Pediatric Immunizations Part 1 · +Rota2 +Rota3 لك ءاطعلا ةصصخملا رامعلاا طقف بولطم :ميعاطملا نم عون تاديلاسلاا يف ةدوجوملا

Pediatric Immunizations Part 1

Prepared by : Dr.Latifa Mari’e

Pediatric Immunizations

A moment’s cry in the name of prevention


+Rota1

+Rota2

+Rota3

االعمار المخصصة العطاء كل

مطلوب فقط : نوع من المطاعيم

االعمار الموجودة في االساليدات

. 4-3رقم

غير ذلك فهو غير مطلوب


• 1st +10th grade (td and opv for 1st class)


Name some

vaccine preventable

diseases


Vaccine Preventable Diseases • Tetanus

• Diphtheria

• Pertussis (Whooping Cough)

• Hemophilis influenza type b (Hib)

• Polio

• Hepatitis A

• Hepatitis B

• Rotavirus

• Mumps

• Measles

• Rubella (German Measles)

• Varicella (Chickenpox)

• Pneumococcus

• Meningococcus

• Influenza

• Human Papilloma Virus

(HPV)


Vaccine Preventable Diseases

• Herd immunity plus aggressive

immunization has made most of these

diseases rare

• Most current residents and medical

students haven’t seen these diseases


Herd Immunity

• Most of population immunized

• Disease itself still exists, but spread

prevented by lack of available hosts

• Unimmunized person less likely to

come in contact with infected

person


Vaccine Preventable Diseases

• To comprehend why we

immunize, you

– Need to have basic childhood disease

knowledge

– Need to know the combinations of

vaccines available to prevent the

illnesses




is a vaccine primarily used against tuberculosis (TB). In

countries where tuberculosis or leprosy is common, one dose is

recommended in healthy babies as close to the time of birth as

possible

Rates of protection against tuberculosis infection vary widely

and protection lasts up to twenty years

Bacillus Calmette–Guérin (BCG) vaccine

https://en.wikipedia.org/wiki/Vaccine

https://en.wikipedia.org/wiki/Tuberculosis

https://en.wikipedia.org/wiki/Leprosy


• BCG is given as a single intradermal injection

at the insertion of the deltoid

• BCG vaccine may cause side effects:

• swollen lymph nodes.

• small red areas at the site of injection.

• fever.

• blood in the urine.

• frequent or painful urination.

• upset stomach.

• vomiting.

https://en.wikipedia.org/wiki/Intradermal

https://en.wikipedia.org/wiki/Deltoid_muscle


• BCG complications can cause

significant morbidity in children and

anxiety in their parents.

Local adverse reactions include

regional suppurative and non-

suppurative

lymphadenitis, injection site

abscesses, persistent injection site

reactions, ulceration and uncommonly

keloid reactions


Diphtheria • Caused by Corynebacterium

diphtheriae

• Incubation 2-5 days

• Early – malaise, sore throat, difficulty in

swallowing, loss of appetite, hoarseness,

mild fever

• Within 2-3 days, adherent, gray

membrane on oral mucous membranes – Extensive membrane - life-threatening airway obstruction.

• Toxin – serious systemic complications including myocarditis

• Death rate 5%-10% Photo from www.cdc.gov. Image in public domain.

http://www.cdc.gov/


Tetanus

• Spread by contact with soil containing

bacterium Clostridium tetani

• Most infections from contaminated

wounds

• Incubation 1-2 weeks

• Not contagious

• Produces exotoxin


Tetanus • 1-2 weeks after infection – progressive

muscle tightening, descending pattern – Trismus (lockjaw)

– Neck stiffness

– Difficulty swallowing

– Abdominal muscle rigidity

• Neonatal tetanus due to no maternal immunity and cutting the umbilical cord with a contaminated instrument (e.g. bamboo in Haiti)


Tetanus

Neonatal tetanus

This patient is displaying a bodily posture known as “opisthotonos” due to tetanus.

