077B INFANT & CHILD IMMUNIZATION (1)

1. 077B INFANT & CHILD IMMUNIZATION (1) • “Discuss the population health benefits of immunization programs” • Probability of contracting communicable disease depends on probability that contacts are already immune, are carriers or have the disease • If sufficient proportion of population is immune, then disease will not spread (herd immunity) • Prevention is usually cheaper and more effective than treatment (if treatment even exists) • Possibility of eradicating some diseases • Implications for school attendance (Ontario) • Mandatory choice vs. mandatory immunization • Exclusion from school for non-immunized children during outbreak

2. Standard immunizationsAge 0-17 • Diphtheria • Tetanus • Pertussis • Polio • H. influenzae B • Mumps • Measles • Rubella • Hepatitis B • Chickenpox (varicella) • Pneumococcus • Meningococcus • Influenza • HPV Taken from: Canadian Immunization Guide, 2007

4. Pneumococcal vaccines (1) • 1,200 cases in Ontario, 2009; pneumonia and meningitis; 4% case fatality rate • Prevnar 13—13 valent pneumococcal conjugate vaccine to protect under age 6 years • Introduced fall 2010 • Routine doses at 2, 4, 12 months of age • 4 doses at 2, 4, 6 and 15 months if chronic disease • Replaced Prevnar (7 valent) due to emergence of 3, 7F and 19A as frequently reported serotypes • 19A is becoming resistant to first line antibiotics • Conjugated with diphtheria toxoid but does not protect against diphtheria • At 12 months, child receives Prevnar 13, Meningococcal C conjugate and MMR vaccines

5. Pneumococcal vaccines (2) 2. Pneumococcal polysaccharide 23 valent vaccine • Anyone age 2 or older with chronic conditions: moderate-severe respiratory, cardiac, cirrhosis, renal, diabetes, asplenia, sickle-cell, CSF leak, immune deficiency, cochlear implant recipients • U.S. adding any asthma and cigarette smoking • Booster dose 3-5 years later • Age 65 years or older—everyone • Residents of nursing homes and chronic care facilities—everyone • 50-80% effectiveness among the immunocompetent

6. Meningococcal vaccines • Meningococcal C Conjugate Vaccine • Give one dose at 12 months • May be offered in Grade 7 or age 14-16 for those unimmunized • Meningococcal ACYW-134 Quadrivalent Conjugate Vaccine 2-55 years if asplenic, complement, properdin or factor D deficiency, or cochlear implant recipient • Meningococcal ACYW-135 Quadrivalent Polysaccharide Vaccine Over 55 years for same indications as (2)

7. Human Papilloma Vaccine (HPV) (1) • Protects against 4 strains of HPV • Types 16 and 18 (linked to 70% of cervical cancer and 80% of anal cancer) • Types 6 and 11 (linked to 90% of anogenital warts) • Gardasil: all 4 types; age 9-26 • Health Canada approved to prevent cancer and warts in females but warts only in males • U.S. FDA approved to prevent cancer and warts in females and males • Cervarix: types 16 and 18, females 9-26

8. Human Papilloma Vaccine (HPV) (2) • Need three doses (at times 0, 2 and 6 months) • Give prior to sexual activity, once active, with previous pap abnormalities or have had a previous HPV infection • However, 40% of women become infected with HPV within 16 months after initiation of sexual activity • Ontario: grade 8 girls in school • Routine vaccination of boys would be useful

9. 077B INFANT & CHILD IMMUNIZATION (2) • “State that a lapse in immunization schedule does not require re-instituting the initial series, merely giving it at the next visit” • You can give a dose too early; you cannot give a dose too late

10. 077B INFANT & CHILD IMMUNIZATION (3) • “Communicate to patients and parents about vaccine benefits and risks” • Obtain an immunization history on all children • Late immunization is still very effective • Immigrants require special attention • Depends on availability of good records; countries have different immunization coverage • When in doubt, start the series again; see Canadian Immunization Guide

11. 077B INFANT & CHILD IMMUNIZATION (4) • Travel • Update regular immunizations • High risk exposure: BCG, cholera, hepatitis A, typhoid, rabies • Meningococcal quadrivalent for meningitis belt and Hajj • Influenza if the right season • Follow legal requirements • Yellow fever (strict) • Cholera (some countries may require; medical exemption letter can be provided)

12. 077B INFANT & CHILD IMMUNIZATION (3) • “Discuss misconceptions about immunization contraindications” • Following are not contraindications: • Mild/moderate local reactions to previous dose • Mild acute illness with or without fever • Taking antibiotics • Allergy to penicillin, duck, molds, pollens • Positive Mantoux TB skin test • TB skin test at same time or one month after live vaccine dose • Breast feeding • Asplenia • Prior febrile seizure reaction (consider prophylactic acetaminophen)

13. 077B INFANT & CHILD IMMUNIZATION (4) • “List possible complications of immunization” • Seizures (secondary to fever) • Anaphylaxis (differentiate from fainting) • Neurological damage (rarely associated) • Casual rather than causal relationship • e.g., no good evidence for MMR causing autism • Introduction of acellular pertussis reduced febrile seizures dramatically and was much more protective

14. 077B INFANT & CHILD IMMUNIZATION (5) • “Discuss immunization of immuno-compromised children (e.g., asplenia, chronic diseases or seizures)” • Asplenia (surgical or congenital/functional) • No contraindication to any vaccine • Particularly need protection against encapsulated bacteria: Streptococcus pneumoniae, Haemophilus influenzae B, Neisseria meningitidis (A,C,Y, W135), to which these individuals are highly susceptible. • Immunosuppression • Avoid live vaccines • Follow regular immunization schedule • High dose steroids can mute immune response • Congenital immunodeficiency • Read the Canadian Immunization Guide!