Case Study: Jennifer and James Amy B. Middleman, MD, MSEd, MPH Assistant Professor, Department of Pediatrics, Adolescent Medicine Section, Baylor College of Medicine August 22, 2012

Jennifer and James  12-year-old twins  In your practice since birth  The month is May and this is a routine visit  Both are up to date on vaccines through age 5 years

Jennifer  Had a Tdap at age 10 years  Experienced syncope with that vaccine  She was evaluated in the emergency department and was released  The twins’ grandmother lives with them  Grandmother is receiving chemotherapy

What Vaccines Does Jennifer Need?  Jennifer has already received Tdap; it is licensed for one-time use only at this time  MCV4  HPV #1 (HPV2 or HPV4)  Confirm receipt of 2 doses of varicella and MMR vaccines; 3 doses of hepatitis B vaccine  Consider hepatitis A vaccine

Any Contraindications?  Jennifer has no contraindications to vaccines  Syncope is a known consequence of procedures involving needles that disproportionately affects adolescents  Adolescents should be observed in a sitting or lying position for 15 minutes after injections  Grandmother’s chemotherapy does not affect the administration of adolescent vaccines

James  No vaccines since age 5 years  Diagnosed with Guillain-Barre syndrome (GBS) at age 8 years  GBS secondary to Campylobacter infection  The twins’ grandmother lives with them  Grandmother is receiving chemotherapy

What Vaccines Does James Need?  Tdap  MCV4  HPV #1 (HPV4 only)  Confirm receipt of 2 doses of varicella and MMR vaccines; 3 doses of hepatitis B vaccine  Consider hepatitis A vaccine

Any Contraindications?  James has no contraindications to vaccines  History of GBS secondary to an infection is not a precaution to vaccination  History of GBS secondary to a specific vaccine is a precaution associated with that vaccine  James should receive all recommended vaccines (and should be observed for 15 minutes after administration)

And, of course…  Both pre-teens should have an appointment made for later in the fall to receive the influenza vaccine (as soon as supply becomes available)

Provider Recommendation  Strong provider recommendation has been shown to be key to parental acceptance  It is critical to let parents know how safe and effective vaccines are  Parents must know that the diseases we vaccinate against still exist and some are epidemic (e.g., pertussis)  Please make a strong case for primary prevention of disease

Vaccines Work Disease Pre-vaccine Era Estimated Annual Morbidity Most Recent Reports/Estimates of US Cases Percent Decrease Diphtheria21, H. Influenzae (invasive, < 5 yrs) 20, Hepatitis A117,33311,04991 Hepatitis B (acute)66,23211,26983 Measles530,21761>99 Mumps162, Pertussis200,75213,50693 Pneumococcal disease (invasive < 5 yrs) 16,0694,16774 Polio (paralytic)16, Rubella47,7454>99 Congenital rubella syndrome Smallpox29, Tetanus Varicella4,085,120449,36389 Adapted from Immunization Action Coalition, Accessed Dec

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