1. PEDIATRIC IMMUNIZATIONS by Dr Aguilera
Goals and Objectives
Dispel myths that surround vaccines
Major changes in the immunization schedule for 2004 – 2005
Key points about vaccines including scheduled series and catch-up.
Also special considerations, and contraindications, according to ACIP, AAP, and AAFP

2. Case #1
A 24 month old girl has been ill for the last four days. She has been less active than usual, has had subjective fevers, runny nose and a sore throat. (+) ill contacts at home and tolerating PO’s. On exam, nontoxic, playful with a T= Throat is red and has thin nasal discharge. You also discover she is not up to date on immunizations; she has only received up to her 6 mo shots.

3. Questions to Case # 1: Prescribe Abx?
Wait until the next visit to give any immunizations as this is not what she is being seen for?
Catch the child up with any five vaccines as this is the maximum # to give in one visit?
Her illness precludes her from receiving any vaccines at this point?

4. Reasons for Missed Vaccinations
Missed appointments
Inadequate access to health care and/or “non-compliance”
Incomplete records
Multiple providers and/or lost yellow cards
Lack of awareness
Myths and misconceptions of parents
Deficient health care delivery
Poor clinical judgement: disease definition
Myths of providers: “too many shots at once”
Complexity of schedule

5. Missed Immunizations Cont’d
Conclusions:
CDC Goal: 90% full immunization by K level
Based on Riverside Co. Public Hlth
71% of our 2 y/o are immunized; retrospective analysis of K level
92.4% of K level entry (Fall) immunized
93.4% of K level at Spring time immunized

6. Immunization Schedule - 1983

7. Immunization Schedule - 1996

8. Changes from 1997-2001 All DTaP series recommended - 1999
Rotavirus introduced & deleted
All IPV series recommended
Hep A recom in selected areas (Ca)
Thimerosal free vaccines produced – 2000
only one that is not => Influenza vaccine
Routine PCV introduced (shortage) – 2001

9. Immunization Schedule - 2004

10. Changes in the Schedule - 2004
Hep B at birth is still appropriate
In addition to Hep A, vaccines for selected populations include Influenza and PCV #5
A highlighted pre-adolescent assessment to emphasize need to check vaccine status
Added catch up bars across age groups to spotlight need of updating status through 18 years
The number of vaccines required for a child by age 5-6 years has increased to >25

11. Case # 2:
A 2 month old is in for the first time for a check up. Prenatal care was unremarkable. Term NSVD and baby is doing well. She is breastfeeding. Mother notes that there is a strong family history of seizures as the great -grandfather, grandfather, father and two uncles all have seizures.

12. Questions to Case # 2:
Given the strong FHx of seizures, DTaP is contraindicated and pt should be given DT?
Has SIDS been associated with the DTaP vaccine?
IPV is contraindicated if the mother were to become pregnant in the next 4 weeks?
If a 5 yr old boy had never received any anti-polio vaccine, how many doses would he need total?
Would it be ok to give this patient the MMR at 11 months?
Does MMR cause Autism?

13. Diphtheria, Tetanus and Pertussis (DTaP, DT, Td)
Intramuscular toxoids and inactivated bac. Ag
2, 4, 6, mo and 4-6 yr booster; Td booster yrs, and every 10 yrs thereafter
5 doses total: 2nd dose at least 4 wks from 1st; 3rd dose 4 wks from 2nd; 4th dose 6 mo from 3rd; and 5th dose 6 mo from 4th dose.
#5 not necessary if #4 given after 4 years of age
Do not restart series

14. DTaP Continued Special Considerations:
< 7 yrs of age, use DT when pertussis is contraindicated
> 7 yrs of age, use Td for primary series
Not associated as cause for SIDS and has not been proven to cause permanent brain damage
Precaution: prior fever >104.8, Sz within 3 days, inconsolable crying > 3 hrs within 2 days, Mod-Severe illness and personal or FHx of seizure

15. DTaP Continued Contraindications Anaphylaxis Pertussis component:
Encephalopathy within 7 days
Neurologic disorder with progressive developmental delay or changing neurologic status
Personal history of Infantile spasms or epilepsy

16. Polio (IPV) Intramuscular, inactivated virus
2, 4, 6-18 mo, and 4-6 yr booster
4 doses total: 2nd at least 4 wks after 1st; 3rd at least 8 wks after 2nd dose
If 3rd shot given > 4 yrs of age, then 4th dose not needed
Unimmunized >18 yr old, none required
>4 yrs old unimmunized but< 18yrs, only need 3 doses; give #1 at the visit, then #2 four wks after #1, and #3 six mo after #2
Do not restart series

17. IPV Continued Special Considerations
Switched to an all IPV to decrease VAPP; no need to avoid pregnant women
Precaution: Mod-severe illness
OPV should only be used:
To control outbreaks
In unimmunized child traveling to endemic area in < 4 wks time
Remember: avoid pregnant women and immunocompromised pts for 4-6 wks

18. IPV Continued Contraindications Anaphylaxis
Allergy to neomycin, polymixin B or streptomycin

19. Measles, Mumps and Rubella (MMR)
Subcutaneous, live virus
12-15 mo, and 4-6 yr booster
2 doses total: if given < 12 mo of age need to repeat after 12 mo of age and at least 4 wks after; rule also applies if given prior to 4 yrs of age
Do not restart series

