Immunizations

Childhood and Adolescent Jan Bazner-Chandler CPNP, MSN, CNS, RN

What Immunization Is

Immunization is the process by which a subject is rendered immune or resistant to a specific disease Natural exposure contact with the agent Artificial exposure parts of the infectious agent or inactivated version is given for the purpose of becoming immune to the disease agent it causes.

Childhood Immunization

Childhood immunization schedule CDC

www.CDC.gov/vaccines Download children age 0 - 6 Download children age 7 - 18

American Academy of Pediatrics: http://www.aap.org

Administering Immunizations

Hand washing Gloves NOT required (only if potential exposure to body fluids from a lesion) Proper equipment and means of needle disposal

Administering Immunizations

1 or 3 mL syringe with 22-25 g needle OSHA recommends needle safety device Check expiration date Document lot number on chart Site:

Thigh for infant less than 1 year Upper outer triceps for greater than 1 year

Hepatitis B (HepB) Vaccine

All infants should receive the first dose before hospital discharge. Second dose - 4 weeks after the first Third dose - 16 weeks after the first dose and at least 8 weeks after the second dose Infants born of HBsAg-postive mothers should receive first immunization within 12 hours of birth as well as HBIG.

Diphtheria, Tetanus, Acellular Pertussis

DTaP Given at 2, 4 and 6 months

4th dose between 15 and 18 months Last DTaP at the 4-6 year pre-K check up

1st Tdap at age 11-12 years or at least 5 years from last DTap Tetanus every 10 years after that

Diphtheria

Called strangling angel of children One of the most common causes of death among children pre-vaccine era Vaccine developed in 1920

Tetanus

Acute illness characterized by an acute onset of hypertonia, painful muscular contraction (muscles of jaw and neck, and generalized muscle spasms Clostridium tetani is found in soil, house dust, animal intestines and human feces Vaccine developed in 1924 Very few reported cases

Pertussis

Highly contagious disease involving the lungs and airways. Caused by Bordetella pertussis found in nose, mouth and throat of the infected person. Overall increase in recent years in adolescents and adults.

Cocooning

New term for 2010 Strategy to protect the newborn up to 6 month old from pertussis or whooping cough Booster available for adults Tdap The goal to immunize all adults who interact with infants to prevent pertussis

Polio

Injection form given at 2 months, 4 months after 6 months and at kindergarten check-up Oral not given due to shedding virus in stool

Incidence of polio

WHO - 650 cases report

Nigeria Pakistan Afghanistan China

Haemophilus Influenza Type b

Hib Given at ages 2 and 4 months and 12 months

Any child entering child care or pre-kindergarten under age 5 years in California are required to have Hib. Not a standard immunization for children born outside the USA

Why?

Haemophilus influenzae type B (Hib) disease is a serious disease caused by bacteria. It usually strikes children under 5 years of age. Leading cause of bacterial meningitis in children under 5 years Pneumonia Epiglottitis severe swelling of epiglottis resulting in death for obstruction of breathing Before Hib immunization 20,000 children per year had the infectious disease with 1000 deaths per year.

Incidence

Increase incidence in England, Wales and Pacific Islands

Measles, Mumps, Rubella

MMR Two doses:

1st 12 months or older 2nd dose kindergarten visit If no record of second dose it should be given at 11 to 12 year old visit May develop a rash a week to ten days after immunization Not immunized against wild strain exposure would bring milder case

Incidence of Measles

Outbreak in LA in 2011 Contact point airplane

12 month old who had not received the immunization yet 19 month un-immunized 220 cases in 2011 all of the results of US citizens returning from international travel New recommendation: if infant is traveling international MMR is give as early as 9 months with a booster after 12 months

Mumps outbreak

2010 in New York 1500 Orthodox Jews over had case of mumps during a 7 month period. One un-immunized child at camp from England spread the disease. Why a problem? Complications

Hearing loss Testicle swelling - infertility

Varicella

Chicken pox recommended at 12 15 months and second dose at 4-6 years or kindergarten visit Un-immunized children over 13 years would receive two doses at least 4 weeks apart

Varicella

Contraindication: allergy to immunization, pregnancy or possibility of pregnancy within 4 wks Children on high dose immunosuppressive therapy or immuno-compromised HIV / AIDS vaccination can be given if CD4 T-lymphocyte percentages or 15% or greater. Precautions:

if blood, plasma or immune globulin given within the past 11 months. Antiviral drugs 24 hours before or 14 days after immunization

Chicken Pox Parties

Fact or fiction?

