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 CDC  www.CDC.gov/vaccines www.CDC.gov/vaccines  Download children age 0 - 6  Download children age 7 - 18 American Academy of Pediatrics: http://www.aap.org

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

5. 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

6. 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.

7. 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  Tetanus every 10 years after that

8. Diphtheria  Called “strangling angel of children”  One of the most common causes of death among children pre-vaccine era  Vaccine developed in 1920’

9. 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

10. 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.

11. 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

12. 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

14. Incidence of polio  WHO - 650 cases report  Nigeria  Pakistan  Afghanistan  China

15. 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

16. 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.

17. Incidence  Increase incidence in England, Wales and Pacific Islands

18. 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

19. 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

20. 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

21. 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

22. 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

23. Chicken Pox Parties  Fact or fiction?

24. 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.

25. 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

26. 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

27. 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  1 st dose  2 nd dose 2 months after 1 st dose  3 rd dose 6 months after dose one

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

29. HPV - males  Gardasil will protect males against genital warts.

30. 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

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

32. 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

33. 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.

34. When to get Flu Vaccination?  October or November yearly

35. 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.

36. 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

37. 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

38. 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.

39. 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

40. 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

41. 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

42. 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

43. 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.

44. 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

45. 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

46. 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.

47. 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.

48. 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.

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

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

51. 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.

52. Varicella

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

55. 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.

56. 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

57. 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.

58. Blotchy rash starts on forehead

59. Measles Conjunctivitis

60. Koplik’s Spots on Palate

61. 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.

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

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

64. 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)

65. 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.

66. 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

67. 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.

68. 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.

69. 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.

70. Fifths Disease