Pediatric Nursing Unit Four Immunizations, 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.

Administering Immunizations: Hand washing Gloves NOT required (only if potential exposure to body fluids from a lesion) Proper equipment and means of needle disposal 1 or 3 mL syringe with 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 – 4 th dose between 15 and 18 months – Last DTaP at the 4-6 year pre-K check up 1 st Tdap at age 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 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 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

Haemophilus Influenza Type b: Hib. Given at ages 2 and 4 months and 12 months. 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.

Measles, Mumps, Rubella: MMR. Two doses: – 1 st 12 months or older. – 2 nd 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 – 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. Measles, Mumps, Rubella:

Mumps outbreak: – 2010 in New York 1500 over had case of mumps during a 7 month period. – One un-immunized child at camp from England spread the disease. – Complications: Hearing loss. Testicle swelling - infertility Measles, Mumps, Rubella:

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. 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

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 4 th 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.

HPV series: – Recommended for all girls years. – 1 st dose: Can be given as young as 9 years. Get HPV before first sexual contact and by 26 years of age. – 2 nd dose 2 months after 1 st dose. – 3 rd dose 6 months after dose one. – Contraindications: Allergy to yeast or reaction to first immunization. HPV will not help if already infected. Human Papillomavirus:

HPV – males: – Gardasil will protect males against genital warts. Human Papillomavirus:

Meningococcal meningitis: Meningococcal disease is a serious illness. Leading cause of bacterial meningitis in 2 – 28 year old in USA. Also called Neisseria meningitides. 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. Meningococcal meningitis:

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. Influenza (Flu) Vaccine:

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

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. 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. Premature Infants:

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. Adolescents:

Hepatitis A: Recommended for children and adolescents living in selected states or regions and for certain high risk groups. 2 doses 6 months apart

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 (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. Varicella:

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 ConjunctivitisKoplik’s Spots on Palate Measles or Rubeola:

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. 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. In mumps the parotid glands swell and obscure the angle of the jaw. Incidence has decreased to about 1,000 per year. Two potential complications: encephalitis and orchitis (inflammation of testicle)

Pertussis (Whooping Cough): An acute respiratory infection caused by Bordetella pertusis that occurs chiefly in children younger than 4 years of age who have not been immunized. It is highly contagious and is particularly threatening in young infants, who have a high morbidity and mortality rate. 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. Pertussis (Whooping Cough):

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. 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. Fifth Disease: