pediatric immunizations part 2 support for this program is made possible by the aafp foundation...

Pediatric ImmunizationsPart 2

Support for this program is made possible by the AAFP Foundation through a grant from Pfizer Inc.

Pediatric Immunizations

Developed for AFMRD byGail Colby, M.D. and Wendy Biggs, M.D.

Midland Family Medicine Residency

Ehab Molokhia, MD and Gerald Liu, MD

University of South Alabama Family Medicine Residency

Updated 2012

Objectives• Medical knowledge

– List at least 5 vaccine-preventable diseases

– List the vaccines given to children that are live-attenuated vaccines

– Recall common combination vaccines for childhood immunizations

– Describe routine and catch-up schedules for common childhood vaccines

Objectives• Interpersonal communication

– Explain to parents or guardian the rationale for immunization against childhood diseases

• Patient care– Assess adolescents for boosters and new

vaccine needs– Provide children with the appropriate

influenza vaccination based on their ages and medical condition(s)

Objectives• Systems-based practice

– Utilize resources to find vaccine recommendations

Let’s recall our case from “Pediatric Immunizations Part 1.”

Tanya brings her 2-month-old infant to your office for a well-child appointment. She also has a 4-year-old son and twin 12-year-olds: 1 boy and 1 girl.

You advised Tanya on the routine 2- month-old vaccines her baby was to receive at today’s visit (DTaP, Hib, PCV-13, IPV, Hepatits B and Rotavirus).

Tanya asks,“What about when my baby gets older? How many more vaccines will she need? Are there other diseases she needs to be protected against?”

What are the routine recommendations for follow-up vaccines?

Case The routine recommendations for

infants are immunizations at:

– 2, 4, 6 and 12-15 months of age

Case Are there vaccines the child needs

in the future that she is too young to receive now?

Case YES

There are additional vaccines needed that cannot be administered until after the baby’s first birthday.

You advise Tanya that the baby will need to come back regularly throughout the year to receive her immunizations.

You also advise Tanya that some immunizations cannot be given until after her daughter turns one year old. These include measles, mumps, rubella, varicella and hepatitis A.

Koplik spots on the buccal mucosa.

Measles (Rubeola)• Acute, highly infectious• Prodrome

– Fever, conjunctivitis, coryza, cough, Koplik spots

• Day 3: red, blotchy rash develops, face, then generalizes

Photos from www.cdc.gov. Images in public domain.

Mumps• Highly infectious• Transmitted by

respiratory droplets, direct contact or fomites

• Incubation 14-18 days• Fever, malaise, headache, myalgias• 48 hours later: parotitis (parotid gland

inflammation) Photo from www.cdc.gov. Image in public domain.

Mumps• Prior to vaccine in 1967

– 100,000 to 200,000 cases/year in U.S.

• After routine vaccination 1980-90– Incidence declined to 5,000

cases/year in U.S.

Mumps• Outbreaks

– 2006 multi-state outbreak of 6,584 cases• Most among Midwestern college students living in dorms• Rates returned to normal 2 years later

– June 2009 - January 2010, largest outbreak since 2006: 1,521 cases • Index case was 11-year-old boy infected in the United Kingdom

during a large outbreak (>7000 cases)• Cases mostly in New York and New Jersey• Among tradition-observant Jewish community (Hasidic) (common

to not immunize)– <3% of cases occurred among persons outside this community

• 61% cases aged 7-18 years, 76% were male

Rubella (German Measles)• Rash and fever for 2-5 days• If acquired while pregnant,

severe congenital defects– Cataracts– Heart defects– Deafness– Mental retardation

Photo from www.cdc.gov. Image in public domain.

MMR• Measles, Mumps, Rubella • Individual components no longer

available• Live attenuated vaccine• Give after 12 months old • Booster at 4-6 years, but may give

4 weeks after 1st dose during outbreaks

Varicella (Chickenpox)• Fever occurs just

before or at start of blister-like rash

• Usually more concentrated on face, trunk and scalp

• Pneumonia or meningitis can occur, especially if acquired as an adolescent or adult

Photo from www.cdc.gov. Image in public domain. Photo by Dr. K.L. Hermann.

