al-Imam (Sudan) 23. Sheikh Mahboub-ul-Rahman (Norway)
6. Sheikh Mufti Ismail Kashoulfi (UK) 24. Sheikh Muhammed Taqi Othmani (Pakistan)
7. Ustadh Ahmed Kadhem Al-Rawi (UK) 25. Sheikh Muhammed Siddique (Germany)
8. Sheikh Ounis Qurqah (France) 26. Sheikh Muhammed Ali Saleh Al-Mansour
9. Sheikh Rashid Al-Ghanouchi (UK) (UAE)
10. Sheikh Dr. Abdullah Ibn Bayya (Saudi Arabia) 27. Sheikh Dr. Muhammed Al-Hawari (Germany)
11. Sheikh Abdul Raheem Al-Taweel (Spain) 28. Sheikh Mahumoud Mujahed (Belguim)
12. Judge Sheikh Abdullah Ibn Ali Salem 29. Sheikh Dr. Mustafa Ciric (Bosnia)
(Mauritania) 30. Sheikh Nihad Abdul Quddous Ciftci
13. Sheikh Abdullah Ibn Yusuf Al-Judai, (UK) (Germany)
14. Sheikh Abdul Majeed Al-Najjar 31. Sheikh Dr. Naser Ibn Abdullah Al-Mayman
15. Sheikh Abdullah ibn Sulayman Al-Manee’ (Saudi Arabia)
(Saudi Arabia) 32. Sheikh Yusf Ibram (Switzerland)
16. Sheikh Dr. Abdul Sattar Abu Ghudda (Saudi
Arabia)
European Fatwa Council - OPV
• European Council of Fatwa and Research (ECFR) which in 2003 opined that
“Out of piety, some brother Muslims in various parts of the world,
particularly in East Asia, have issued a fatwa that it is not permissible to
administer this vaccine (OPV) to children, due to the fact that porcine
trypsin is used in preparing it.”
• The Council argued as follows:
– a) what God forbids is the partaking of pork, and trypsin has nothing to do with pork
– b) even if we admit that trypsin is forbidden, the amount used in preparing the vaccine
is negligible, if one applies the rule that “when the amount of water exceed 2 qillas (343
litres)”, impurities no longer affect it”
– c) supposing that trypsin is unclean, it is thoroughly filtered, that it leaves no traces
whatsoever in the final vaccine d) in case the three arguments forwarded are still
insufficient, the haram (forbidden) is made permissible in cases of necessity. In their
concluding remarks they emphasized, “
• The Council urges Muslim leaders and officials at Islamic Centers not to be
too strict in such matters that are open to considered opinion and that
bring considerable benefits to Muslim children, as long as these matters
involve no conflict with any definite text.”
12/10/2018 JKN Pahang | www.suhazeli.com 98
Malaysian Fatwa Council
• Fatwa on Enoxaparine and Fraxiparine
• Fatwa on Meningoccal vaccine (Mencevax vs
Monumen)
• Fatwa on RotaTeq (Rotaviral vaccine) and
Biothrax (Anthrax vaccine)
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menegaskan bahwa kerajaan
mempunyai hak dari SEGI POLISI
dan UNDANG-UNDANG untuk
MEWAJIBKAN kepada anak-anak
kita.

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Re-emergence of diseases
UICID 2018| Duyung Marina |
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Poliomyelitis, 1974 - 2015
1977 - Last major outbreak of wild poliovirus (121 cases)
140 120

120
100

100
80

80
No. of cases

% coverage
60

60

40
40

20
20
3 imported cases
in 1992

0 0

Poliomyelitis case Immunisation Coverage

UICID 2018| Duyung Marina |


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UICID 2018| Duyung Marina |
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No of Cases

Marina |
250

150

0
50
100
200
300

1975
1976

www.suhazeli.com
1977

UICID 2018| Duyung


1978
1979
1980
1981
1982
1983
1 death
2015: 4 cases
2014: 2 cases

1984
1985
1986
1987
1988
1989
1990
1991
1992
1993

111
1994
1995

Year
1996
1997
1998
1999
2000
2001
2002
Diphteria Cases, 1975 – 2015

2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Nombor insiden

500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
4,000,000
4,500,000
5,000,000

