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PEDIATRIC IMMUNIZATIONS by Dr Aguilera

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.

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PEDIATRIC IMMUNIZATIONS by Dr Aguilera

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  1. PEDIATRIC IMMUNIZATIONSby 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= 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.

  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 1999-2000 • All IPV series recommended - 2000 • Hep A recom in selected areas (Ca) - 2000 • 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, 15-18 mo and 4-6 yr booster; Td booster 11-16 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 12-15 mo booster • 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

  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 12-15 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

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