20. MMR Continued Special Considerations
Avoid pregnancy 4wks after given vaccine, and small theoretical risk of transmission to unim-munized pregnant women – so avoid for 3 mo
May give to child with immune pregnant mother
Born before 1957 – considered immune.
No association with Autism: closest vaccine at age of identification (18-30 mo)
May suppress PPD response, therefore give on same day or after 4 wks

21. MMR Continued Contraindications Anaphylaxis Allergy to neomycin
Immunocompromised patients and only symptomatic HIV patients
Unimmunized pregnant females
Rubella has a 1.6% risk of transmission
MM have a theoretical risk

22. Case #3:
A 15 mo old girl is in for a WCC. She recently arrived from the Phillipines. She is otherwise healthy and has developed well according to her milestones. Exam is unremarkable. According to mom she has only received 4 shots. There is no “yellow” card.

23. Questions to Case # 3:
Would you do catch up starting as if the pt would have never received any vaccines?
The shortest interval between vaccines should be 8 weeks?
Is it harmful to give the same vaccine if already given or pt is immunized?
Would it be recommended to do a serologic titer to check and see if she has been immunized to Hep B?
If this patient was > 5 years she would only need one Hib shot?

24. Haemophilus Influenza type b (ActHib, HibTITER, PedvaxHib)
Intramuscular, protein conjugate
2, 4, 6 mo and mo booster
4 doses total, but:
If 7-11 mo of age: 2 doses plus a booster
If mo of age: 1 dose plus a booster
If mo of age: 1 dose
If > 5 yrs: none required unless high risk (i.e. sickle cell, HIV, asplenia)
Do not restart series

25. Hib Continued Special Considerations
Patients with history of invasive disease do not develop immunity to Hib
Precaution with mod-severe illness
Combination vaccines:
created to decrease the number of injections
still have to be aware of the factors with both vaccines
No increase in side effects.
TriHIBiT; Tetramune; Comvax

26. Hepatitis B (Recombivax and Engerix)
Intramuscular, inactivated viral Ag
10 mcgms 0-19 yrs
20 mcgms > 20 yrs
birth-2mo, 1-4mo, 6-18mo
3 doses total: 2nd dose at least 1 mo after 1st, and 3rd dose at least 2 mo after 2nd and 4 mo after 1st
Do not restart series

27. Hepatitis B Continued Special Considerations
may use the different types interchangeably
HbsAg (+) mother: give baby 1st dose within 12 hrs after birth along with HBIG, then 2nd dose at 1-2 mo, and 3rd at 6 mo of age
Unknown HbsAg status: draw blood, and give 1st dose w/in 12 hrs of birth. If (+) give HBIG (within 1 wk)
Serologic testing: high risk only (Hep C+, health care workers, IVDA users, immunocompromised)
Precaution: mod-severe illness

28. Hepatitis B Continued Contraindications allergy to yeast
prior anaphylaxis

29. Case # 4
A 15 year old boy comes in for a regular check up. Offers no complaints, but notes he has had many ear infections as a child. On exam you note bilateral sclerosis on the tympanic membranes and a LUQ abdominal scar from a splenectomy secondary to trauma. He has never had the chicken-pox.

30. Questions to Case #4 Give 2 doses of varivax 4-8 weeks apart?
Since he is 15 years old there is no need to give him Hep A vaccine?
Since he is 15 years old there is no need to give him PCV?
If he was 12 months of age without a splenectomy, giving him PCV would have prevented a majority of his ear infections?

31. Varicella (Varivax) Subcutaneous, live virus
Target all children without chickenpox hx
12mo - 18mo, but <12 yrs of age: 1 dose
> 13 yrs: 2 doses, 4-8 wks apart
CDC recom Childcare and Kindergarten to require immunity (active or passive)
Efficacy 70-90% complete protection and >95% protection against severe disease = >50 lesions
durable protection: humoral and cell mediated immune responses

32. Varicella Continued Special Considerations
Sfx: pain, redness and swelling
~5% develop a chickenpox-like rash (~5 lesions)
May interfere with TB skin test, so give it on same day or wait at least 4 wks
Avoid ASA use for 6 wks => poss Reye’s Syn
Contraindications
Anaphylaxis, allergy to neomycin and immuno-deficient

33. Hepatitis A (Havrix & Vaqta)
Intramuscular, inactivated viral Ag
Target all children in high risk areas (Calif)
2 doses total:
> 24 mo of age: 1st dose, then 6 mo after
Pre-exposure prophylaxis:
complete series < 2wks prior to exposure
Foreign travel, health care workers, outbreaks
Post-exposure:
Use IgG within 2 wks followed by vaccine
Contraindications
Allergy to aluminum

34. Pneumococcus (Prevnar)
Intramuscular, heptavalent protein conjugate
Primary series: 2, 4, 6 and mo
4 doses total: 2nd dose at least 4 wks after 1st, 3rd 4 wks after 2nd, and 4th 6 mo after 3rd
If 2-5 yrs old and healthy: 1 dose only needed
If 2-5 yrs old and high risk: 2 doses 8 wks apart
It is not an Otitis Media vaccine!
Only 6% effective against all Acute OM
It protects against 80-90% of invasive disease
Pneumococcus has > 90 serotypes
Contraindications
hypersensitivity

35. The End