Varicella Vaccine (Varivax®)• Live-attenuated varicella vaccine• Dose after 12 months old• Give with MMR or separated by 4 weeks• Booster at 4-6 years, but may give at

least 4 weeks after 1st dose• Many states now require booster for

school entry

Varicella Vaccine• Immune to varicella if

– Born before 1966– Confirmed infection ’66-’97– Received vaccine – History of shingles – Varicella titer proven If you can remember

this, you are considered immune

to varicella

Varicella Vaccine• Contraindications

– Severe allergic reaction (e.g., anaphylaxis) after previous dose

– Substantial suppression of cellular immunity– Pregnancy

• Precautions– Recent (<11 months) receipt of antibody containing

blood product (specific interval depends on product)– Moderate or severe acute illness with or without

Safe Situations to Administer Varicella Vaccine • Pregnancy of recipient’s mother or other

close or household contact• Immunodeficient family member or

household contact• Asymptomatic or mildly symptomatic

HIV infection (CD4 count >200)• Humoral immunodeficiency (e.g.,

agammaglobulinemia)

Combination Vaccine: ProQuad®

Tetanus Hepatitis A Pneumococcus

Diphtheria Hepatitis B Meningococcus

Pertussis Rotavirus Influenza

Hib MMR HPV

Polio Varicella

ProQuad®• Measles, Mumps, Rubella and Varicella

• Live attenuated vaccine

• Approved age 12 months - 12 years

Hepatitis A• Caused by Hepatitis A virus• Fecal/oral transmission• Contaminated food or water• Self-limited• Incubation 28 days (range 15-50 days)• Viral shedding 2 weeks before to 1 week after

symptoms• Young children often asymptomatic

Hepatitis A• Symptoms

– Jaundice– Fatigue– Abdominal pain– Anorexia– Nausea

Hepatitis A• 2 different vaccines available for children

– Havrix®

– Vaqta®

• Effective 2005, all children should receive vaccine

• 2-dose series, 6 month minimum interval• Start at 12 months old• Catch-up vaccination for older children

Going for the what?FLU SHOT!

Influenza• “Influence of the stars”

– 1st Pandemic documented in Italy in 1590

• 3 pandemics in 20th century• “Spanish” influenza

1918-1919– 21 million deaths world wide– 500,000 deaths in U.S.

• 2009 H1N1 pandemic influenza

Makeshift hospital during 1918 Influenza epidemic at Camp Funston, Kansas.

Photo courtesy of the National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington, D.C.

Influenza• Pandemic occurs when unpredicted antigenic

shift occurs– Genetic recombination between

Influenza A viruses

– Usually involves viruses that affect humans and birds

• Influenza A & B virus isolated in 1930’s

• Vaccine developed in 1950’s

Influenza• 2 different strains

– Influenza A• More aggressive

– Influenza B• More common in children

• Each strain has 2 different antigens– H and N• These are further subdivided into numbers

– e.g. H1N1, H2N3

Influenza• Causes more deaths than any other

vaccine-preventable disease• 36,000 deaths per year in U.S.

– Most among elderly– Some among children

• High hospitalization rates among children <12 months old

Influenza• Spread by coughing, sneezing, breathing• Abrupt onset of fever, sore throat, cough,

headache, chills, muscle aches• Virus changes seasonally• Requires yearly vaccine updates• School-aged children

– Major source of disease transmission– Highest attack rates in a community– Contagious prior to symptoms and up to 10 days total

Severe Influenza Complications• Pneumonia• Reye Syndrome• Myocarditis• Death rate 0.5-1/1000 cases

Live Attenuated Influenza Vaccine (LAIV or Flumist®)• Flumist® (live attenuated)

– 2-49 years old

– Non-pregnant

– Healthy

Photo from www.cdc.gov. Image in public domain. Photo by James Gathany.

Live Attenuated Influenza Vaccine (LAIV or Flumist®)• Contraindications

– Any child diagnosed with asthma – Child less than 5 years old with one or

more episodes of wheezing during the last year

– Cerebral palsy– Children on long-term aspirin therapy– Any metabolic disease, such as diabetes

Influenza 2012

• Effective 2011-12, the ACIP and CDC recommend universal influenza vaccine for ALL people >6 months of age

Influenza• The first year vaccinated (6 months - <9 years)

– Requires 2 doses 1 month apart

• 6-35 months:– 0.25 mL IM

• 36 months and older:– 0.5 mL IM

• Flumist® may be administered starting at 2 years old

“This information has been very helpful.

