Immunization and RSV/Palivizumab Clinic Update Advances in preventative care for our pediatric population

Immunization and Immunization and RSV/Palivizumab RSV/Palivizumab Clinic UpdateClinic Update

Advances in preventative care for our Advances in preventative care for our pediatric populationpediatric population

Immunization UpdateImmunization Update

The ever changing quagmire of pediatric The ever changing quagmire of pediatric immunization schedulesimmunization schedulesChanges and clarifications for the 2000-2001 Changes and clarifications for the 2000-2001 immunization recommendations for Evans immunization recommendations for Evans Army Community HospitalArmy Community Hospital

Basic Immunization Basic Immunization OverviewOverview

Hepatitis B initial vaccination to be given at Hepatitis B initial vaccination to be given at birth birth

Prevnar (pneumococcal conjugate vaccine) Prevnar (pneumococcal conjugate vaccine) currently in use starting at 2 months, soon to currently in use starting at 2 months, soon to be expandedbe expanded

Selective PPD skin testingSelective PPD skin testing

Current Immunization Current Immunization ScheduleSchedule

Birth 2 Months 4 Months 6 Months 12Months

18Months

4-6Yrs.

11-12Yrs.

Hep B 1 DTaP 1IPV 1Comvax 1Prevnar 1

DTaP 2IPV 2Prevnar 2

DTaP 3IPV 3Comvax 2Prevnar 3

MMR 1Prevnar 4PediVaxHib (#3)VarivaxPPD*

DTaP 4(Varivax)

DTaP 5IPV 4MMR 2PPD*

Td(MMR 2)(Hep Bseries)

* PPD only as clinically required or as required by day care programs or school

Hepatitis B changesHepatitis B changes

Current AAP, ACIP and CDC recommendations Current AAP, ACIP and CDC recommendations encourage changing back to thimerisol-free encourage changing back to thimerisol-free Hepatitis B at birth for all infantsHepatitis B at birth for all infants

Comvax (Hib and Hep B) will be given at 2 months Comvax (Hib and Hep B) will be given at 2 months and 6 monthsand 6 months

PediVax Hib at 12 months will provide the third and PediVax Hib at 12 months will provide the third and final Haemophilius influenza B immunizationfinal Haemophilius influenza B immunization

Prevnar AdditionPrevnar Addition

Prevnar (pneumococcal 7-valent conjugate Prevnar (pneumococcal 7-valent conjugate vaccine) has been added to the routine vaccine) has been added to the routine immunization schedule for all 2 month oldsimmunization schedule for all 2 month olds

Catch-up immunizations for other age groups Catch-up immunizations for other age groups will be initiated at the start of the new year…will be initiated at the start of the new year…based on vaccine availabilitybased on vaccine availability

Current Prevnar Current Prevnar RecommendationsRecommendations

VACCINE SCHEDULE FOR INFANTS AND TODDLERS

Dose 1 Dose 2 Dose 3 Dose 4

2 Months 4 Months 6 Months 12-15 Months

May be given asearly as 6 weeks

Dosing interval is 4-8 weeks Should be given at least 2months after third dose

VACCINE SCHEDULE FOR UNVACCINATED CHILDREN 7 MONTHS OF AGE

Age at first dose Total doses Dosing information

7-11 Months 3 2 doses at least 4 wks apart, 3rd dose after 12months of age and 2 months after 2nd dose

12-23 Months 2 2 doses at least 2 months apart.

24 Months to 9years

1 One dose

* PPD only as clinically required or as required by day care programs or school

Tuberculin Skin TestingTuberculin Skin Testing

The TST is the only practical tool for diagnosing The TST is the only practical tool for diagnosing tuberculosis infection in asymptomatic persons. tuberculosis infection in asymptomatic persons. The Mantoux test containing 5 tuberculin units (TU) The Mantoux test containing 5 tuberculin units (TU) of purified protein derivative (PPD), administered of purified protein derivative (PPD), administered intradermally, is the recommended TST. Other intradermally, is the recommended TST. Other strengths of Mantoux skin tests (1 or 250 TU) strengths of Mantoux skin tests (1 or 250 TU) should not be used. Multiple puncture tests are not should not be used. Multiple puncture tests are not recommended because they lack adequate recommended because they lack adequate sensitivity and specificity.sensitivity and specificity.


The AAP recommends a TST for children who are at The AAP recommends a TST for children who are at increased risk of acquiring tuberculosis infection and increased risk of acquiring tuberculosis infection and disease. disease. Routine TST administration, including Routine TST administration, including school-based programs that include populations at school-based programs that include populations at low risk, that has either a low yield of positive results low risk, that has either a low yield of positive results or a large number of false-positive results represents or a large number of false-positive results represents an inefficient use of health care resources.an inefficient use of health care resources. Children Children without risk factors, including children who are without risk factors, including children who are younger than 1 year of age, do not need routine TSTs.younger than 1 year of age, do not need routine TSTs.


