1. Immunizations Childhood and Adolescent Jan Bazner-Chandler CPNP, MSN, CNS, RN

2. What Immunization Is • Immunization is the process by which a subject is rendered immune or resistant to a specific disease • Natural exposure – contact with the agent • Artificial exposure – parts of the infectious agent or inactivated version is given for the purpose of becoming immune to the disease agent it causes.

3. Childhood Immunization • Childhood immunization schedule CDC • www.CDC.gov/vaccines • Download children age 0 - 6 • Download children age 7 - 18 American Academy of Pediatrics: http://www.aap.org

4. Administering Immunizations • Hand washing • Gloves NOT required (only if potential exposure to body fluids from a lesion) • Proper equipment and means of needle disposal

5. Administering Immunizations • 1 or 3 mL syringe with 22-25 g needle • OSHA recommends needle safety device • Check expiration date • Document lot number on chart • Site: • Thigh for infant less than 1 year • Upper outer triceps for greater than 1 year

6. Hepatitis B (HepB) Vaccine • All infants should receive the first dose before hospital discharge. • Second dose - 4 weeks after the first • Third dose - 16 weeks after the first dose and at least 8 weeks after the second dose • Infants born of HBsAg-postive mothers should receive first immunization within 12 hours of birth as well as HBIG.

7. Diphtheria, Tetanus, Acellular Pertussis • DTaP • Given at 2, 4 and 6 months • 4th dose between 15 and 18 months • Last DTaP at the 4-6 year pre-K check up • 1st Tdap at age 11-12 years or at least 5 years from last DTap • Tetanus every 10 years after that

8. Diphtheria • Called “strangling angel of children” • One of the most common causes of death among children pre-vaccine era • Vaccine developed in 1920’

9. Tetanus • Acute illness characterized by an acute onset of hypertonia, painful muscular contraction (muscles of jaw and neck, and generalized muscle spasms • Clostridium tetani is found in soil, house dust, animal intestines and human feces • Vaccine developed in 1924 • Very few reported cases

10. Pertussis • Highly contagious disease involving the lungs and airways. • Caused by Bordetella pertussis found in nose, mouth and throat of the infected person. • Overall increase in recent years in adolescents and adults.

11. Cocooning • New term for 2010 • Strategy to protect the newborn up to 6 month old from pertussis or “whooping cough” • Booster available for adults Tdap • The goal to immunize all adults who interact with infants to prevent pertussis

12. Polio • Injection form given at 2 months, 4 months after 6 months and at kindergarten check-up • Oral not given due to shedding virus in stool

14. Incidence of polio • WHO - 650 cases report • Nigeria • Pakistan • Afghanistan • China

15. Haemophilus Influenza Type b • Hib • Given at ages 2 and 4 months and 12 months • Any child entering child care or pre-kindergarten under age 5 years in California are required to have Hib. • Not a standard immunization for children born outside the USA

16. Why? • Haemophilus influenzae type B (Hib) disease is a serious disease caused by bacteria. It usually strikes children under 5 years of age. • Leading cause of bacterial meningitis in children under 5 years • Pneumonia • Epiglottitis – severe swelling of epiglottis – resulting in death for obstruction of breathing • Before Hib immunization 20,000 children per year had the infectious disease with 1000 deaths per year.

17. Incidence • Increase incidence in England, Wales and Pacific Islands

18. Measles, Mumps, Rubella • MMR • Two doses: • 1st 12 months or older • 2nd dose kindergarten visit • If no record of second dose it should be given at 11 to 12 year old visit • May develop a rash a week to ten days after immunization • Not immunized against wild strain – exposure would bring milder case

19. Incidence of Measles • Outbreak in LA in 2011 • Contact point airplane • 12 month old who had not received the immunization yet • 19 month un-immunized • 220 cases in 2011 all of the results of US citizens returning from international travel • New recommendation: if infant is traveling international MMR is give as early as 9 months with a booster after 12 months

20. Mumps outbreak • 2010 in New York 1500 Orthodox Jews over had case of mumps during a 7 month period. • One un-immunized child at camp from England spread the disease. • Why a problem? • Complications • Hearing loss • Testicle swelling - infertility

21. Varicella • Chicken pox – recommended at 12 – 15 months and second dose at 4-6 years or kindergarten visit • Un-immunized children over 13 years would receive two doses at least 4 weeks apart

22. Varicella • Contraindication: allergy to immunization, pregnancy or possibility of pregnancy within 4 wks • Children on high dose immunosuppressive therapy or immuno-compromised HIV / AIDS – vaccination can be given if CD4 T-lymphocyte percentages or 15% or greater. • Precautions: • if blood, plasma or immune globulin given within the past 11 months. • Antiviral drugs 24 hours before or 14 days after immunization

23. Chicken Pox Parties • Fact or fiction?

24. Shingles • Varicella virus dormant in nerve roots • Shingles rash appears on one side of the face or body and lasts from 2 to 4 weeks • Only someone who has had chickenpox can get shingles. The virus stays in your body and can cause shingles many years later. • New recommendation: a single dose of singles vaccine is recommended for adults 60 years of age and older.