Child with painful muscle contractions from tetanus

Photos from www.cdc.gov. Images in public domain.

http://www.cdc.gov/


Pertussis • Caused by Bordetella pertussis

• Highly contagious

• 90% of household contacts will acquire

• Starts as URI

• After 1-2 weeks – paroxysms of severe coughing followed by “whoop” with loud inspiration

• Worse for very young Photo from www.cdc.gov. Image in public domain.

http://www.cdc.gov/


Pertussis

• Symptoms can last several weeks

– Severe coughing

– Whooping

– Post-tussive vomiting

• 1 in 10 cases develop pneumonia

• 1 in 50 cases develop convulsions

• 1 in 250 cases develop encephalopathy


DTaP

• Capital letter denotes full dose vaccine

• Small “a” for acellular

• Compared to Td or Tdap

– Small letter denotes half dose vaccine for

booster effect

• Diphtheria and Pertussis vaccines only

given as combination with Tetanus


DTaP

• Diphtheria

• Tetanus

• Acellular pertussis

• Primary series

– 2, 4, 6 months

– 12-18 months (at least 6 months from the 3rd dose)

– 4 years

– 12-14 years Tdap

– Then Td boosters every 10 years


DTaP • Contraindications

– Severe allergic reaction (e.g., anaphylaxis) after a previous

vaccine dose or to a vaccine component

– Encephalopathy (e.g., coma, decreased level of

consciousness; prolonged seizures)

• not attributable to another identifiable cause

• within 7 days of administration of previous dose of DTP or DTaP

– Progressive neurologic disorder

• including infantile spasms

• uncontrolled epilepsy

• progressive encephalopathy

– Defer DTaP until neurologic status clarified and stabilized


DTaP • Precautions

– Temperature of >104°F (>40.5°C) • For <48 hours after a previous dose of DTP or DTaP

– Collapse or shock-like state • Occurs <48 hours after a previous dose of DTP/DTaP

– Seizure • <3 days after a previous dose of DTP/DTaP

– Persistent, inconsolable crying • lasting >3 hours within 48 hours of a dose of DTP/DTaP

– Guillain-Barre syndrome (GBS) • <6 weeks after dose of tetanus toxoid-containing vaccine

– Moderate or severe acute illness with or without fever


Safe Situations to Administer DTaP

• Temperature of <105°F (<40.5°C) after dose

• Fussiness after dose

• Mild drowsiness after dose

• Family history of seizures

• Family history of sudden infant death syndrome

• Family history of an adverse event after vaccine

• Stable neurologic conditions

– cerebral palsy

– well-controlled seizure disorder

– developmental delay


Polio

• Very infectious virus

• Up to 95% of people infected

with polio have no symptoms

• 4-8% minor symptoms –

fatigue, myalgias, stiffness

• <1% have paralysis from virus

attacking motor neurons

Photo from www.cdc.gov. Image in public domain.

http://www.cdc.gov/


IPV • Inactivated polio vaccine

• 4 dose series – 2, 4, 6-18 months

– Booster at 4 years

• Dose 4 must be 6 months after 3rd dose

• If dose 3 is after 4 years old and >6 months from dose 2, a 4th dose is not needed

• If 4 doses received prior to 4 years old, a 5th dose is required


contraindications

• Previous anaphylactic rxn

• Precautions

• Moderate to severe acute illness

• pregnancy


Hepatitis B

• Viral infection can be

transmitted perinatally from

Hepatitis B infected mothers

• Symptoms range from none

to severe hepatitis & liver

failure

• Up to 90% of infected

neonates become chronic carriers

Ascites and jaundice due to liver failure.

Photo by Charle Goldberg, M.D. http://meded.ucsd.edu/clinicalmed/abdomen.htm

http://meded.ucsd.edu/clinicalmed/abdomen.htm


Engerix-B® (HBV) • Recombinant Hepatitis B

• 3 doses, given IM

• Dose should be given shortly after birth

– If not given to infant

• Document your order to hold vaccine

• Copy of negative maternal Hepatitis B surface antigen

(HbsAg) in chart and documented by physician

• If mom HBsAg positive

– Give HBV and Hepatitis B immunoglobulin (HBIG) within 12

hours of birth

– Test for HbsAg and HbsAb 1-2 months after completed

vaccine series at age 9-18 months


Contraindications • Previous anaphylactic rxn

• Precautions

• Moderate to severe acute illness


Hemophilus Influenza B (Hib)

