PEDIATRIC IMMUNIZATIONSby Dr Aguilera

Goals and ObjectivesGoals and Objectives Dispel myths that surround vaccinesDispel myths that surround vaccines Major changes in the immunization schedule Major changes in the immunization schedule

for 2004 – 2005for 2004 – 2005 Key points about vaccines including Key points about vaccines including

scheduled series and catch-up.scheduled series and catch-up. Also special considerations, and Also special considerations, and

contraindications, according to ACIP, AAP, contraindications, according to ACIP, AAP, and AAFPand AAFP

Case #1

A 24 month old girl has been ill for the last A 24 month old girl has been ill for the last four days. She has been less active than four days. She has been less active than usual, has had subjective fevers, runny nose usual, has had subjective fevers, runny nose and a sore throat. (+) ill contacts at home and a sore throat. (+) ill contacts at home and tolerating PO’s. On exam, nontoxic, and tolerating PO’s. On exam, nontoxic, playful with a T= 99.9. Throat is red and playful with a T= 99.9. Throat is red and has thin nasal discharge. You also discover has thin nasal discharge. You also discover she is not up to date on immunizations; she she is not up to date on immunizations; she has only received up to her 6 mo shots.has only received up to her 6 mo shots.

Questions to Case # 1:

A.A. Prescribe Abx?Prescribe Abx?

B.B. Wait until the next visit to give any Wait until the next visit to give any immunizations as this is not what she is being immunizations as this is not what she is being seen for?seen for?

C.C. Catch the child up with any five vaccines as Catch the child up with any five vaccines as this is the maximum # to give in one visit?this is the maximum # to give in one visit?

D.D. Her illness precludes her from receiving any Her illness precludes her from receiving any vaccines at this point?vaccines at this point?

Reasons for Missed Vaccinations Missed appointmentsMissed appointments

Inadequate access to health care and/or “non-Inadequate access to health care and/or “non-compliance”compliance”

Incomplete recordsIncomplete records Multiple providers and/or lost yellow cardsMultiple providers and/or lost yellow cards

Lack of awarenessLack of awareness Myths and misconceptions of parents Myths and misconceptions of parents

Deficient health care deliveryDeficient health care delivery Poor clinical judgement: disease definitionPoor clinical judgement: disease definition Myths of providers: “too many shots at once”Myths of providers: “too many shots at once” Complexity of scheduleComplexity of schedule

Missed Immunizations Cont’d

Conclusions:Conclusions: CDC Goal: 90% full immunization by K levelCDC Goal: 90% full immunization by K level Based on Riverside Co. Public Hlth Based on Riverside Co. Public Hlth

71% of our 2 y/o are immunized; 71% of our 2 y/o are immunized; retrospective analysis of K levelretrospective analysis of K level

92.4% of K level entry (Fall) immunized92.4% of K level entry (Fall) immunized93.4% of K level at Spring time immunized93.4% of K level at Spring time immunized

Immunization Schedule - 1983

Immunization Schedule - 1996

Changes from 1997-2001 All DTaP series recommended - 1999All DTaP series recommended - 1999 Rotavirus introduced & deleted 1999-2000 Rotavirus introduced & deleted 1999-2000 All IPV series recommended - 2000All IPV series recommended - 2000 Hep A recom in selected areas (Ca) - 2000Hep A recom in selected areas (Ca) - 2000 Thimerosal free vaccines produced – 2000Thimerosal free vaccines produced – 2000

only one that is not => Influenza vaccineonly one that is not => Influenza vaccine Routine PCV introduced (shortage) – 2001 Routine PCV introduced (shortage) – 2001

