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Fulltext Parents' and healthcare professionals' perception toward the introduction of a new fully liquid hexavalent vaccine in the Malaysian national immunization program: a cross-sectional study instrument development and its application

Al Bashir L, Ismail A, Aljunid SM

Front Immunol, 2023;14:1052450.
PMID: 37180162 DOI: 10.3389/fimmu.2023.1052450

A newly developed fully liquid hexavalent vaccine that comprises six antigens for Diphtheria, Tetanus, acellular Pertussis, Inactivated Poliomyelitis, Haemophilus Influenza type b., and Hepatitis B, is proposed to be introduced in the Malaysian national immunization program, instead of the non-fully liquid pentavalent vaccine and monovalent Hepatitis B vaccine that is currently employed in the immunization schedule. Although the introduction of new vaccines is a necessary intervention, it still needs to be accepted by parents and healthcare professionals. Hence, this study aimed to develop three structured questionnaires and to investigate the participants' perception and acceptability toward the incorporation of the new fully liquid hexavalent vaccine. A cross-sectional study was conducted among a sample of 346 parents, 100 nurses, and 50 physicians attending twenty-two primary health care centers in the states of Selangor and the Federal Territory of Kuala Lumpur and Putrajaya during 2019-2020. The study found that Cronbach's alpha coefficients for the study instruments ranged from 0.825 to 0.918. Principal components analysis produced a good fit with KMO>0.6. For the parents' perception questionnaire, the only extracted factor explained 73.9 % of the total variance; for the nurses' perception toward a non-fully and fully liquid combined vaccine, there was a sole extracted factor that explained 65.2 % and 79.2% of the total variance, respectively. Whereas for the physicians' perception, there was one factor extracted that explains 71.8 % of the total variance. The median score for all the questionnaire items ranged from 4 to 5 (Q1 and Q3 vary between 3-5). Parents' ethnicity was significantly associated (P-value ≤ 0.05) with the perception that the new hexavalent vaccine would reduce their transportation expenses. Moreover, a significant association (P-value ≤ 0.05) was found between physicians' age and the perception of the hexavalent vaccine's ability to decrease patient overcrowding in primary healthcare centers. The instruments used in this study were valid and reliable. Parents of Malay ethnicity were the most concerned about transportation expenses since they have the lowest income and are more concentrated in rural areas compared to other races. Younger physicians were concerned about reducing patient crowding and hence reducing their workload and burnout.

Matched MeSH terms: Diphtheria-Tetanus-Pertussis Vaccine*
Effects of supplementation with tocotrienol-rich fraction on immune response to tetanus toxoid immunization in normal healthy volunteers

Mahalingam D, Radhakrishnan AK, Amom Z, Ibrahim N, Nesaretnam K

Eur J Clin Nutr, 2011 Jan;65(1):63-9.
PMID: 20859299 DOI: 10.1038/ejcn.2010.184

Vitamin E is an essential fat-soluble vitamin that has been shown to induce favorable effects on animal and human immune systems. The objective of this study was to assess the effects of tocotrienol-rich fraction (TRF) supplementation on immune response following tetanus toxoid (TT) vaccine challenge in healthy female volunteers.

Matched MeSH terms: Tetanus Toxoid/administration & dosage; Tetanus Toxoid/immunology*
Fulltext Timing of antenatal tetanus immunization for effective protection of the neonate

Chen ST, Edsall G, Peel MM, Sinnathuray TA

Bull World Health Organ, 1983;61(1):159-65.
PMID: 6601539

The relationship between the timing of maternal tetanus toxoid immunization and the presence of protective antitoxin in placental cord blood was investigated among women admitted to the obstetrical service of the University Hospital in Kuala Lumpur, Malaysia. The 1st dose was given between 13-39 weeks of gestation, with a median of 29 weeks. The 2nd dose was given an average of 4 weeks later. Protection was conferred on 80% or more of newborns whose mothers received their 1st tetanus toxoid injection 60 days or more before delivery. Protective levels were seen in all cord blood samples from infants whose mothers had received their 1st injection 90 days before delivery. Similarly,protective titers were found in 100% of cord blood samples when the 2nd maternal injection was give 60 days or more before delivery. There was no significant degree of protection when immunization was carried out less than 20 days before delivery. A single-dose schedule provided no protection when less than 70 days before delivery. Cord and maternal antiotoxin titers differed by no more than 1 2-fold dilution for almost all of the individual paired sera. A cord: maternal antitoxin ratio of 2 was more likely to occur with increasing time between the 2nd injection and delivery. Overall, these findings indicate that the 1st injection of a 2-dose maternal tetanus toxoid schedule should be given at least 60 days and preferably 90 days before delivery.

