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

2. 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.

3. Childhood Immunization Childhood immunization schedule American Academy of Pediatrics  http://www.cispimmunize.org/ http://www.cispimmunize.org/  Download children age 0 - 6  Download children age 7 - 18

4. 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.

5. 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 11-12 years or at least 5 years from last DTap Every 10 years after that

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

7. 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

8. 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

9. 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

10. 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 4 th dose after 12 months of age

11. 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

12. 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  1 st dose  2 nd dose 2 months after 1 st dose  3 rd dose 6 months after dose one

13. HPV Contraindications:  Allergy to yeast or reaction to first immunization  HPV will not help if already infected

14. Meningococcal Meningococcal disease is a serious illness Leading cause of bacterial meningitis in 2 – 28 year old in USA

15. Meningococcal polysaccharide Vaccine MPSV4 Prevents 4 types of meningococcal diseases – 2 out of 3 of the most common strains seen in the US

16. 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

17. 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.

18. When to get Flu Vaccination? October or November yearly

19. 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.

20. 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.

21. Premature continued 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

22. 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

23. 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

24. 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

25. 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.

26. 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

27. 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

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

29. 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.

30. 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.

31. 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.

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

33. Communicable Diseases Chicken pox (varicella) Measles (Rubeola) Pertussis (Whooping Cough) Rubella (German Measles) Scarlet Fever Mumps

34. 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.

35. Varicella

37. Communicability: children who have “chicken-pox” are infectious for two days before the vesicles erupt until all vesicles are crusted over.

38. 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.

39. 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.

43. 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.

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

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

46. 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)

47. 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.

48. 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

49. 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.

50. Scarlet Fever

51. 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.

52. 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.

53. 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.

54. 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.

55. Fifths Disease