Immunization Schedule - 2004

Changes in the Schedule - 2004

Hep B at birth is still appropriateHep B at birth is still appropriate In addition to Hep A, vaccines for selected In addition to Hep A, vaccines for selected

populations include Influenza and PCV #5populations include Influenza and PCV #5 A highlighted pre-adolescent assessment to A highlighted pre-adolescent assessment to

emphasize need to check vaccine statusemphasize need to check vaccine status Added catch up bars across age groups to Added catch up bars across age groups to

spotlight need of updating status through 18 spotlight need of updating status through 18 yearsyears

The number of vaccines required for a child by The number of vaccines required for a child by age 5-6 years has increased to >25age 5-6 years has increased to >25

Case # 2:

A 2 month old is in for the first time for a A 2 month old is in for the first time for a check up. Prenatal care was unremarkable. check up. Prenatal care was unremarkable. Term NSVD and baby is doing well. She is Term NSVD and baby is doing well. She is breastfeeding. Mother notes that there is a breastfeeding. Mother notes that there is a strong family history of seizures as the great strong family history of seizures as the great -grandfather, grandfather, father and two -grandfather, grandfather, father and two uncles all have seizures.uncles all have seizures.

Questions to Case # 2:

A.A. Given the strong FHx of seizures, DTaP is Given the strong FHx of seizures, DTaP is contraindicated and pt should be given DT?contraindicated and pt should be given DT?

B.B. Has SIDS been associated with the DTaP vaccine?Has SIDS been associated with the DTaP vaccine?

C.C. IPV is contraindicated if the mother were to become IPV is contraindicated if the mother were to become pregnant in the next 4 weeks?pregnant in the next 4 weeks?

D.D. If a 5 yr old boy had never received any anti-polio If a 5 yr old boy had never received any anti-polio vaccine, how many doses would he need total?vaccine, how many doses would he need total?

E.E. Would it be ok to give this patient the MMR at 11 Would it be ok to give this patient the MMR at 11 months?months?

F.F. Does MMR cause Autism? Does MMR cause Autism?

Diphtheria, Tetanus and Pertussis (DTaP, DT, Td)

Intramuscular toxoids and inactivated bac. AgIntramuscular toxoids and inactivated bac. Ag 2, 4, 6, 15-18 mo and 4-6 yr booster; Td 2, 4, 6, 15-18 mo and 4-6 yr booster; Td

booster 11-16 yrs, and every 10 yrs thereafterbooster 11-16 yrs, and every 10 yrs thereafter 5 doses total: 25 doses total: 2ndnd dose at least 4 wks from 1 dose at least 4 wks from 1stst; ;

33rdrd dose 4 wks from 2 dose 4 wks from 2ndnd; 4; 4thth dose 6 mo from 3 dose 6 mo from 3rdrd; ; and 5and 5thth dose 6 mo from 4 dose 6 mo from 4thth dose. dose.

#5 not necessary if #4 given after 4 years of #5 not necessary if #4 given after 4 years of ageage

Do not restart seriesDo not restart series

DTaP Continued Special Considerations:Special Considerations:

< 7 yrs of age, use DT when pertussis is < 7 yrs of age, use DT when pertussis is contraindicatedcontraindicated

> 7 yrs of age, use Td for primary series> 7 yrs of age, use Td for primary series Not associated as cause for SIDS and has Not associated as cause for SIDS and has

not been proven to cause permanent brain not been proven to cause permanent brain damagedamage

Precaution: prior fever >104.8, Sz within 3 Precaution: prior fever >104.8, Sz within 3 days, inconsolable crying > 3 hrs within 2 days, inconsolable crying > 3 hrs within 2 days, Mod-Severe illness and personal or days, Mod-Severe illness and personal or FHx of seizureFHx of seizure

DTaP Continued ContraindicationsContraindications

AnaphylaxisAnaphylaxis Pertussis component:Pertussis component:

Encephalopathy within 7 daysEncephalopathy within 7 daysNeurologic disorder with progressive Neurologic disorder with progressive

developmental delay or changing developmental delay or changing neurologic statusneurologic status

Personal history of Infantile spasms or Personal history of Infantile spasms or epilepsy epilepsy