Can you tell me whether my 4-year-old

child needs any immunizations? I don’t

think he has received any vaccines

since his 1-year-old shots.”

How can you verify the 4-year-old child’s vaccine needs?

– Paper records if available

– State immunization information system

You review the 4-year-old child’s vaccine record. It shows the child has received the following vaccines:– DTaP received at 2, 4, 6 and 15 months old– IPV received at 2, 4, 6 and 15 months old– Hepatitis B received at birth, 2, 4, and 6 months old– Hib received at 2, 4, 6 and 15 months old– PCV 7 received at 2, 4, 6 and 15 months old– MMRV received at 12 months old– Hepatitis A received at 12 months old

Case What vaccines do you advise

Tanya her 4-year-old child needs?

Case• DTaP (routine 4-year-old vaccine)• IPV (repeat dose, 4th dose given too early)

• MMR (routine 4-year-old vaccine)• Varicella (routine 4-year-old vaccine)• Influenza (if influenza season)• PCV13 (booster dose)• Hepatitis A (never received 2nd dose)

Case “Ok, I think I understand for my younger

children. What about my 12-year-olds? They shouldn’t need anything since they had all their immunizations as infants and had shots to start kindergarten, right?”

Case Do early adolescents need any

vaccines?

Boostrix®• Tdap• Ages 10-64 years• Give as booster at 11-12 years in place of Td• Follow up boosters of Td every 10 years• Pertussis epidemics occur periodically

• Pertussis in the US:– 1976 – 1020 cases– 2004 – 25,827 cases– 2007 – 10,454 cases

• Routine Tdap boosters instituted in 2006

Adacel®• Tdap• Ages 11-64 years• Same indications as Boostrix®• One time booster at least 2 years after

previous Td booster– High-risk shorter than 2-year interval

• Healthcare worker• Close contact with infants• During a Pertussis outbreak

• To protect against resurgence of pertussis

Tdap• Contraindications

– Severe allergic reaction (e.g., anaphylaxis) after a previous vaccine dose (DTaP)

– Encephalopathy (e.g., coma, decreased level of consciousness, and prolonged seizures) • Not attributable to another identifiable cause

within 7 days of previous dose of DTP/DTaP

Tdap• Precautions

– Moderate or severe acute illness with or without fever

– GBS <6 weeks after dose of tetanus based vaccine

– Progressive/unstable neurological disorder, uncontrolled seizures or progressive encephalopathy until treatment regimen established and condition stabilized

– History of arthus reaction

Tdap• Arthus reaction

– Type III hypersensitivity reaction– Occurs 4-12 hours after vaccination– Symptoms:

• Local severe pain• Swelling• Induration

• If occurs, defer vaccination until at least 10 years have elapsed since the last tetanus toxoid-containing vaccine, even for wound prophylaxis

• Edema• Hemorrhage• Occasionally necrosis

Safe Situations to Administer Tdap• Temperature of >104° F (>40.5° C) for < 48

hours after vaccination with a previous dose of DTP or DTaP

• Collapse or shock-like state (i.e., hypotonic episode) <48 hours after receiving a previous dose of DTP/DTaP

• Seizure <3 days after receiving a previous dose of DTP/DTaP

• Persistent, inconsolable crying lasting >3 hours within 48 hours after receiving a previous dose of DTP/DTaP

Safe Situations to Administer Tdap• History of extensive limb swelling after

DTP/DTaP/Td that is not an arthus-type reaction

• Stable neurologic disorder• Brachial neuritis• Latex allergy (non-anaphylactic)• Breast feeding• Immunosuppression

Meningococcal Disease:Neisseria Meningitis• Leading cause of bacterial meningitis in children and

young adults

• Overall mortality rate 13%

• Sudden onset – Fever

– Severe myalgias

– Nausea/vomiting

• Rash and meningeal signs 12-15 hours after onset of symptoms

4-month-old infant with gangrene of hands due to meningococcemia.

