2. PEDIATRIC IMMUNIZATIONS by Dr Aguilera Goals and Objectives 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

3. 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= 99.9. 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.

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

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

6. Missed Immunizations Cont’d Conclusions: 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

7. Immunization Schedule - 1983

8. Immunization Schedule - 1996

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

10. Immunization Schedule - 2004

11. Changes in the Schedule - 2004 Hep B at birth is still appropriate Hep B at birth is still appropriate In addition to Hep A, vaccines for selected populations include Influenza and PCV #5 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 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 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 The number of vaccines required for a child by age 5-6 years has increased to >25

12. 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.

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

14. Diphtheria, Tetanus and Pertussis (DTaP, DT, Td) Intramuscular toxoids and inactivated bac. Ag Intramuscular toxoids and inactivated bac. Ag 2, 4, 6, 15-18 mo and 4-6 yr booster; Td booster 11-16 yrs, and every 10 yrs thereafter 2, 4, 6, 15-18 mo and 4-6 yr booster; Td booster 11-16 yrs, and every 10 yrs thereafter 5 doses total: 2 nd dose at least 4 wks from 1 st ; 3 rd dose 4 wks from 2 nd ; 4 th dose 6 mo from 3 rd ; and 5 th dose 6 mo from 4 th dose. 5 doses total: 2 nd dose at least 4 wks from 1 st ; 3 rd dose 4 wks from 2 nd ; 4 th dose 6 mo from 3 rd ; and 5 th dose 6 mo from 4 th dose. #5 not necessary if #4 given after 4 years of age #5 not necessary if #4 given after 4 years of age Do not restart series Do not restart series

15. DTaP Continued Special Considerations: 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

16. DTaP Continued Contraindications 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

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

18. IPV Continued Special Considerations 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

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

20. Measles, Mumps and Rubella (MMR) Subcutaneous, live virus Subcutaneous, live virus 12-15 mo, and 4-6 yr booster 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 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 Do not restart series

21. MMR Continued Special Considerations 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

22. MMR Continued Contraindications 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

23. 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. 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.

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

25. Haemophilus Influenza type b (ActHib, HibTITER, PedvaxHib) Intramuscular, protein conjugate Intramuscular, protein conjugate 2, 4, 6 mo and 12-15 mo booster 2, 4, 6 mo and 12-15 mo booster 4 doses total, but: 4 doses total, but:  If 7-11 mo of age: 2 doses plus a booster  If 12-14 mo of age: 1 dose plus a booster  If 15-59 mo of age: 1 dose  If > 5 yrs: none required unless high risk (i.e. sickle cell, HIV, asplenia) Do not restart series Do not restart series

26. Hib Continued Special Considerations 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

27. Hepatitis B (Recombivax and Engerix) Intramuscular, inactivated viral Ag Intramuscular, inactivated viral Ag  10 mcgms 0-19 yrs  20 mcgms > 20 yrs birth-2mo, 1-4mo, 6-18mo 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 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 Do not restart series

28. Hepatitis B Continued Special Considerations 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

29. Hepatitis B Continued Contraindications Contraindications  allergy to yeast  prior anaphylaxis

30. 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. 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.

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

32. Varicella (Varivax) Subcutaneous, live virus Subcutaneous, live virus Target all children without chickenpox hx 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) CDC recom Childcare and Kindergarten to require immunity (active or passive) Efficacy 70-90% complete protection and >95% protection against severe disease = >50 lesions Efficacy 70-90% complete protection and >95% protection against severe disease = >50 lesions durable protection: humoral and cell mediated immune responses durable protection: humoral and cell mediated immune responses

33. Varicella Continued Special Considerations 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 Contraindications  Anaphylaxis, allergy to neomycin and immuno- deficient

34. Hepatitis A (Havrix & Vaqta) Intramuscular, inactivated viral Ag   Target all children in high risk areas (Calif)   2 doses total:   > 24 mo of age: 1 st 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

35. Intramuscular, heptavalent protein conjugate Intramuscular, heptavalent protein conjugate Primary series: 2, 4, 6 and 12-15 mo Primary series: 2, 4, 6 and 12-15 mo 4 doses total: 2 nd dose at least 4 wks after 1 st, 3 rd 4 wks after 2 nd, and 4 th 6 mo after 3 rd 4 doses total: 2 nd dose at least 4 wks after 1 st, 3 rd 4 wks after 2 nd, and 4 th 6 mo after 3 rd  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! It is not an Otitis Media vaccine!  Only 6% effective against all Acute OM It protects against 80-90% of invasive disease It protects against 80-90% of invasive disease  Pneumococcus has > 90 serotypes Contraindications Contraindications  hypersensitivity Pneumococcus (Prevnar)

36. The End The End