Polio (IPV) Intramuscular, inactivated virusIntramuscular, inactivated virus 2, 4, 6-18 mo, and 4-6 yr booster2, 4, 6-18 mo, and 4-6 yr booster 4 doses total: 24 doses total: 2ndnd at least 4 wks after 1 at least 4 wks after 1stst; 3; 3rdrd at at

least 8 wks after 2least 8 wks after 2ndnd dose dose If 3If 3rdrd shot given > 4 yrs of age, then 4 shot given > 4 yrs of age, then 4 thth dose dose

not needednot needed Unimmunized >18 yr old, none requiredUnimmunized >18 yr old, none required >4 yrs old unimmunized but< 18yrs, only need >4 yrs old unimmunized but< 18yrs, only need

3 doses; give #1 at the visit, then #2 four wks 3 doses; give #1 at the visit, then #2 four wks after #1, and #3 six mo after #2after #1, and #3 six mo after #2

Do not restart seriesDo not restart series

IPV Continued Special ConsiderationsSpecial Considerations

Switched to an all IPV to decrease VAPP; Switched to an all IPV to decrease VAPP; no need to avoid pregnant womenno need to avoid pregnant women

Precaution: Mod-severe illness Precaution: Mod-severe illness OPV should only be used:OPV should only be used:

To control outbreaksTo control outbreaksIn unimmunized child traveling to In unimmunized child traveling to

endemic area in < 4 wks timeendemic area in < 4 wks timeRemember: avoid pregnant women and Remember: avoid pregnant women and

immunocompromised pts for 4-6 wksimmunocompromised pts for 4-6 wks

IPV Continued

ContraindicationsContraindications AnaphylaxisAnaphylaxis Allergy to neomycin, polymixin B or Allergy to neomycin, polymixin B or

streptomycinstreptomycin

Measles, Mumps and Rubella (MMR) Subcutaneous, live virusSubcutaneous, live virus 12-15 mo, and 4-6 yr booster12-15 mo, and 4-6 yr booster 2 doses total: if given < 12 mo of age need 2 doses total: if given < 12 mo of age need

to repeat after 12 mo of age and at least 4 to repeat after 12 mo of age and at least 4 wks after; rule also applies if given prior to wks after; rule also applies if given prior to 4 yrs of age4 yrs of age

Do not restart seriesDo not restart series

MMR Continued Special ConsiderationsSpecial Considerations

Avoid pregnancy 4wks after given vaccine, and Avoid pregnancy 4wks after given vaccine, and small theoretical risk of transmission to unim-small theoretical risk of transmission to unim-munized pregnant women – so avoid for 3 momunized pregnant women – so avoid for 3 mo

May give to child with immune pregnant motherMay give to child with immune pregnant mother Born before 1957 – considered immune.Born before 1957 – considered immune. No association with Autism: closest vaccine at No association with Autism: closest vaccine at

age of identification (18-30 mo)age of identification (18-30 mo) May suppress PPD response, therefore give on May suppress PPD response, therefore give on

same day or after 4 wkssame day or after 4 wks

MMR Continued

ContraindicationsContraindications AnaphylaxisAnaphylaxis Allergy to neomycinAllergy to neomycin Immunocompromised patients and only Immunocompromised patients and only

symptomatic HIV patientssymptomatic HIV patients Unimmunized pregnant femalesUnimmunized pregnant females

Rubella has a 1.6% risk of transmissionRubella has a 1.6% risk of transmissionMM have a theoretical riskMM have a theoretical risk

Case #3:

A 15 mo old girl is in for a WCC. She A 15 mo old girl is in for a WCC. She recently arrived from the Phillipines. She is recently arrived from the Phillipines. She is otherwise healthy and has developed well otherwise healthy and has developed well according to her milestones. Exam is according to her milestones. Exam is unremarkable. According to mom she has unremarkable. According to mom she has only received 4 shots. There is no “yellow” only received 4 shots. There is no “yellow” card.card.

