TEXAS IMMUNIZATIONSADVANCED NEWBORN HEALTH ASSESSMENT

GNRS 5303

UNIVERSITY OF TEXAS MEDICAL BRANCH IN GALVESTON

Marissa Hampton RN, BSN, SNNPand

Gabriela Olivas RN, BSN, SNNP

GoalsObjective To describe each disease process for

immunization To discuss the origin and history of vaccination,

particularly in Texas To detail each part of immunization and its

purpose To provide evidence based practices of

immunization To identify any long term outcome or

management issues if vaccination is not provided

Definitions Immunization: The method in which a

person becomes protected from a disease process.

Vaccination: Injection of a killed or weakened infectious organism in order to prevent the disease.

Vaccine: A product that produces immunity against the disease.

(Centers for Diseases Control and Prevention [CDC], 2012c)

How do immunizations work?o When bacteria/virus enter the

body, they multiple and attack healthy cells.

o The immune system fights invaders and makes memory cells to recognize them so the body can fight if ever attacked again.

o Vaccines develop immunity by imitating infection. This imitation does not cause illness, but instead helps the individual to build an immunity. If exposed again, the body will use memory cells to fight the infection.

(CDC, 2012b)

Recommended immunizations by the Center for Disease Control and Prevention

Immunizations as recommended from the state of Texas

Vaccine administration

(Immunization Action Coalition, 2012)

Hepatitis B Viral disease that is spread via puncture wounds through the skin or

through blood and body fluid secretions Signs and symptoms:

Vary with age Most newly infected patients and infants are asymptomatic Fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, joint

pain, jaundice High risk individuals:

Include sex with an infected partner , injection drug use or needle sticks, an infant born to an infected mother or contact with blood or open sores of infected person

Acute Hepatitis B: at time of initial infection Chronic Hepatitis B: Progressive worsening of liver disease; Chronic

patients may continue to have signs and symptoms, further complications and cause infection in others.

Persons with chronic HBV infection might be asymptomatic, have no evidence of liver disease, or have a spectrum of disease ranging from chronic hepatitis to cirrhosis or hepatocellular carcinoma (a type of liver cancer).

(Texas Department State of Health Services, 2013a)

Hepatitis BHistory United States Before 1982: 200,000 to 300,000 people infected including 20,000

children 90 % chance transmission from + mother to infant without prophylaxis 25 % infected at childhood will die from cirrhosis

No method for pre exposure prophylaxis 1984: Advisory committee on immunization practices (ACIP)

recommends testing for high risk individuals 1988: ACIP recommends screening pregnant women for Hepatitis B 1991: ACIP recommends comprehensive strategy: prenatal

screening, prophylaxis treatment of infants from + mothers, universal childhood vaccination

Texas 1991: Texas implemented recommendations from CDC into state law Vaccination is required prior to day care and school admission in

Texas (Morbidity and Mortality Weekly Report, 2002)(Wasley, Kruszon-Moran, Kuhnert, Simard, Finelli, McQuillan,& Bell, 2012)(Texas Department State of Health Services, 2013a)

Hepatitis B Vaccine Heptavax-B, Recombivax HB, Engerix-B Indication and Use: Immunization against infection caused by all known subtypes of

hepatitis B virus in individuals Actions: Promotes immunity by inducing the production of specific antibodies to the virus Dosage:

Infants born to hepatitis B surface antigen(HBsAg)-positive mothers: First does within the first 12 hours of life even if premature and regardless of birth weight (hepatitis immune globulin should also be administered at the same tie/different site); second dose at 1-2 months of age; third dose at 6 months. Check anti-HBs and HBsAg at 9-15 months of age. IF anti-HBs and HBsAg are negative, reimmunize with 3 doses 2 months apart and reassess.

Infants born to HBsAg-negative mothers: First dose prior to discharge; however, the first dose may be given at 1-2 months of age. Another dose given 1-2 months later, and a final dose at 6 months of age. A total of 4 doses of vaccine may be given if a “birth dose” is administered and a combination vaccine is used to complete the series.

