1. 5th Annual Advocacy Project: ImmuneWise Section on Medical Students, Residents, and Fellowship Trainees 2009-2010

2. Morning Report

3. CC: 12 month old male with rash

4. You are in the busy emergency department at the community hospital… What questions do you want to start with?

5. CC: 12 month old male with rash 12 month old awoke with small spots on his face (right side > left) and fainter spots on his stomach and back He went to his pediatrician this morning for evaluation The rash worsened/spread this afternoon/evening to include genitals, legs, palms of his hands – more confluent and itchy

6. CC: 12 month old male with rash ROS: Decreased PO intake today (UOP x 3) Tactile fever Rhinorrhea this evening No vomiting or diarrhea No blisters or vesicles No ingestions/medications

7. CC: 12 month old male with rash General: Happy infant with diffuse rash T 36.8 HR 120 RR 30 Pain 0/10 HEENT: NC/AT, EOMI, no conjunctival injection, no oral lesions or erythema Neck: Supple, no LAD Chest: Lungs CTA, HRRR Abd: Normal bowel sounds, soft, NT, no HSM

8. CC: 12 month old male with rash

9. Differential Diagnosis - Discussion

10. Management

11. Erythema Multiforme Minor Self-limiting Acute onset of acral and symmetrical erythematous papules evolving into target lesions Relative absence of constitutional symptoms Most commonly caused by infections, especially by HSV and Mycoplasma pneumoniae

12. MMR Vaccine Reactions Pain, redness, swelling at the site Fever in 5-15%, with an onset within the 6-12 days following injection Non-specific rash in 5%, particularly within the second week following vaccination (more common with MMRV than MMR) –One case report from Bernardini et al. Erythema multiforme following live attenuated trivalent measles-mumps-rubella vaccine –Finnish studies show EM minor from MMR to be common Thrombocytopenia associated with measles component Arthritis/Arthralgias associated with rubella component

13. Vaccine Adverse Events Reporting System (VAERS) Cooperative program of the CDC and FDA started in 1990 Post-marketing safety surveillance program Passive reporting system Collects information about adverse events that occur after the administration of US licensed vaccines Can identify safety signal but cannot determine causation

14. Vaccine Adverse Events Reporting System (VAERS) –Who reports? Health care professionals, manufacturers, parents, state immunization programs –What to report? Any event after a vaccine concerning to the reporter – fever, rash, seizure, fainting, etc. A reporter does not have to be certain the vaccine caused the event –Why report? To improve vaccine safety and strengthen public trust in the FDA and CDC –How to report? http://vaers.hhs.gov/ 1-800-822-7967

15. Reporting Adverse Reactions

16. Vaccine Adverse Events Reporting System (VAERS) National Childhood Vaccine Injury Act requires physicians to report two events to VAERS 1.Any event listed by the manufacturer as a contraindication to subsequent vaccine dosages 2. Any event listed in the Reportable Events Table that occurs within the specified time period after the vaccination

17. Exam Questions about Vaccine Reactions

18. Vaccine Reactions CME questions from Pediatric Emergency Care Which of the following vaccines is most strongly associated with hypotonic-hyporesponsive episodes? A. MMR B. DTaP C. IPV D. Pneumococcal conjugate E. Hib

19. Vaccine Reactions CME questions from Pediatric Emergency Care Which of the following vaccines is most strongly associated with hypotonic-hyporesponsive episodes? A. MMR B. DTaP – episodes occur within the first 48 hours; lasts 1 minute to 48 hours C. IPV D. Pneumococcal conjugate E. Hib

20. Vaccine Reactions CME questions from Pediatric Emergency Care Which of the following vaccines has a known association with protracted inconsolable crying? A. Hep B B. IPV C. MMR D. DTaP E. Pneumococcal conjugate

21. Vaccine Reactions CME questions from Pediatric Emergency Care Which of the following vaccines has a known association with protracted inconsolable crying? A. Hep B B. IPV C. MMR D. DTaP – events lasting > 3 hours and occurring within 48 hours of injection E. Pneumococcal conjugate

22. Vaccine Reactions CME questions from Pediatric Emergency Care Which of the following vaccines is most likely to be implicated as causing thrombocytopenia? A. IPV B. MMR C. Hib D. Pneumococcal conjugate E. Hep B

23. Vaccine Reactions CME questions from Pediatric Emergency Care Which of the following vaccines is most likely to be implicated as causing thrombocytopenia? A. IPV B. MMR – 1 in 30,000 doses (0.003%), usually 2-3 weeks post vaccine C. Hib D. Pneumococcal conjugate E. Hep B