Questions to Case # 3:A.A. Would you do catch up starting as if the pt Would you do catch up starting as if the pt

would have never received any vaccines?would have never received any vaccines?B.B. The shortest interval between vaccines The shortest interval between vaccines

should be 8 weeks?should be 8 weeks?C.C. Is it harmful to give the same vaccine if Is it harmful to give the same vaccine if

already given or pt is immunized?already given or pt is immunized?D.D. Would it be recommended to do a Would it be recommended to do a

serologic titer to check and see if she has serologic titer to check and see if she has been immunized to Hep B?been immunized to Hep B?

E.E. If this patient was > 5 years she would If this patient was > 5 years she would only need one Hib shot?only need one Hib shot?

Haemophilus Influenza type b (ActHib, HibTITER, PedvaxHib) Intramuscular, protein conjugateIntramuscular, protein conjugate 2, 4, 6 mo and 12-15 mo booster2, 4, 6 mo and 12-15 mo booster 4 doses total, but:4 doses total, but:

If 7-11 mo of age: 2 doses plus a boosterIf 7-11 mo of age: 2 doses plus a booster If 12-14 mo of age: 1 dose plus a boosterIf 12-14 mo of age: 1 dose plus a booster If 15-59 mo of age: 1 doseIf 15-59 mo of age: 1 dose If > 5 yrs: none required unless high risk (i.e. If > 5 yrs: none required unless high risk (i.e.

sickle cell, HIV, asplenia)sickle cell, HIV, asplenia) Do not restart series Do not restart series

Hib Continued

Special ConsiderationsSpecial Considerations Patients with history of Patients with history of invasive diseaseinvasive disease do not do not

develop immunity to Hibdevelop immunity to Hib Precaution with mod-severe illnessPrecaution with mod-severe illness Combination vaccines:Combination vaccines:

created to decrease the number of injectionscreated to decrease the number of injectionsstill have to be aware of the factors with both still have to be aware of the factors with both

vaccinesvaccinesNo increase in side effects. No increase in side effects. TriHIBiT; Tetramune; ComvaxTriHIBiT; Tetramune; Comvax

Hepatitis B (Recombivax and Engerix) Intramuscular, inactivated viral AgIntramuscular, inactivated viral Ag

10 mcgms 0-19 yrs10 mcgms 0-19 yrs 20 mcgms > 20 yrs20 mcgms > 20 yrs

birth-2mo, 1-4mo, 6-18mobirth-2mo, 1-4mo, 6-18mo 3 doses total: 2nd dose at least 1 mo after 3 doses total: 2nd dose at least 1 mo after

1st, and 3rd dose at least 2 mo after 2nd and 1st, and 3rd dose at least 2 mo after 2nd and 4 mo after 1st4 mo after 1st

Do not restart seriesDo not restart series

Hepatitis B Continued

Special ConsiderationsSpecial Considerations may use the different types interchangeablymay use the different types interchangeably HbsAg (+) mother: give baby 1st dose within 12 hrs HbsAg (+) mother: give baby 1st dose within 12 hrs

after birth along with HBIG, then 2nd dose at 1-2 mo, after birth along with HBIG, then 2nd dose at 1-2 mo, and 3rd at 6 mo of ageand 3rd at 6 mo of age

Unknown HbsAg status: draw blood, and give 1st dose Unknown HbsAg status: draw blood, and give 1st dose w/in 12 hrs of birth. If (+) give HBIG (within 1 wk)w/in 12 hrs of birth. If (+) give HBIG (within 1 wk)

Serologic testing: high risk only (Hep C+, health care Serologic testing: high risk only (Hep C+, health care workers, IVDA users, immunocompromised)workers, IVDA users, immunocompromised)