Previous immunization with bacille Calmette-Guérin Previous immunization with bacille Calmette-Guérin (BCG) is not a contraindication to TST skin testing.(BCG) is not a contraindication to TST skin testing.

Current guidelines from the CDC, American Current guidelines from the CDC, American Thoracic Society, and the AAP accept 15 mm or Thoracic Society, and the AAP accept 15 mm or greater of induration as a positive TST result for any greater of induration as a positive TST result for any person. Interpretation of 5 mm or more or 10 mm or person. Interpretation of 5 mm or more or 10 mm or more induration from a TST is outlined in the Red more induration from a TST is outlined in the Red Book.Book.

Children for whom Children for whom immediateimmediate TST is indicated: TST is indicated:

Contacts of persons with confirmed or suspected Contacts of persons with confirmed or suspected infectious tuberculosis; including children identified as infectious tuberculosis; including children identified as contacts of family members or -associates in jail or contacts of family members or -associates in jail or prison during the last 5 yearsprison during the last 5 years

Children with radiographic or clinical findings Children with radiographic or clinical findings suggesting tuberculosis diseasesuggesting tuberculosis disease

Children immigrating from endemic countriesChildren immigrating from endemic countries Children with travel histories to endemic countries Children with travel histories to endemic countries

and/or significant contact with indigenous persons from and/or significant contact with indigenous persons from such countriessuch countries

Children who should have Children who should have annual TST :annual TST :

Children infected with HIV or living in Children infected with HIV or living in household with HIV-infected persons.household with HIV-infected persons.

Incarcerated adolescentsIncarcerated adolescents

Children who should be Children who should be tested every 2–3 years:tested every 2–3 years:

Children exposed to the following persons: Children exposed to the following persons: HIV-infected, homeless, residents of nursing HIV-infected, homeless, residents of nursing homes, institutionalized adolescents or homes, institutionalized adolescents or adults, users of illicit drugs, incarcerated adults, users of illicit drugs, incarcerated adolescents or adults, and migrant farm adolescents or adults, and migrant farm workers; foster children with exposure to workers; foster children with exposure to adults in the preceding high-risk groups are adults in the preceding high-risk groups are includedincluded

Considerations for TST at 4–6 Considerations for TST at 4–6 and 11–16 years of age:and 11–16 years of age:

Children whose parents immigrated (with unknown Children whose parents immigrated (with unknown TST status) from regions of the world with high TST status) from regions of the world with high prevalence of tuberculosis; continued potential prevalence of tuberculosis; continued potential exposure by travel to the endemic areas and/or exposure by travel to the endemic areas and/or household contact with persons from the endemic household contact with persons from the endemic areas (with unknown TST status) should be an areas (with unknown TST status) should be an indication for a repeated TSTindication for a repeated TST

Children without specific risk factors who reside in Children without specific risk factors who reside in high-prevalence areashigh-prevalence areas

Interpretation of TST Results:Interpretation of TST Results: Induration >5 mmInduration >5 mm

Children in close contact with known or suspected Children in close contact with known or suspected contagious cases of tuberculosis disease:contagious cases of tuberculosis disease:• Households with active or previously active cases if Households with active or previously active cases if

treatment cannot be verified as adequate before treatment cannot be verified as adequate before exposure, treatment was initiated after the child’s exposure, treatment was initiated after the child’s contact, or reactivation of latent tuberculosis infection is contact, or reactivation of latent tuberculosis infection is suspectedsuspected


Children suspected to have tuberculosis disease:Children suspected to have tuberculosis disease:• Chest radiograph consistent with active or previously Chest radiograph consistent with active or previously

active tuberculosisactive tuberculosis• Clinical evidence of tuberculosis disease†Clinical evidence of tuberculosis disease†

Children receiving immunosuppressive therapy‡ or Children receiving immunosuppressive therapy‡ or with immunosuppressive conditions, including HIV with immunosuppressive conditions, including HIV infectioninfection


Children at increased risk of disseminated Children at increased risk of disseminated disease:disease:• Young age: younger than 4 years of ageYoung age: younger than 4 years of age• Other medical conditions, including Hodgkin Other medical conditions, including Hodgkin

disease, lymphoma, diabetes mellitus, chronic disease, lymphoma, diabetes mellitus, chronic renal failure, or malnutritionrenal failure, or malnutrition


Children with increased exposure to tuberculosis Children with increased exposure to tuberculosis disease:disease:• Born or whose parents were born in high-prevalence Born or whose parents were born in high-prevalence

regions of the worldregions of the world• Frequently exposed to adults who are HIV-infected, Frequently exposed to adults who are HIV-infected,

homeless, users of illicit drugs, residents of nursing homeless, users of illicit drugs, residents of nursing homes, incarcerated or institutionalized persons, and homes, incarcerated or institutionalized persons, and migrant farm workersmigrant farm workers