0
Tahun 1980
Tahun 1981
Tahun 1982
Tahun 1983
Tahun 1984
Tahun 1985
Tahun 1986
Tahun 1987
Tahun 1988
Tahun 1989
Tahun 1990
Tahun 1991
Tahun 1992
Tahun 1993
Tahun 1994
Tahun 1995
Tahun 1996
Tahun 1997

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Tahun 1998

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Tahun 1999
Tahun 2000
Tahun 2001
Tahun 2002
Incidence of Diseases 1980 - 2010

Tahun 2003
Tahun 2004
Tahun 2005
Tahun 2006
Tahun 2007
Tahun 2008
Tahun 2009
Incidence Global 1981-2010

Tahun 2010
112
measles
pertussis
diphtheria
Incidence Rate
VPD Max Cases Peak Year 2001 Percentage of
Year reduction (%)
Smallpox 48,164 1901 0 100
Diphtheria 206,939 1921 2 99.99
Pertussis 265,269 1934 4788 98.2
Tetanus 1,560 1923 26 98.34
Polio 21,269 1952 0 100
Measles 894,134 1941 96 99.99
Rubella 57,686 1969 19 99.97
Mumps 152,209 1968 216 99.86
Haemophilus influenzae type-b 20,000 1992 51 99.75

http://radiofreethinker.com/2013/03/15/the-case-for-censoring-the-anti-vax-movement/
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Measles Cases in Malaysia; 1980 – 2015

700 120

600
100

500
80

400

60

300

40
200

20
100

0 0
1980

2002
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001

2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
IR per 1mil. pop MCV1 Coverage MCV2 Coverage

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Coverage of Vaccine-Preventable Diseases
(2015)

https://reference.medscape.com/features/slideshow/vaccine-preventable-diseases#page=15
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Immunization Coverage, 2004 - 2015
100

95

90

85

80

75

70

65
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

BCG DPT (3) POLIO (3) Hep B (3) Measles Hib (3)

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MEASLES CASES BY RASH ONSET, MALAYSIA
2012 – SEPT 2017

Lab-confirmed measles Epi-linked Clinically confirmed


300

250

200

150

100

50

Sept
July

July
Nov

Nov

Nov

Nov

Nov
Sep
Sep

Sep

Sep

Sep
Mar

Mar

Mar

Mar

Mar

Mar
Jan '12

Jan '13

Jan '14

Jan '15

Jan '16

Jan '17
Jul

Jul

Jul

Jul
May
May

May

May

May

May
2012 2013 2014 2015
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2016 2017
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0
100
200
300
400
500
600
700
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999

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2000
2001

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2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Measles Mortality Cases in Malaysia; 1980 – 2015

2012
2013
2014
2015
0
20
40
60
80
100
120
140

119
Incidence Rate of Pertussis in Malaysia
2011 – 2015

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Data Source: Preliminary Health Facts (SID)
E-Notifikasi
120
Neonatal Tetanus; 1975 – 2015

1.40

1.20

1.00

0.80

0.60
0.45
0.40
0.12
0.20

0.00

NT rate Sabah NT rate M'sia


Number of births in Sabah contributes ~11% of total birth

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Insiden Rubella dan CRS, 2000 – 2014
IR Rubella IR CRS

35 100

90
30
80
25 70

60
20
50
15
40

10 30

20
5
10

0 0
2000 2002 2004 2006 2008 2010 2012 2014

Incidence Rubella (per 1 mill. Pop) Incidence CRS (per 1000 LB)
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Effect of Vaccine Refusal
1800
1600
1400
Number of Cases

1200
1000
800
600
400
200
0
2013 2014 2015 2016
Refusal 637 918 1541 1603
Measles Cases 195 235 1316 1587

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Low Coverage of Immunization

In 2011, China polio free since


2000 had an outbreak with
imported virus from Pakistan 2015: Measles outbreak in
California, 45% of 110 cases
unvaccinated and 43% unknown
status (final 147 cases)