Shingles

Varicella virus dormant in nerve roots Shingles rash appears on one side of the face or body and lasts from 2 to 4 weeks Only someone who has had chickenpox can get shingles. The virus stays in your body and can cause shingles many years later. New recommendation: a single dose of singles vaccine is recommended for adults 60 years of age and older.

Pneumococcal Vaccine

PCV - Prevnar Recommended for all children 2 to 23 months and certain populations up to 59 months 2, 4, 6 and 4th dose after 12 months of age High risk populations

Asthma Sickle cell anemia Cystic fibrosis

Human Papillomavirus

HPV is the most common sexually transmitted virus 40 types of HPV Spread through sexual contact Can cause cervical cancer Can also cause genital warts

Human Papillomavirus

HPV series Recommended for all girls 11-12 years Can be given as young as 9 years Get HPV before first sexual contact and by 26 years of age

1st dose 2nd dose 2 months after 1st dose 3rd dose 6 months after dose one

HPV

Contraindications:

Allergy to yeast or reaction to first immunization HPV will not help if already infected

HPV - males

Gardasil will protect males against genital warts.

Meningococcal meningitis

Meningococcal disease is a serious illness Leading cause of bacterial meningitis in 2 28 year old in USA Also called Neisseria meningtides High risk populations

High school students College age students Military boot camp Travel to third-world countries

Meningococcal polysaccharide Vaccine

MPSV4 Prevents 4 types of meningococcal diseases 2 out of 3 of the most common strains seen in the US

Recommendations

MPSV4 recommended for all children at their routine preadolescent visit (11 12 years) College freshmen living in dorms U.S. military recruits Traveling to Africa Persons exposed to meningitis outbreak

Influenza (Flu) Vaccine

Flu shot: Inactivated vaccine containing the virus

Approved for infants older than 6 months Approved for children over 5 years to 49 years.

Nasal spray flu vaccine: live, weakened flu viruses

When to get Flu Vaccination?

October or November yearly

Contraindications to Flu Vaccine

Children with severe allergy to chicken eggs. Severe reaction to influenza vaccination in the past. Less than 6 months of age. Children who have developed Guillain-Barre syndrome after previous immunization. Do not give if child has moderate to severe illness with fever until a later date.

Rotavirus

Rotavirus causes severe diarrhea Rotarix (RV1) or RotaTeq (RV5) given at 2, 4 and 6 months First dose may be given as early as 6 weeks Give final dose no later than 8 months of age Contraindications: allergy to previous immunization or allergy to latex (use RV5) Precaution: moderate or severe illness, moderate to severe acute gastroenteritis or pre-existing gastrointestinal disease or history of Intussusception

Rotovirus

Leading cause of severe acute gastroenteritis among children worldwide. 527,00 deaths worldwide 85% in Africa and Asia 2 million hospitalized with severe dehydration

Premature Infants

AAP currently recommends that all premature infants receive full dose immunizations at the same chronologic age as term infants even if hospitalized Contraindications : significant febrile seizure, active seizure disorders, encephalopathy Infants with BPD (Bronchopulmonary dysplasia) or RAD (Reactive Airway Disease) should receive influenza immunizations Infants with congenital heart and premature infants immunization against Respiratory Syncytial Virus or RSV.

Premature continued

Hepatitis B may be deferred until discharge unless mother is Hep B positive Do NOT dilute dosages Usually given when they reach at least 2 kg or 4.4 pounds

To Immunize or Not to Immunize

Children on antibiotics Children with minor illness otitis, cough, diarrhea, sore throat, low grade fever Children with mild allergies Breast feeding infants Children with pregnant household contacts

All can and should be immunized

True Contraindications to immunization

True allergic response

Rash or hives after previous vaccination Allergy to eggs or egg products should not be given influenza vaccination

Reactions to Immunizations

Fever greater than 103, shock or collapse, or inconsolable crying for greater than 3 hours. (DTaP) Low grade fever, fussiness, and soreness at injection site are not reasons to prevent further vaccinations Mild rash or fever may occur 10 days to 2 weeks after MMR or Varicella

Interventions post immunization

Tylenol every 4 hours for fussiness or low grade fever Warm bath NO ASPIRIN NO Motrin for infants under 6 months of age AAP recommends Tylenol for all ages due to confusion in dosing.