Travel and exposure to high-prevalence regions of Travel and exposure to high-prevalence regions of the worldthe world


Children 4 years of age or older without any Children 4 years of age or older without any risk factorsrisk factors

Treatment of latent Treatment of latent tuberculosis infectiontuberculosis infection

Isoniazid daily for 9 monthsIsoniazid daily for 9 months Other regimens as noted in the Red BookOther regimens as noted in the Red Book

RSV/Palivizumab RSV/Palivizumab ClinicClinicUpdateUpdate

Advances in preventative care for our Advances in preventative care for our pediatric populationpediatric population

Respiratory Syncytial Virus Respiratory Syncytial Virus EpidemiologyEpidemiology

100% of infants by 2 yrs infected with RSV100% of infants by 2 yrs infected with RSV 40 % of infants with bronchopulmonary 40 % of infants with bronchopulmonary

dysplasia (BPD) hospitalized with RSV by 1 dysplasia (BPD) hospitalized with RSV by 1 year oldyear old

90,000 hospitalizations with 2% (4,500) deaths 90,000 hospitalizations with 2% (4,500) deaths annually annually

Risk of development of asthma after RSV Risk of development of asthma after RSV infectionsinfections

Prior Treatment OptionsPrior Treatment Options

Mostly supportive with oxygen Mostly supportive with oxygen supplementation and respiratory assistancesupplementation and respiratory assistance

Antiviral agent ribavirin only approved Antiviral agent ribavirin only approved treatmenttreatment• Efficacy and use are controversialEfficacy and use are controversial

Prophylactic infusions with Respiratory Prophylactic infusions with Respiratory Syncytial Virus Immune Globulin (RSV-IGIV, Syncytial Virus Immune Globulin (RSV-IGIV, Human)Human)

Introduction of PalivizumabIntroduction of Palivizumab

First monoclonal antibody for the prevention First monoclonal antibody for the prevention of diseaseof disease

Prophylaxis results in:Prophylaxis results in:• 55% decrease in hospitalization due to RSV55% decrease in hospitalization due to RSV• 78% decrease in RSV hospitalization for infants 78% decrease in RSV hospitalization for infants

without BPDwithout BPD• 39% decrease in RSV hospitalization for infants 39% decrease in RSV hospitalization for infants

with BPDwith BPD

Introduction of PalivizumabIntroduction of Palivizumab

Prophylaxis results in:Prophylaxis results in:• Fewer total RSV hospital daysFewer total RSV hospital days• Fewer RSV hospital days on supplemental Fewer RSV hospital days on supplemental

oxygenoxygen• Lower incidence of ICU admissionLower incidence of ICU admission

Safe and well tolerated with no significant Safe and well tolerated with no significant reported adverse effectsreported adverse effects

Palivizumab RegimenPalivizumab Regimen

Monthly administration of medicationMonthly administration of medication Dose of 15 mg/kg by intramuscular injectionDose of 15 mg/kg by intramuscular injection Provided during anticipated high RSV Provided during anticipated high RSV

season:season:• October through MarchOctober through March

High-Risk Infant Inclusion High-Risk Infant Inclusion CriteriaCriteria

Infants with CLD up to 2 yrs with medical Infants with CLD up to 2 yrs with medical intervention within 6 monthsintervention within 6 months

Infants born up to 28 wk EGA without CLD if less Infants born up to 28 wk EGA without CLD if less then 12 months at onset of RSV seasonthen 12 months at onset of RSV season

Infants born between 28-32 wk EGA if less then 6 Infants born between 28-32 wk EGA if less then 6 months at onset of RSV seasonmonths at onset of RSV season

Infants born between 32-35 wk EGA if less then 6 Infants born between 32-35 wk EGA if less then 6 months at onset of RSV season and increased risk months at onset of RSV season and increased risk factor for infectionfactor for infection

High-Risk Infant Inclusion High-Risk Infant Inclusion CriteriaCriteria

Selected factors that increase RSV disease severity:Selected factors that increase RSV disease severity:• prematurityprematurity• chronic lung diseasechronic lung disease• male sexmale sex• congenital heart diseasecongenital heart disease• low socioeconomic statuslow socioeconomic status• T-cell immunodeficiency T-cell immunodeficiency

EACH Synagis ClinicEACH Synagis Clinic

Held monthly from October to March Held monthly from October to March (anticipated)(anticipated)

Located in Carson Care ClinicLocated in Carson Care Clinic Contact Janet Meuth or LTC Chandler with Contact Janet Meuth or LTC Chandler with

patient informationpatient information

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Immunization and RSV/Palivizumab Clinic Update Advances in preventative care for our pediatric population