Precaution: mod-severe illnessPrecaution: mod-severe illness

Hepatitis B Continued

ContraindicationsContraindications allergy to yeastallergy to yeast prior anaphylaxisprior anaphylaxis

Case # 4

A 15 year old boy comes in for a regular A 15 year old boy comes in for a regular check up. Offers no complaints, but notes check up. Offers no complaints, but notes he has had many ear infections as a child. he has had many ear infections as a child. On exam you note bilateral sclerosis on the On exam you note bilateral sclerosis on the tympanic membranes and a LUQ abdominal tympanic membranes and a LUQ abdominal scar from a splenectomy secondary to scar from a splenectomy secondary to trauma. He has never had the chicken-pox.trauma. He has never had the chicken-pox.

Questions to Case #4

A.A. Give 2 doses of varivax 4-8 weeks apart?Give 2 doses of varivax 4-8 weeks apart?B.B. Since he is 15 years old there is no need to Since he is 15 years old there is no need to

give him Hep A vaccine?give him Hep A vaccine?C.C. Since he is 15 years old there is no need to Since he is 15 years old there is no need to

give him PCV?give him PCV?D.D. If he was 12 months of age without a If he was 12 months of age without a

splenectomy, giving him PCV would have splenectomy, giving him PCV would have prevented a majority of his ear infections?prevented a majority of his ear infections?

Varicella (Varivax) Subcutaneous, live virusSubcutaneous, live virus Target all children without chickenpox hxTarget all children without chickenpox hx

12mo - 18mo, but <12 yrs of age: 1 dose12mo - 18mo, but <12 yrs of age: 1 dose > 13 yrs: 2 doses, 4-8 wks apart> 13 yrs: 2 doses, 4-8 wks apart

CDC recom Childcare and Kindergarten to CDC recom Childcare and Kindergarten to require immunity (active or passive)require immunity (active or passive)

Efficacy 70-90% complete protection and Efficacy 70-90% complete protection and >95% protection against severe disease = >95% protection against severe disease = >50 lesions>50 lesions

durable protection: humoral and cell durable protection: humoral and cell mediated immune responsesmediated immune responses

Varicella Continued

Special ConsiderationsSpecial Considerations Sfx: pain, redness and swellingSfx: pain, redness and swelling ~5% develop a chickenpox-like rash (~5 ~5% develop a chickenpox-like rash (~5

lesions)lesions) May interfere with TB skin test, so give it on May interfere with TB skin test, so give it on

same day or wait at least 4 wkssame day or wait at least 4 wks Avoid ASA use for 6 wks => poss Reye’s SynAvoid ASA use for 6 wks => poss Reye’s Syn

ContraindicationsContraindications Anaphylaxis, allergy to neomycin and immuno-Anaphylaxis, allergy to neomycin and immuno-

deficientdeficient

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

Intramuscular, heptavalent protein conjugateIntramuscular, heptavalent protein conjugate Primary series: 2, 4, 6 and 12-15 moPrimary series: 2, 4, 6 and 12-15 mo 4 doses total: 24 doses total: 2ndnd dose at least 4 wks after 1 dose at least 4 wks after 1stst, 3, 3rdrd 4 wks 4 wks

after 2after 2ndnd, and 4, and 4thth 6 mo after 3 6 mo after 3rdrd If 2-5 yrs old and healthy: 1 dose only neededIf 2-5 yrs old and healthy: 1 dose only needed If 2-5 yrs old and high risk: 2 doses 8 wks apartIf 2-5 yrs old and high risk: 2 doses 8 wks apart

It is not an Otitis Media vaccine!It is not an Otitis Media vaccine! Only 6% effective against all Acute OMOnly 6% effective against all Acute OM

It protects against 80-90% of It protects against 80-90% of invasive diseaseinvasive disease Pneumococcus has > 90 serotypesPneumococcus has > 90 serotypes

ContraindicationsContraindications hypersensitivityhypersensitivity

Pneumococcus (Prevnar)

The EndThe End