Immunizations in Childhood and Adolescent

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 American Academy of Pediatrics
http://www.cispimmunize.org/
Download children age 0 - 6
Download children age 7 - 18

Hepatitis B (HepB) Vaccine
All infants should receive the first dose soon after birth or before hospital discharge.
Second dose should be given at least 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
Every 10 years after that

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

Haemophilus Influenza Type b
Hib
Given at ages 2 and 4 months
Last dose at 12 months
Any child entering child care or pre-kindergarten under age 5 years would be required to have Hib.
Not a standard immunization for children born outside the USA

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

Varicella
Chicken pox – recommended at 12 months and second dose at 4-6 years or kindergarden visit
Susceptible children over 13 years would receive two doses at least 4 weeks apart

Pneumococcal Vaccine
PCV - Prevnar
Recommended for all children 2 to 23 months and certain populations up to 59 months
Asthma
Sickle cell anemia
Cystic fibrosis
2, 4, 6 and 4th dose after 12 months of age

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
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

Meningococcal
Meningococcal disease is a serious illness
Leading cause of bacterial meningitis in 2 – 28 year old in USA
Meningococcal polysaccharide Vaccine
MPSV4
Prevents 4 types of meningococcal diseases – 2 out of 3 of the most common strains seen in the US

Recommendations
MCV4 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
Nasal spray flu vaccine: live, weakened flu viruses
Approved for children over 5 years to 49 years.

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.

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 include: significant febrile seizure, active seizure disorders, encephalopathy (DTaP)
Infants with BPD or RAD should receive influenza immunizations
Infants with congenital heart and premature infants immunization against RSV.
Hepatitis B may be deferred until discharge unless mother is Hep B positive
OPV should not be given in NICU
Do NOT dilute dosages
Usually given when they reach at least 2 kg or 4.4 pounds

To Immunize or Not to Immunize (common myths not to immunize: invalid)
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

True Contraindications
True allergic response
Rash or hives after previous vaccination
Allergy to eggs or egg products should not be given influenza vaccination
Allergic to streptomycin should not be given IPV or 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
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

Live Vaccines
MMR and Varicella
Pregnancy
HIV +
Immunodeficiency
Chemotherapy: not given until 6 months after treatment is completed.

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 Manoux test is positive a chest x-ray is required
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
Communicability: children who have "chicken-pox" are infectious for two days before the vesicles erupt until all vesicles are crusted over.
Management of Varicella
Isolation
Skin care: tepid bath, calamine lotion, clip finger nails.
Keep from scratching
Antihistamines for itching - Benadryl
No ASA – acetaminophen only.
Varicella vaccine now available.

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.



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
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

Scarlet Fever
Caused by group A Streptococcus
Rash is usually seen in children under age 18 years.
Rash appears on chest and abdomen – feels rough like a piece of sandpaper
Redder in the arm pits and groin area.
Rash lasts 2-5 days
After rash disappears fingers and toes begin to peel
Face is flushed with a pale area around the lips.
Scarlet Fever
Management of Scarlet Fever
Respiratory precautions for 24 hours.
Oral antibiotic for 10 days.
Treat sore throat with analgesics, gargles, lozenges, and antiseptic throat spray.
Encourage fluids.
See health care provider if fever persists.

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 child’s 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.