Meningococcal Vaccine• All currently available vaccines effective

against Groups A, C, Y, and W-135• None effective against Group B• 1st vaccine available was polysaccharide

vaccine (Menomune®)– Poor immunogenicity– Lacks memory

• Conjugated vaccines developed– Produces memory cells– Preferred vaccine choice

Menomune® (MPSV4)• First meningococcal vaccine• Tetravalent meningococcal polysaccharide

vaccine• Groups A, C, Y, and W-135

– No protection against B, 30% cause of meningitis

• Not effective age <2 years old• Immunity decreases after 3 years

– Does not stimulate B-cell immunity

Menomune® (MPSV4)• Contraindications

– Severe allergic reaction after a previous dose or to a vaccine component

• Precautions– Moderate or severe acute illness with or

without fever

Meningococcal Conjugate Vaccine (MCV)• 2 vaccines available, 1-dose series

– Menactra™ (MCV4)– Menveo® (MenCYW-135)

• Protects against A, C, Y, and W-135 strains– No protection against B strain

• Preferred over polysaccharide vaccine (MPSV4)– Conjugate stimulates B-cell immunity– Produces memory cells

• CDC makes no preference between Menactra™ or Menveo® as of March 2010

Meningococcal Conjugate Vaccine (MCV)• Routine vaccine at 11-12 years old• 2008 recommendation: all adolescents

should receive MCV– Vaccinate 11-18 year olds at earliest opportunity

• Give to 19-55 year olds with increased risk– College freshman or military recruits– Asplenic persons– Travel to high risk areas– Persistent complement deficiency

Meningococcal Conjugate Vaccine: Menactra™• Ages 2-55• Contraindications

– Severe allergic reaction (e.g., anaphylaxis) after a previous vaccine dose

• Precautions– Moderate or severe acute illness with or without fever– History of Guillain-Barré syndrome (if not at high risk

for meningococcal disease)

• Conjugated to diphtheria toxoid

Meningococcal Conjugate Vaccine: Menveo®• Ages 11-55• Contraindications

– Severe allergic reaction (e.g., anaphylaxis) after previous vaccine or PCV

• Precautions– Moderate or severe acute illness with or without fever

• No data on Guillain-Barre available yet• Conjugated to CRM197 diphtheria toxoid (same

as PCV)– Liquid and powder components reconstituted

Meningococcal Vaccine Boosters• Indicated for high-risk groups

– Persistent complement component deficiencies (e.g., C3, properdin, Factor D, and late complement component deficiencies)

– Anatomic or functional asplenia– Prolonged exposure (e.g., microbiologists routinely

working with Neisseria meningitidis)– Travelers to or residents of countries where

meningococcal disease is hyperendemic or epidemic

Meningococcal Vaccine Boosters• Give booster dose of Meningococcal

conjugate vaccine if remains at high risk:– 3 years after last polysaccharide or

conjugate meningococcal vaccine if age 2-6 years old when dose given

– Every 5 years after last polysaccharide or conjugate meningococcal vaccine if age 7 or older when dose given if remains at high risk

Human Papilloma Virus (HPV)

Photos from www.cdc.gov. Images in public domain.

Human Papilloma Virus (HPV)• HPV 16 and 18 most common types

associated with the severe cervical dysplasia (CIN 2/3), which may lead to cervical cancer

• HPV 6 and 11 most common types of HPV found in genital warts

• Ideally administer before onset of sexual activity

• 2 vaccines available (Not Interchangeable!)– Quadrivalent (Gardasil®) – Bivalent (Cervarix®)

Human Papilloma Virus (HPV)• Do not restart the vaccine series if schedule

is interrupted• Inactivated vaccine – can be administered

either with, before, or after a live vaccine• Same vaccine product should be used to

complete series (Not interchangeable!)• Quadrivalent vaccine is not approved for use

in pregnancy

Human Papilloma Virus (HPV)• Quadrivalent vaccine (Gardasil®)

– HPV 6,11,16 and 18– Approved in US in 2007 for use in girls and

women 9-26 years of age– ACIP approved in US in 2009 for use in boys

9-26 years of age for prevention of genital warts• “Permissive” but not a routine recommendation

– Also approved for prevention of genital warts, vulvar and vaginal pre-cancers and cancers

