Vaccination is a realm that we pharmacists in Malaysia rarely venture into due to the lack of exposure to them. However, in many other countries, pharmacists are trained to be vaccinators to aid with the public’s mass immunization, especially during the COVID-19 pandemic. As the new regulations roll into place enabling pharmacists to provide vaccination services, we should equip ourselves with knowledge regarding different vaccinations available in Malaysia to provide better patient-centered care. Here in this article, I will talk about two combination vaccines that are very common in Malaysia. I chose to talk about these two combinations because all of the diseases mentioned here are transmitted through air droplets, except tetanus, which makes them highly transmissible if herd immunity is not achieved.

Measles, Mumps and Rubella (MMR)

The MMR vaccine is recommended to be given at 12 months of age as most of the children affected by these diseases are around 1-2 years of age. The MMRV is also beneficial for the prevention of malformations in infants from the infection of any of the said viruses during pregnancy. However, care should be taken to avoid vaccination during pregnancy.

Measles is caused by rubeola virus, which belongs to the group of the paramyxovirus family. The rashes caused by measles can turn into blotchy patches on the body. Oral rehydration salt should be given to patients with complications such as diarrhoea. Vitamin A supplements are sometimes given to prevent eye damage and blindness. Antibiotics will be prescribed if chest, eye or ear infections are present.

Like measles, mumps is caused by a virus in the paramyxovirus family. Mumps spreads through respiratory droplets and causes swelling of the parotid glands. Mumps can sometimes develop complications such as inflammation of the testicles, ovaries, and breast tissues, as well as pancreas and hearing loss. There are currently no treatments available for mumps infection. Treatment is mainly supportive: plenty of rest, adequate fluid & nutrition. Paracetamol may be given for pain and fever, and a cold compress can be applied to the swollen parotid gland. Patients are advised to have soft & easy to swallow food.

Rubella, or German Measles, is caused by a virus in the Togaviridae group. Rubella virus is the sole member of the genus Rubivirus, in the family Matonaviridae. Rubella symptoms are usually mild in adults and even children, characterized by blotchy rashes similar to measles. However, detrimental malformations or even miscarriages can occur if a pregnant lady contracted Rubella, especially in the first trimester. The babies who survived the ordeal would develop heart problems, loss of hearing and eyesight, intellectual disability, and liver or spleen damage, collectively known as congenital rubella syndrome. Currently, there are no treatments available for Rubella, so vaccination is vital to prevent contraction of the disease.

From left: Measles, Mumps and Rubella. Photos extracted from Centers for Disease Control and Prevention (CDC)

Diphtheria, Tetanus and Pertussis

Diphtheria is caused by a toxin released by Corynebacterium diphtheriae, resulting in shortness of breath and possibly death. The nose and throat linings will turn thick-grey as the toxin kills off the tissues, forming a pseudomembrane. Affected individuals often have sore throats, fever, malaise and swollen glands in the neck (which makes differential diagnosis to mumps slightly challenging). Diphtheria is often managed by giving an antitoxin to halt the damage to the respiratory linings and antibiotics such as benzylpenicillin, azithromycin or phenoxymethylpenicillin to stop the spread of bacteria.

Pertussis, commonly known as whooping cough, is caused by Bordetella Pertussis. The symptoms are cold-like and mild in adults, but it can cause a cough that lasts for weeks or even months. In children, especially infants, whooping cough can result in pneumonia thus difficulty breathing, brain damage and death. Pertussis can be treated with antibiotics such as azithromycin, clarithromycin or trimethoprim and sulfamethoxazole.

Tetanus. Photos extracted from Centers for Disease Control and Prevention (CDC)

Tetanus, a result of Clostridium tetani infection, is transmitted through direct contact, in contrast to all the other diseases mentioned here. Lockjaw (spasm of the jaw muscles) is often the first sign of a tetanus attack, followed by contractions of other muscles in the body. A tetanus toxoid vaccine and an antibiotic such as metronidazole or Penicillin G (benzylpenicillin) are given if a person is diagnosed with tetanus. Tetanus immunoglobulin may be given to people who were not vaccinated in the past.

Epilogue 

Being in primary healthcare, pharmacists are often the first health professionals the public will approach. Basic knowledge of vaccine-preventable diseases allows us to make the right call to refer individuals in a timely manner, to prevent further harm to both the individual who was infectious, and the community in which he or she lives. Through this summary, I hope we, as pharmacists, are able to recognize the telltale signs of notifiable diseases and stop the infection in its tracks.

Special thanks to Dwayne ‘t Hart for proofreading the article.

References:

1. Albrecht MA. Mumps [Internet]. WA: UpToDate; [updated 2021 July 23; cited 2023 October 3]. Available from: https://www.uptodate.com/contents/mumps?search=mumps&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
2. American Osteopathic Association. Public Education Critical To Preventing Measles, Mumps And Other Disease Outbreaks. 2015 Feb 3. Picture available from: https://www.prnewswire.com/news-releases/public-education-critical-to-preventing-measles-mumps-and-other-disease-outbreaks-300029553.html
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4. Centers for Disease Control and Prevention (CDC). Mumps. Available from: https://www.cdc.gov/mumps/infographics/mumps-protect-yourself-508.pdf
5. Centers for Disease Control and Prevention (CDC). Pertussis. Available from: https://www.cdc.gov/pertussis/index.html
6. Clinical Practice Guideline Malaysia. Childhood Immunisation [Internet]. Putrajaya: Malaysia Health Technology Assessment Section (MaHTAS), Malaysia;2004. Available from: https://www.moh.gov.my/moh/attachments/3934.pdf
7. Edwards MS and Shetty A. Rubella [Internet]. WA: UpToDate; [updated 2022 November 29; cited 2023 October 3]. Available from: https://www.uptodate.com/contents/rubella?search=rubella%20&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
8. Gans H and Maldonado YA. Measles: Clinical manifestations, diagnosis, treatment, and prevention [Internet]. WA: UpToDate; [updated 2023 March 14; cited 2023 October 3]. Available from: https://www.uptodate.com/contents/measles-clinical-manifestations-diagnosis-treatment-and-prevention?search=measles&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
9. Thwaites L. Tetanus [Internet]. WA: UpToDate; [updated 2022 June; cited 2023 October 3]. Available from: https://www.uptodate.com/contents/tetanus?search=tetanus&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H25