pediatric immunizations part 1 support for this program is made possible by the aafp foundation...

Pediatric ImmunizationsPart 1

Support for this program is made possible by the AAFP Foundation through a grant from Pfizer Inc.

Pediatric Immunizations

Developed for AFMRD byGail Colby, M.D. and Wendy Biggs, M.D.

Midland Family Medicine Residency

2010

Ehab Molokhia, MD and Gerald Liu, MD

University of South Alabama Family Medicine Residency

Updated 2012


Objectives• Medical knowledge

– List at least 5 vaccine-preventable diseases

– List the vaccines given to children that are live attenuated vaccines

– Recall common combination vaccines for childhood immunizations

– Describe routine vaccine schedules for common childhood vaccines


Objectives• Interpersonal communication

– Explain to parents or guardian the rationale for immunization against childhood diseases

• Patient care– Recall Hepatitis B vaccine must be given to

neonate– Explain the age restriction for Hib vaccine


Objectives• Systems-based practice

– Utilize resources to find vaccine recommendations

– Describe how a child qualifies for the Vaccines for Children program


A moment’s cry in the name of prevention


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


Tanya brings her 2-month-old infant to your office for a well-child appointment. She also has a 4-year-old son and twin 12-year-olds – one boy and one girl. She states:

Case


“I know the baby needs shots, but I don’t have insurance that pays for vaccines. I’m not sure how I am going to afford them.”

Case

What do you tell Tanya about vaccine coverage?

Case


Vaccines For Children Program (VFC)• Federally funded• Provides free vaccines

to doctors who serve eligible children– Medicaid-eligible or uninsured– American Indian/Alaskan Native

http://www.sanantonio.gov/health/images/immunizations/Immunizations-VFC_clip_image002.jpg


Vaccine For Children Program (VFC)• Office can charge an administration

fee to give vaccine– Fee charged set regionally

• Vaccines cannot be denied to eligible children

• Covers all ACIP recommended vaccines


You tell Tanya that vaccines for all her children will be covered under your state’s VFC program. She is relieved to hear this.

Case

“But Doctor, what diseases do the vaccines prevent?”

Case


DiphtheriaPolioPolio

HIb

Hepatitis A

PneumococcusMeningococcus

Influenza Pertussis

Case From what diseases does Tanya’s

baby need protection?

Case


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.


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.


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


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



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


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


Engerix-B® (HBV)• Recombinant Hepatitis B• 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


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


Hemophilus Influenza B (Hib)• 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


Hemophilus Influenza B (Hib)• 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


PedvaxHIB®• Hemophilus influenza type b vaccine• Antigen conjugated to Meningococcal

Group B outer membrane protein (PRP-OMP)

• 2-dose primary series plus booster• 2, 4 months and 12-15 month booster• Also comes in a combination vaccine

with Hepatitis B (Comvax®)


Act-HIB®• Hemophilus influenza type b vaccine• Conjugated to tetanus toxoid (PRP-T)• 3-dose primary series plus booster• 2, 4, 6 months and booster at 12-15

months• Also comes in 2 combination vaccines

– With DTaP, and IPV (Pentacel®) Primary series

– With DTaP (TriHibIt®) Booster dose only


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


Combination Vaccines: Comvax®

Diphtheria Hepatitis A Pneumococcus

Tetanus Hepatitis B Meningococcus

Pertussis Rotavirus Influenza

Hib MMR HPV

Polio Varicella


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®


Combination Vaccines: Pediarix®

Tetanus Hepatitis A Pneumococcus

Diphtheria Hepatitis B Meningococcus


Hib MMR HPV

Polio Varicella


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®


Combination Vaccines: TriHibIt®

Diphtheria Hepatitis A Pneumococcus

Tetanus Hepatitis B Meningococcus


Hib MMR HPV

Polio Varicella


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


Combination Vaccines: Pentacel®

Tetanus Hepatitis A Pneumococcus

Diphtheria Hepatitis B Meningococcus


Hib MMR HPV

Polio Varicella


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


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



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 DosingAge 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





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

1 dose, ≥ 8 weeks after the most recent dose

4 doses of PCV7 or other age-appropriate, complete PCV7 schedule

1 supplemental dose, ≥ 8 weeks after the most recent dosehttp://www.cdc.gov/vaccines/recs/provisional/downloads/pcv13-mar-2010-508.pdf





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

4 doses of PC7 or other age-appropriate, complete PCV7 schedule

1 supplemental dose, ≥ 8 weeks 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

1 dose, ≥ 8 weeks after the most recent dose

4 doses of PCV7 or other age-appropriate, complete PCV7 schedule

1 supplemental dose, ≥ 8 weeks after the most recent dose

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


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


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).

CaseCase


Tanya asks, “Are all the vaccines shots? I thought some were given orally.”

CaseCase


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 • 3 shots, one oral

– Comvax® (Hep B, Hib), DTaP, IPV, PCV13, Rotavirus• 4 shots, one oral

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


Case

If the children were foreign-born adoptees and received their immunizations in another country before coming to the U.S., what would you advise Tanya?


Foreign-Born Children• Foreign-received vaccine valid if

– Same age and dosing intervals as U.S.– Written documentation

• If not valid, 2 options:– Repeat series – Serology testing• May not predict disease protection• Requires accurate interpretation


Lots of pros. So what’s the

con?Vaccines are expensive!!


VACCINE VFC PRIVATE PAY

DTaP $13.25-14.25 $20.96-23.76

Pediarix® (DTaP, Hep B, IPV) $49.75 $70.72

Pentacel® (DTaP, IPV, Hib) $50.70 $75.33

IPV $11.74 $24.71

Comvax® (Hib, HepB) $29.50 $43.56

HPV $96.08-108.73 $128.75-130.27

Hib $8.66-11.51 $22.77-23.61

Hepatitis A $13.25 $28.74

Hepatitis B $10.25 $21.37

CDC Vaccine Price List Prices last reviewed/updated: May 14, 2010

Vaccines Are Expensive

http://www.cdc.gov/vaccines/programs/vfc/cdc-vac-price-list.htm


Vaccines are ExpensiveVACCINE VFC PRIVATE PAY

MMRV $85.72 $128.90

MMR $18.64 $48.31

Meningococcal $79.75 $102.66

Rotavirus $59.18-93.75 $69.59-102.50

PCV13 $91.75 $108.75

Varicella $67.08 $80.58

Remember: These are the costs for 1 dose. Many series require 3 or 4 doses.

CDC Vaccine Price List Prices last reviewed/updated: May 14, 2010

http://www.cdc.gov/vaccines/programs/vfc/cdc-vac-price-list.htm


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?”

CaseCase


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.


Summary• Systems-based Practice

– Vaccines for Children (VFC) is a federal program that provides ACIP recommended vaccines for administration to the Medicaid/uninsured patients and Native American/Alaskan populations Use resources to stay up-to-date with vaccine information

• Review the immunization schedule regularly


Resources• www.cdc.gov/vaccines

• (National Immunization Program)

• www.immunize.org/childrules • (Immunization Action Coalition)

• www.cdc.gov/vaccines/programs/iis/contact-state.htm

• State Health Department immunization programs

• Epidemiology and Prevention of Vaccine-Preventable Diseases. The Pink Book: Course Textbook 12th Edition

pediatric immunizations part 1 support for this program is made possible by the aafp foundation...

Documents

pediatric immunizations

hib vaccine slide

childhood immunizations

case slide

children program slide

prevention slide

vaccinepreventable diseases

vaccine fee