Adolescents

Hepatitis A (recommended only) Pneumococcal if they have any chronic disease: heart, sickle cell disease, cystic fibrosis, diabetes, or organ transplant or receiving chemotherapy Hepatitis B MMR: second booster D Tap Varicella if no reliable history or negative titers Meningococcemia for all college freshman and all military Influenza yearly

Hepatitis A

Recommended for children and adolescents living in selected states or regions and for certain high risk groups This would include California, Texas, and Arizona 2 doses 6 months apart

L.A. Unified Recommendations

Complete health and immunization record All new students must have written results of a PPD test for tuberculosis within 12 months If PPD is positive a chest x-ray is recommended Treatment is recommended unless the child has some immune suppressed condition.

PPD Waiver

I hear by request exemption of the child from the tuberculosis assessment requirement for school / childcare entry because this is contrary to my beliefs. I understand that should there be cause to believe that my child is infected with active TB or should there be a tuberculosis outbreak, my child may be temporarily excluded from school.

Pre-school and Child Care

Pre-kindergarteners must be immunized against Haemophilus influenza type B or Hib. This is not a standard immunization for children born outside the United States Hib would not be required for a child over 5 years of age.

Kindergarten

Second MMR: Measles, Mumps, Rubella Hepatitis B Hepatitis A in high risk areas D Tap: tetanus, diphtheria, pertussis

Communicable Diseases

Chicken pox (varicella) Measles (Rubeola) Pertussis (Whooping Cough) Rubella (German Measles) Scarlet Fever Mumps

Varicella

Agent: varicella zoster virus Incubation: 10 14 days Transmission: respiratory Period of communicability: 2 days before eruption of vesicles until lesions crusted. Prodromal phase: slight fever, malaise, pruritic rash; macular to papular to vesicular.

Varicella

Varicella

Communicability: children who have chicken-pox are infectious for two days before the vesicles erupt until all vesicles are crusted over (about 5 days).

Management of Varicella

Isolation Skin care: tepid bath, calamine lotion, clip finger nails. Keep from scratching Antihistamines for itching - Benadryl No ASA (salicylate containing products) acetaminophen only. Varicella vaccine now available.

Reyes Syndrome

Almost always preceded by a viral illness, URI, Flu, chickenpox Linked to the use of aspirin or aspirin containing medications (salicylates) Assessment

Persistent vomiting Lethargy or sleepiness Confusion, irrational or combative behavior Seizures to coma

Measles or Rubeola

Agent: Virus Transmission: respiratory, blood and urine Incubation period: 10 to 20 days Period of Communicability: 4 days before and 5 days after rash appears. Prodromal stage: fever, cough, conjunctivitis, Koplik spots.

Blotchy rash starts on forehead

Measles Conjunctivitis

Kopliks Spots on Palate

Rubella or German Measles

Agent: Rubella virus Source: nasopharyngeal secretions; secretions in blood, stool, and urine. Transmission: direct contact. Incubation period: 14 to 21 days Period of communicability: 7 days before to 5 days after appearance of rash.

Rubella

Rash first appears on face and rapidly spreads downward Isolate from pregnant women TORCH affects fetus

Mumps
In mumps the parotid glands swell and obscure the angle of the jaw.

Mumps

Disease caused by a virus that spreads through saliva and infects many parts of the body especially the parotid salivary gland. Incidence has decreased to about 1,000 per year. Two potential complications: encephalitis and orchitis (inflammation of testicle)

Pertussis (Whooping Cough)

Agent: Bordetella Pertussis Source: Respiratory Transmission: droplet spread or contact with contaminated article. Incubation period: 10 days Period of communicability: before onset of paroxysms to 4 weeks after onset.

Interventions

Erythromycin for the child and all contacts Very dangerous for the neonate most often the contact is an adult with a chronic cough May led to hospital admission ventilator assist

Fifth Disease

Fifth disease is a mild childhood illness caused by the human parvovirus B19 that causes flu-like symptoms and a rash. It is called fifth disease because it was fifth on a list of common childhood illnesses that are accompanied by a rash, including measles, rubella (or German measles), scarlet fever (or scarlatina), and scarlatinella, a variant of scarlet fever.

Fifth Disease

Primarily seen in school-age children between ages 5 and 14 years. Causes a reddish rash on the childs face that looks as if the child has been slapped.

Fifth Disease Symptoms

Starts as a vague illness. Fever, nasal congestion, sore throat, fatigue, muscle aches and headache. 7-10 days later the facial rash appears (slapped cheeks rash). Light pink rash on arms and spreads to the trunk in a lacelike pattern.

Fifths Disease