2013: Measles outbreak in


England, due to MMR
refusal since 1998
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HERD Immunity Threshold

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Cairo Declaration
Pakistan Case 2012

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Introduction

Global Vaccine Action Plan by 2020


GOALS 2015 2020
World free polio Interrupt circulation by Certification by 2018
2014
Meet global and MNTE MNTE
regional target Measles, rubella & CRS Measles, rubella & CRS
Vaccination coverage 90% national & 80% 90% national & 80%
district levels for DPT district levels
Introduce new vaccine 90% low income & All low income &
middle income middle income
countries countries
Achieve MDG4 Reduce 2/3 U5MR Exceed

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Introduction
Achievement of National Immunisation Goals

(1) sustaining polio-free status

(2) maternal and neonatal tetanus elimination

(3) measles elimination OFF TRACK

(4) hepatitis B accelerated control

(5) rubella elimination

(6) introduction of new vaccines – PCV

(7) meeting regional vaccination coverage targets

(8) accelerated control of Japanese encephalitis

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Epidemiology WPR Measles, Rubella & CRS Elimination

By 2012, the Western Pacific Region should eliminate measles


By 2018, 100% of countries have verified interruption of endemic
measles virus transmission for a period of >36 months in the
presence of verification standard surveillance, which is defined as
follows:
1) reporting rate of non-measles non-rubella cases at the
Measles national level of >2 cases per 100,000 population per year;
elimination 2) >80% of second administrative level reporting at least 2 non-
measles non-rubella cases per 100,000 population per year;
3) >80% of suspected cases with adequate investigation initiated
within 48 hours of notification; and
4) >80% of suspected cases with adequate specimen for
detecting acute measles infection collected and tested in a
proficient laboratory

Rubella and (Member States from the Western Pacific Region (WPR) to set an
CRS elimination incidence target by 2015 of <10 per million)
MCV Coverage

Number of Districts with Measle Vaccine Coverage,


2012 - 2015
2012 2013 2014 2015
MCV1 Coverage
n % n % n % n %

≥95% 94 66.2 67 47.2 58 40.9 61 42.9

90 - <95% 13 9.2 11 7.7 15 10.6 15 10.6

80 – <90% 27 19.0 38 26.8 32 22.5 38 26.8

50 - <80% 8 5.6 26 18.3 34 23.9 28 19.7

<50% 0 0 0 0 3 2.1 0 0

TOTAL DISTRICTS 142 100 142 100 142 100 142 100
Effect of Vaccine Refusal
1800
1600
1400
Number of Cases

1200
1000
800
600
400
200
0
2013 2014 2015 2016
Refusal 637 918 1541 1603
Measles Cases 195 235 1316 1587

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MCV Coverage
REASONS FOR INCOMPLETE IMMUNISATION
Findings from NHMS 2016: MCH

REASONS Prevalence Upper CI Lower CI


no time 20.29 13.45 29.42
child unwell 17.41 10.58 27.29
cost/transport 16.80 9.62 27.71 47.18%
no vaccine stock at private 10.90 5.82 19.49
forgotten 10.09 6.02 16.41
not due yet at private 6.32 2.87 13.36
refused vaccine 4.07 1.72 9.34
don't trust vaccine 2.11 0.83 5.25
allergic 1.52 0.55 4.17
doubt halal 1.37 0.47 3.92 10.10%
worried SE 1.03 0.34 3.10
religion do not allow 0.93 0.26 3.21
bad experience 0.59 0.10 3.61
others 6.58 3.49 12.04
How?

We should

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Internet Traffic
• Users using internet in Malaysia:

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22 Million
Malaysians

https://www.skmm.gov.my/skmmgovmy/media/General/pdf/MCMC-Internet-Users-Survey-2017_v2.pdf
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Social Media Impact

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2016

27 kes Positive dengan 5 Kematian

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SPREAD NEGATIVE IDEOLOGY!!!

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New Challenges
• Dengue Vaccine
• HFMD Vaccine
• HIV Vaccine

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