• Prior to vaccine, Hib was leading cause of

childhood

– Bacterial meningitis

– Epiglottitis

– Pneumonia

– Empyema

– Pericarditis

– Bacteremia

– Septic arthritis Photo courtesy of Children’s Immunization Project, St. Paul, Minnesota



• 2 vaccines available

– 1 is 3-dose series (PedvaxHIB®)

– 1 is 4-dose series (ActHIB®)

• Vaccines are interchangeable

– If changed at 2 or 4 months of age, need a

6-month dose of either vaccine

– Either vaccine may be given for the

12-month booster dose

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• Cannot give any form of Hib to

infants less than 6 weeks old

– Have decreased immune response to

polysaccharide capsule (PRP) of Hib

• May also prevent future ability to develop

antibodies


Tanya exclaims, “Those are scary

diseases! That’s a lot of shots!”

Case

Do any vaccines come in combination?

YES!

Case


Combination Vaccines

• Many vaccines come in

combinations

• However, different manufacturers

make different components

– Multiple different combinations

– Vaccination schedule may vary based

on which vaccines given or available

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Combination Vaccines: Comvax®

Diphtheria Hepatitis A Pneumococcus

Tetanus Hepatitis B Meningococcus

Pertussis Rotavirus Influenza

Hib MMR HPV

Polio Varicella

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Combination Vaccines: Comvax®

• Hepatitis B + Hib (PedvaxHIB®)

• Remember – cannot give Hib before 6 weeks of age

– Cannot use Comvax® as Hepatitis B birth or 1 month dose

• Doses at 2, 4, >12 months

– Final dose after age 12 months

– Interchangable with PedvaxHIB®

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Combination Vaccines: Pediarix®

Tetanus Hepatitis A Pneumococcus

Diphtheria Hepatitis B Meningococcus


Hib MMR HPV

Polio Varicella

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Combination Vaccines: Pediarix®

• Given 2, 4, 6 months

• 4 weeks minimum interval

• OK to get a 4th dose of Hep B

• Maximum 3 doses of Pediarix®

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Combination Vaccines: TriHibIt®

Diphtheria Hepatitis A Pneumococcus

Tetanus Hepatitis B Meningococcus


Hib MMR HPV

Polio Varicella

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Combination Vaccines: TriHibIt®

• DTaP + ActHIB®

• Only for booster dose (dose #4) – Decreased Hib immunogenicity when combined

with DTaP, no effect on DTaP

• NOT for use as a primary series – If used as primary will need to repeat Hib series

– DTaP series portion can be counted

• Do not use if child has not received any Hib vaccines

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Combination Vaccines: Pentacel®

Tetanus Hepatitis A Pneumococcus

Diphtheria Hepatitis B Meningococcus


Hib MMR HPV

Polio Varicella

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Combination Vaccines: Pentacel®

• Combination vaccine – DTaP

– IPV

– ActHIB®

• Recommended for 2, 4, 6, and 12-15 months

• Can give if any of the components are indicated and none contraindicated

• Hib immunogenicity not affected

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note

• Hib vaccine is not routinely giver to

children age 5 yrs and older


contraindications

• Anaphylactic rxn

• Age <6 weeks

• Precautions

• Acute moderate to severe illness


Tanya ponders,“Wasn’t there some

vaccine that was going to stop my baby

from having ear infections? Which one

is that?”

Case


Pneumococcal Disease

• Streptococcus pneumoniae

– Common cause of community

acquired pneumonia and

otitis media

• Can cause invasive disease

– Bacteremia

– Meningitis

– Sepsis

• Invasive risk related to serotype present

pneumococcal meningitis at autopsy

Photo from www.cdc.gov. Image in public domain.

http://www.cdc.gov/


Prevnar® (PCV-7)

• Pneumococcal conjugate 7 valent vaccine

• 2, 4, 6 and 12 months

• Recommended for all children 2-23

months

• Give if 24-59 months old with risk factors

• Not for children >5 years old

• Replaced by PCV-13 Spring 2010


PCV-7 PCV-13 (Prevnar™13)