25. Pneumococcal Vaccine • PCV - Prevnar • Recommended for all children 2 to 23 months and certain populations up to 59 months • 2, 4, 6 and 4th dose after 12 months of age • High risk populations • Asthma • Sickle cell anemia • Cystic fibrosis

26. Human Papillomavirus • HPV is the most common sexually transmitted virus • 40 types of HPV • Spread through sexual contact • Can cause cervical cancer • Can also cause genital warts

27. Human Papillomavirus • HPV series • Recommended for all girls 11-12 years • Can be given as young as 9 years • Get HPV before first sexual contact and by 26 years of age • 1st dose • 2nd dose 2 months after 1st dose • 3rd dose 6 months after dose one

28. HPV • Contraindications: • Allergy to yeast or reaction to first immunization • HPV will not help if already infected

29. HPV - males • Gardasil will protect males against genital warts.

30. Meningococcal meningitis • Meningococcal disease is a serious illness • Leading cause of bacterial meningitis in 2 – 28 year old in USA • Also called Neisseria meningtides • High risk populations • High school students • College age students • Military – boot camp • Travel to third-world countries

31. Meningococcal polysaccharide Vaccine • MPSV4 • Prevents 4 types of meningococcal diseases – 2 out of 3 of the most common strains seen in the US

32. Recommendations • MPSV4 recommended for all children at their routine preadolescent visit (11 – 12 years) • College freshmen living in dorms • U.S. military recruits • Traveling to Africa • Persons exposed to meningitis outbreak

33. Influenza (Flu) Vaccine • “Flu shot”: Inactivated vaccine containing the virus • Approved for infants older than 6 months • Nasal spray flu vaccine: live, weakened flu viruses • Approved for children over 5 years to 49 years.

34. When to get Flu Vaccination? • October or November yearly

35. Contraindications to Flu Vaccine • Children with severe allergy to chicken eggs. • Severe reaction to influenza vaccination in the past. • Less than 6 months of age. • Children who have developed Guillain-Barre syndrome after previous immunization. • Do not give if child has moderate to severe illness with fever until a later date.

36. Rotavirus • Rotavirus causes severe diarrhea • Rotarix (RV1) or RotaTeq (RV5) given at 2, 4 and 6 months • First dose may be given as early as 6 weeks • Give final dose no later than 8 months of age • Contraindications: allergy to previous immunization or allergy to latex (use RV5) • Precaution: moderate or severe illness, moderate to severe acute gastroenteritis or pre-existing gastrointestinal disease or history of Intussusception

37. Rotovirus • Leading cause of severe acute gastroenteritis among children worldwide. • 527,00 deaths worldwide • 85% in Africa and Asia • 2 million hospitalized with severe dehydration

38. Premature Infants • AAP currently recommends that all premature infants receive full dose immunizations at the same chronologic age as term infants even if hospitalized • Contraindications : significant febrile seizure, active seizure disorders, encephalopathy • Infants with BPD (Bronchopulmonary dysplasia) or RAD (Reactive Airway Disease) should receive influenza immunizations • Infants with congenital heart and premature infants immunization against Respiratory Syncytial Virus or RSV.

39. Premature continued • Hepatitis B may be deferred until discharge unless mother is Hep B positive • Do NOT dilute dosages • Usually given when they reach at least 2 kg or 4.4 pounds

40. To Immunize or Not to Immunize • Children on antibiotics • Children with minor illness – otitis, cough, diarrhea, sore throat, low grade fever • Children with mild allergies • Breast feeding infants • Children with pregnant household contacts • All can and should be immunized

41. True Contraindications to immunization • True allergic response • Rash or hives after previous vaccination • Allergy to eggs or egg products should not be given influenza vaccination

42. Reactions to Immunizations • Fever greater than 103, shock or collapse, or inconsolable crying for greater than 3 hours. (DTaP) • Low grade fever, fussiness, and soreness at injection site are not reasons to prevent further vaccinations • Mild rash or fever may occur 10 days to 2 weeks after MMR or Varicella

43. Interventions post immunization • Tylenol every 4 hours for fussiness or low grade fever • Warm bath • NO ASPIRIN • NO Motrin for infants under 6 months of age • AAP recommends Tylenol for all ages due to confusion in dosing.

44. Adolescents • Hepatitis A (recommended only) • Pneumococcal if they have any chronic disease: heart, sickle cell disease, cystic fibrosis, diabetes, or organ transplant or receiving chemotherapy • Hepatitis B • MMR: second booster • D Tap • Varicella if no reliable history or negative titers • Meningococcemia for all college freshman and all military • Influenza yearly

45. Hepatitis A • Recommended for children and adolescents living in selected states or regions and for certain high risk groups • This would include California, Texas, and Arizona • 2 doses 6 months apart

46. L.A. Unified Recommendations • Complete health and immunization record • All new students must have written results of a PPD test for tuberculosis within 12 months • If PPD is positive a chest x-ray is recommended • Treatment is recommended unless the child has some immune suppressed condition.

47. PPD Waiver • I hear by request exemption of the child from the tuberculosis assessment requirement for school / childcare entry because this is contrary to my beliefs. I understand that should there be cause to believe that my child is infected with active TB or should there be a tuberculosis outbreak, my child may be temporarily excluded from school.

48. Pre-school and Child Care • Pre-kindergarteners must be immunized against Haemophilus influenza type B or Hib. • This is not a standard immunization for children born outside the United States • Hib would not be required for a child over 5 years of age.

49. Kindergarten • Second MMR: Measles, Mumps, Rubella • Hepatitis B • Hepatitis A in high risk areas • D Tap: tetanus, diphtheria, pertussis

50. Communicable Diseases • Chicken pox (varicella) • Measles (Rubeola) • Pertussis (Whooping Cough) • Rubella (German Measles) • Scarlet Fever • Mumps