Pediatric Immunizations Update and Controversies Diane Dooley MD March 27, 2009

Immunizations The most effective component of well child care 1796 – Edward Jenner develops cowpox vaccine 1873 – 175,000 Americans died of infectious diseases. The majority of these were children dying of whooping cough, measles, scarlatina, diphtheria, etc 1880 – Pasteur, Koch and others demonstrated that diphtheria and cholera were infectious diseases transmitted by microbes – Last known case of smallpox occurs in Somalia

Immunizations 2009 Recent Hib Deaths Measles cases Pertussis New Immunization registry

Vaccine Schedule

Rotavirus Vaccine Most common cause of severe diarrhea in infants and children 1/14 of children in US seen in ER or admitted by age 5 Live, oral 2 or 3 dose series 85-98% protection vs severe disease

Toddler Gap Immunization rates drop in the second year of life, especially DTaP MMR rates 90% DTaP rates 71% Health disparity for African Americans

Toddler gap Issues contributing to toddler gap: Health care coverage gaps Simultaneous administration of multiple shots – MMR,VZV,HIB, PNV, DTaP Parental/family issues Systems issues

Coordinating Immunizations with a well child exam Well child schedule: Less then 1 week, 1 mo, 2mo, 4mo, 6mo 9mo, 12mo, 15mo, 18mo Annually from 2-18 years Goals re: well child care Regular visits for developmental screening, anticipatory guidance Timely administration of vaccines Continuity relationship with provider Always reappoint to the next well child visit with PCP!

Vaccine Schedule

Teen Vaccinations Meningitis vaccine (MCV4) years College freshman HPV Females aged 9-26 years Tdap year olds who have completed their DTaP series but have not received Td year olds if they have completed their DTaP series and either missed their Td at or it has been 5 years since they received their Td

Special Considerations Preterm infants HBsAg + mothers Immunocompromised Egg allergy Reactions to a previous vaccine Progressive neurologic disorder/seizures Minor illness with or without fever does not contraindicate immunization

Reasons Why Kids Miss Shots Health System Issues Cost of vaccines HPV, Rotavirus, MMR-V, MCV4 Vaccine shortages Inappropriate deferral of shots Health coverage

Reasons Why Kids Miss Shots Parental Issues Fear of autism Fear of injections, early exposure Lack of trust Disbelief about infections Belief in herd immunity Pediatrics: The Problem with Dr. Bob’s Alternative Vaccine Schedule January 2009

Dealing with Parental Refusals 70% of pediatricians report recent parental refusal of vaccines Clarify concerns Religious or philosophical grounds Concerns re: injections, combined vaccines Risk/Benefit ratio

Dealing with Parental Refusals Educate Risk/Benefit Herd immunity Clinical management of acute illnesses School entry laws Websites Negotiate Continuing Care ?Medical Neglect