• ACIP voted 2/24/10 to replace PCV-7

• Transition guidelines published

• Protects against 13 instead of 7 strains

• Expanded vaccination for high-risk

groups to 72 months

• Same dosing interval as PCV-7 for

never vaccinated children

X


PCV-13

• High risk children include

– Immunocompetent children with • Cyanotic congenital heart defects

• Chronic lung disease

• Asthma needing oral steroid treatment

• Diabetes

• CSF leaks

• Cochlear implants

• Asplenia (congenital or acquired)

• Sickle cell and other hemoglobinopathies


PCV-13

• High risk children include

– Immunocompromised children

• HIV

• Chronic renal failure

• Nephrotic syndrome

• Lymphoma and leukemia

• Chemotherapy

• Organ transplant

• Congenital immunodeficiencies


PCV-13 Transition Dosing

Age at examination (mos) Vaccination history: total

number of PCV7 and/or

PCV13 doses received

previously

Recommended PCV13 Regimen

2 through 6 mos:

0 doses 3 doses, 8 weeks apart; fourth

dose at age 12–15 mos

1 dose

2 doses, 8 weeks apart; fourth

dose at age 12–15 mos

2 doses

1 dose, 8 weeks after the most

recent dose; fourth dose at

age 12-15 mos

http://www.cdc.gov/vaccines/recs/provisional/downloads/pcv13-mar-2010-508.pdf

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PCV-13 Transition Dosing Age at examination

(mos)

Vaccination history: total

number of PCV7 and/or PCV13

doses received previously


12 through 23 mos 0 doses 2 doses, ≥ 8 weeks apart

1 dose before age 12 mo

2 doses, ≥ 8 weeks apart

1 dose at ≥12 mo

1 dose, ≥ 8 weeks after the most

recent dose

2 or 3 doses before age 12 mo


recent dose

4 doses of PCV7 or other age-

appropriate, complete PCV7

schedule

1 supplemental dose, ≥ 8 weeks

after the most recent dose


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PCV-13 Transition Dosing Age at examination

(mos)

Vaccination history: total number

of PCV7 and/or PCV13 doses

received previously


24 through 59 mos 0 doses 1 doses, ≥ 8 weeks after most

recent dose

4 doses of PC7 or other age-


schedule


after most recent dose

Children 24 through 71

mos with underlying

medical conditions

Unvaccinated or any incomplete

schedule of <3 doses

2 doses, one ≥ 8 weeks after the

most recent dose and another

dose ≥ 8 weeks later

Any incomplete schedule of 3

doses


recent dose

4 doses of PCV7 or other age-


schedule


after the most recent dose


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New for PCV-13 • Single dose for children 6-18 years old at

increased risk for invasive pneumococcal disease

• Give regardless of previous PCV-7 or PPSV-23 vaccination

• Includes: – Sickle cell disease

– HIV (or other immunocompromised state)

– Cochlear implant

– CSF leaks


contraindications

• Anaphylactic rxn

• Precautions

• Acute moderate to severe illness


You advise Tanya:

Ear infections are caused by a lot of

different bacteria and viruses, so some

ear infections will be prevented by the

pneumococcal vaccine, but not all.

PCV-13 is more than 90% effective against

invasive disease (the really severe

infections).

Case Case


Tanya asks, “Are all the vaccines

shots? I thought some were given

orally.”

Case Case


Oral Vaccines

• Oral Polio no longer available

in the U.S.

• Rotavirus vaccine is given orally


Rotavirus

• Most common cause of gastroenteritis worldwide

• Can cause severe dehydration

• Prior to vaccine introduction in 2006

– 80% of U.S. children had disease by age 5

– 410,000 physician visits

– 205,000 to 272,000 ER visits

– 55,000 to 70,000 hospitalizations

– $1 Billion direct/indirect costs


Rotavirus Vaccine • Contraindications

– Severe allergic reaction after a previous dose or to a vaccine component

• Precautions – Moderate or severe acute illness with or without

fever

– Immunosuppression

– Receipt of an antibody-containing blood product within 6 weeks

– Pre-existing gastrointestinal disease

– Previous history of intussusception


Rotavirus Vaccine

• First vaccine was Rotashield® (RRV-TV)

• Licensed 1998

• Withdrawn from market less than 1 year later

due to increased risk of intussusception

• New Rotavirus vaccines do not show

increased risk for intussusception


Rotavirus Vaccine

• 2 currently available are

interchangeable for dosing

– RotaTeq® (RV5)