Human Papilloma Virus (HPV)• Bivalent vaccine (Cervarix®)

– HPV 16, 18– Approved in U.S. in October 2009– Most common HPV vaccine used in

Europe– Has a unique adjuvant monophosphyoryl

lipid A (MPL) that acts as an immune modulator

– Not approved for use in boys at this time

Human Papilloma Virus (HPV)• ACIP recommends routine vaccination of

females 11-12 years with 3 doses – 0, 1 month and 6 months after first dose

– Minimum interval between 1st and 2nd doses is 4 weeks

– Minimum between 2nd and 3rd doses is 12 weeks

– Minimum between 1st and 3rd doses is 24 weeks

• Can be started as early as 9 years of age

Human Papilloma Virus (HPV)• Precautions

– Quadrivalent vaccine contraindicated for people with immediate hypersensitivity to yeast

– Bivalent vaccine contraindicated for people with anaphylaxis to latex

– Syncope can occur after vaccination• 15-minute observation after vaccination prudent,

due to increased syncope in adolescents

RecommendationVaccine Pros Cons

12-year-old girl

Either Recommended

Quad-rivalent

HPV 16, 18 – decrease cervical cancer risk

HPV 6, 11 – decrease genital warts risk

Risks of syncope

Rare adverse events

BivalentHPV 16, 18 – decrease cervical cancer risk

Risks of syncope

Rare adverse events

No protection against genital warts

12-year-old boy

Permissive (Permitted)

Quad-rivalent

HPV 6, 11 - Decrease genital wart risk

HPV 16, 18 – Decrease SPREAD to females

Risks of syncope

Rare adverse events

Not recommended BivalentOnly HPV 16, 18 – Decrease SPREAD to females

Risks of syncope

Rare adverse events

No protection against genital warts

Case Recommendations

Case Do you need any additional

information before advising Tanya on the vaccines her 12 year old children need?– YES!– You review the twins’ vaccine records and

identify that they only received 1 varicella vaccine. The remainder of their vaccines are current through age 4.

– What vaccines do you advise be given?

Case• Tdap• Meningococcal conjugate vaccine• Varicella• Influenza (in season)• HPV

– Either recommended for the daughter– Quadrivalent permissive for the son

Case Tanya is very thankful for all your help

explaining the vaccines her children need.

You administer the appropriate vaccines for all the children today and schedule interval follow-up appointments for booster dosing.

Summary• Medical knowledge

– Many childhood diseases are rare due to immunizations• Diphtheria, tetanus, polio, invasive pneumococcal

and meningococcal disease, measles, mumps, rubella

– Live vaccines for children are MMR, Varicella and Rotavirus

– Vaccines come in multiple combinations which vary by manufacturer

Summary of Vaccines• Medical knowledge

– 12-15 months• DTaP (if > 6 mos from dose 3), Hib, PCV, MMR,

Varicella, Hepatitis A

– 2 years• Hepatitis A

– 4 years• DTaP, IPV, MMR, Varicella

– 11-12 years• Tdap, HPV, Meningococcal, Hepatitis A if not received,

any other catch-up vaccines

Summary• Patient care

– Adolescents need one-time Tdap booster, meningococcal vaccine, varicella update and HPV consideration

– Influenza vaccine should be administered to all children >6 months old

– LAIV may be administered starting at age 2– 2 doses of influenza vaccine are required the first

season a child receives flu vaccine– Asthma diagnosis or wheezing in the past 1 year

in a child <5 years old is a contraindication to LAIV

Summary• Systems-based practice

– Vaccines for Children (VFC) is a federal program that provides ACIP recommended vaccines for administration to the Medicaid/uninsured patients and Native American/Alaskan populations

– Use resources to stay up-to-date with vaccine information

• Review the immunization schedule regularly

Resources• www.cdc.gov/vaccines

• (National Immunization Program)

• www.immunize.org/childrules • (Immunization Action Coalition)

• www.cdc.gov/vaccines/programs/iis/contact-state.htm

• State Health Department immunization programs

• Epidemiology and Prevention of Vaccine-Preventable Diseases. The Pink Book: Course Textbook 12th Edition

pediatric immunizations part 2 support for this program is made possible by the aafp foundation...

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