Matched MeSH terms: Tetanus/prevention & control*; Tetanus Antitoxin/analysis; Tetanus Toxoid/administration & dosage*
Fulltext Supplementation with natural forms of vitamin E augments antigen-specific TH1-type immune response to tetanus toxoid

Radhakrishnan AK, Mahalingam D, Selvaduray KR, Nesaretnam K

Biomed Res Int, 2013;2013:782067.
PMID: 23936847 DOI: 10.1155/2013/782067

This study compared the ability of three forms of vitamin E [tocotrienol-rich fraction (TRF), alpha-tocopherol (α-T), and delta-tocotrienol (δ-T3)] to enhance immune response to tetanus toxoid (TT) immunisation in a mouse model. Twenty BALB/c mice were divided into four groups of five mice each. The mice were fed with the different forms of vitamin E (1 mg) or vehicle daily for two weeks before they were given the TT vaccine [4 Lf] intramuscularly (i.m.). Booster vaccinations were given on days 28 and 42. Serum was collected (days 0, 28, and 56) to quantify anti-TT levels. At autopsy, splenocytes harvested were cultured with TT or mitogens. The production of anti-TT antibodies was augmented (P < 0.05) in mice that were fed with δ-T3 or TRF compared to controls. The production of IFN-γ and IL-4 by splenocytes from the vitamin E treated mice was significantly (P < 0.05) higher than that from controls. The IFN-γ production was the highest in animals supplemented with δ-T3 followed by TRF and finally α-T. Production of TNF-α was suppressed in the vitamin E treated group compared to vehicle-supplemented controls. Supplementation with δ-T3 or TRF can enhance immune response to TT immunisation and production of cytokines that promote cell-mediated (TH1) immune response.

Matched MeSH terms: Tetanus Toxoid/administration & dosage*
Total paralysis regime in severe tetanus

Alhady SMA, Bowler DP, Reid HA, Scott LT

Br Med J, 1960;1:540-545.

Tetanus may be mild, moderate, severe, or inevitably fatal. Our clinical experience suggests it may be classified as severe (or, maybe, inevitably fatal) when a tetanic spasm stops respiration. Ten patients with severe tetanus were treated by the total paralysis regime (T.P.R.), consisting of tracheostomy, curarization, and intermittent positiveor positive/negative-pressure respiration. Two of the patients were saved by T.P.R. and therefore only limited effectiveness can be claimed for the regime. In inevitably fatal cases survival can be prolonged by T.P.R. so that further effects of tetanus toxin emerge. Of these, the most important appears to be direct damage to the myocardium.

Matched MeSH terms: Tetanus
Fulltext Economic impact of switching from partially combined vaccine "Pentaxim® and hepatitis B" to fully combined vaccine "Hexaxim®" in the Malaysian National Immunization Program

Aljunid SM, Al Bashir L, Ismail AB, Aizuddin AN, Rashid SAZA, Nur AM

BMC Health Serv Res, 2022 Jan 05;22(1):34.
PMID: 34986870 DOI: 10.1186/s12913-021-07428-7

BACKGROUND: The decision to implement new vaccines should be supported by public health and economic evaluations. Therefore, this study was primarily designed to evaluate the economic impact of switching from partially combined vaccine (Pentaxim® plus hepatitis B) to fully combined vaccine (Hexaxim®) in the Malaysian National Immunization Program (NIP) and to investigate healthcare professionals (HCPs)' and parents'/caregivers' perceptions.
METHODS: In this economic evaluation study, 22 primary healthcare centers were randomly selected in Malaysia between December 2019 and July 2020. The baseline immunization schedule includes switching from Pentaxim® (four doses) and hepatitis B (three doses) to Hexaxim® (four doses), whereas the alternative scheme includes switching from Pentaxim® (four doses) and hepatitis B (three doses) to Hexaxim® (four doses) and hepatitis B (one dose) administered at birth. Direct medical costs were extracted using a costing questionnaire and an observational time and motion chart. Direct non-medical (cost for transportation) and indirect costs (loss of productivity) were derived from parents'/caregivers' questionnaire. Also, HCPs' and parent's/caregivers' perceptions were investigated using structured questionnaires.
RESULTS: The cost per dose of Pentaxim® plus hepatitis B vs. Hexaxim® for the baseline scheme was Malaysian ringgit (RM) 31.90 (7.7 United States dollar [USD]) vs. 17.10 (4.1 USD) for direct medical cost, RM 54.40 (13.1 USD) vs. RM 27.20 (6.6 USD) for direct non-medical cost, RM 221.33 (53.3 USD) vs. RM 110.66 (26.7 USD) for indirect cost, and RM 307.63 (74.2 USD) vs. RM 155.00 (37.4 USD) for societal (total) cost. A similar trend was observed for the alternative scheme. Compared with Pentaxim® plus hepatitis B, total cost savings per dose of Hexaxim® were RM 137.20 (33.1 USD) and RM 104.70 (25.2 USD) in the baseline and alternative scheme, respectively. Eighty-four percent of physicians and 95% of nurses supported the use of Hexaxim® in the NIP. The majority of parents/caregivers had a positive perception regarding Hexaxim® vaccine in various aspects.
CONCLUSIONS: Incorporation of Hexaxim® within Malaysian NIP is highly recommended because the use of Hexaxim® has demonstrated substantial direct and indirect cost savings for healthcare providers and parents/caregivers with a high percentage of positive perceptions, compared with Pentaxim® plus hepatitis B.
TRIAL REGISTRATION: Not applicable.

Matched MeSH terms: Diphtheria-Tetanus-Pertussis Vaccine*
Intensive therapy in neonatal tetanus

Ganendran A

Anaesthesia, 1974 May;29(3):356-62.
PMID: 4599155
Matched MeSH terms: Tetanus/drug therapy; Tetanus/etiology; Tetanus/epidemiology; Tetanus/therapy*; Tetanus Antitoxin/therapeutic use