– Rotarix® (RV1)

• Narrow administration window

– First dose must be before 15 weeks

– Last dose must be before 8 months


Rotavirus Efficacy and Safety Trial (REST) • 4,512 infants through 1st rotavirus season

after vaccination with RV5 Vaccine (RotaTeq®)

• Reduced severe rotavirus gastroenteritis cases by 98% – In other trials – RV1 vaccine (Rotarix®)

reduced by 96%

• Reduced any severity case of rotavirus by 74% – RV1 vaccine reduced by 86%


Rotavirus Efficacy and Safety Trial (REST) • RV5 vaccination reduced health care

utilization

– Reduced ER visits by 93%

– Reduced office visits by 86%

– Reduced hospitalization rates by 95%

– Reduced hospitalization rates for all strains

rotavirus gastroenteritis by 58%


Rotavirus Vaccines

• RotaTeq® (RV5)

– 5 reassortant live

rotaviruses from 5 human

and 1 bovine strain

– 3-dose series

• 2, 4, 6 months

– Pre-filled (ready to dose)

• Rotarix® (RV1)

– Live human rotavirus

strain G1P1A

– 2-dose series

• 2, 4 months

– Requires

reconstitution

CDC states no preference between formulations


• Tanya’s 2-month-old child can receive the

following regimens: – Pediarix® (Hep B, DTaP, IPV), Hib, PCV13, Rotavirus

• 3 shots, one oral

– Pentacel® (DTaP, IPV, Hib), Hep B, PCV13, Rotavirus


– Comvax® (Hep B, Hib), DTaP, IPV, PCV13, Rotavirus


Case


Case

Tanya is very thankful for all your help explaining the vaccines her infant needs.

She asks, though,“I have a friend who said I shouldn’t let my baby get any vaccines because they will make her autistic. Is that really true?”


Case

What is your response to Tanya?

Parents often express concerns about the thimerosal preservative in vaccines and the MMR vaccine.

Healthcare providers should reassure parents.


Vaccine Safety

Vaccination never been proven associated with autism

• In 2010, Lancet retracted

the 1998 article

– Was initial paper linking MMR with autism

• There are multiple web-based sites that have

false information regarding vaccine risks


Tanya asks,“What about when my baby

gets older? How many more vaccines

will she need? Are there other diseases

she needs to be protected against?”

Case Case


What are the routine recommendations for follow-up vaccines?

Case


Case

The routine recommendations are

immunizations at:

– 2, 4, 6 and 12-15 months of age


Case

Are there vaccines the child needs in the future that she is too young to receive now?


Case

YES

There are additional vaccines needed

that cannot be administered until after

the baby’s first birthday.

We will pick up here in “Pediatric

Immunizations Part 2”


Summary • Medical Knowledge

– Many childhood diseases are rare due to

immunizations

• Diphtheria, tetanus, polio, invasive pneumococcal

and meningococcal disease, measles, mumps,

rubella

– Live vaccines for children are MMR, Varicella

and Rotavirus

– Vaccines come in multiple combinations

which vary by manufacturer


Summary

• Medical Knowledge

– Birth • Hepatitis B

– 2 Months • Hepatitis B, DTaP, IPV, Hib, PCV, Rotavirus

– 4 Months • DTaP, IPV, Hib, PCV, Rotavirus

– 6 Months • Hepatitis B, DTaP, IPV, Hib, PCV, Rotavirus, Influenza

(if current flu season)


Summary

• Patient Care

– Birth dose of Hepatitis B must be given

(If not given, reason must be well

documented)

– Do not give Hib vaccine to an infant less

than 6 weeks old due to their immature

immune system’s inability to produce an

appropriate immune response.


Notes

• All live attenuated vaccine must be

given on the same day ,if not 28 days

apart

• Preterm immunization is the same for

term do not postpone his /her vaccines


•Thank you

Documents

Pediatric Immunizations Part 1 · +Rota2 +Rota3 لك ءاطعلا ةصصخملا رامعلاا طقف بولطم :ميعاطملا نم عون تاديلاسلاا يف ةدوجوملا