Infants born to mothers whose HBsAg status is unknown at birth: first dose within 12 hours of birth even if premature, regardless of birth weight; second dose following 1-2 months later, and a final dose at 6 months of age. If the mother’s blood HBsAg test is positive, the infant should receive hepatitis immune globulin as soon as possible (no later than 1 week

(Cunningham, Eyal & Gomella, 2013)

Effects of Hepatitis B Vaccine

United States 1990-2004: Hepatitis B rates have declined by 94% in children

due to screening, universal vaccination and prophylaxis, if needed.

Texas 1991- 2012: Steady decline of Hepatitis B rates in Texas

In 2012 , 170 reportable cases of acute Hepatitis B, lowest rates in history.

Overall decline was greatest among children and adolescents under 18 years.

(Texas Department State of Health Services, 2013a)

Long term outcome or management if untreated

Treatment No specific therapy for acute HBV infection. Treatment is supportive. Interferon is the most effective treatment for chronic

HBV infection and is successful in 25% to 50% of cases. Hepatitis B complications

• Fulminant hepatitis, hospitalization, cirrhosis, hepatocellular carcinoma, death

(CDC, 2012a)

Female patient from Cambodia with a heptoma due to chronic Hepatitis B infection.(CDC, 1995c)

Rotavirus Leading cause of gastroenteritis in infants and

children under age 5 Prior to vaccination 4 out 5 children will be

infected by age 5 Transmitted Fecal- Oral Route Signs and Symptoms

Fever, vomiting, diarrhea, abdominal pain, loss of appetite, dehydration.

Dehydration may be severe; may cause electrolyte imbalance, shock and death

(Morbidity and Mortality Weekly Report, 2009)(CDC, 2011c)

Rotavirus

State of Texas does not currently recommend immunization against rotavirus

RotaTeq® [RV5] 3 dose series licensed in 2006 Given at 2, 4, 6 months Recommended by ACIP for all infants

Rotarix® [RV1] 2 dose series licensed in 2008 Given at 2, 4 months Recommended by ACIP to replace previous vaccine

(Morbidity and Mortality Weekly Report, 2009)

Long term outcome and management if untreated

For persons with healthy immune systems, rotavirus gastroenteritis is a self-limited illness, lasting for only a few days. Treatment is nonspecific and consists of oral rehydration therapy to prevent dehydration. About 1 out of 70 children with rotavirus gastroenteritis will require hospitalization for intravenous fluids.

(CDC, 2011c)

DTaP Diphtheria

Infection caused by Corynebacterium diphtheriae bacteria Spread by respiratory droplets or contaminated objects Bacteria invades the respiratory system and produces toxins Cause weakness, sore throat, fever, swollen glands in the neck,

pseudomembrane- build up of dead tissue that causes difficulty breathing Toxins damages the heart, kidneys and nerves

Tetanus Infection caused by bacteria Clostridium tetani. Enters the body through broken skin, from contaminated objects. Causes headache, jaw cramping, sudden, involuntary muscle tightening – often

in the stomach (muscle spasms), painful muscle stiffness, difficulty swallowing, seizures, fever, sweating, high blood pressure and fast heart rate

Pertussis Infectious disease caused by the bacterium Bordetella pertussis. Early symptoms: runny nose, low-grade fever, mild, occasional cough , apnea, With progression, traditional symptoms appear: Many, rapid coughs followed by

a high-pitched "whoop“, vomiting, exhaustion after coughing fits. Coughing fits can go on for up to 10 weeks or more.

(CDC, 2011a)(CDC, 2013d)(CDC, 2012d)

DTaPHistoryDiphtheria Early 1900s: First prophylaxis was attempted 1921: toxoid was developed but not used until 1930 1940: Vaccine was incorporated with tetanus toxoid and pertussis.Tetanus 1914- 1919: World War I- passive immunity used for treatment and

prophylaxis 1920: Inactivating tetanus toxin process 1924: Development of tetanus toxid; widely used in World War II 1940’s: Tetanus toxid introduced into routine childhood

immunizations Tetanus became nationally notifiable; 500-600 cases annually

Pertussis 1906: First isolated organism 1940: Development of pertussis vaccine

200,000 cases reported annually

DTaP vaccine 4 combination vaccines: DTaP, Tdap, DT, and

Td. DTaP and DT are given to children younger than 7 years of age Tdap and Td are given to older children and adults.

DTaP Children should get 5 doses of DTaP, one dose at each of the

following ages: 2, 4, 6, and 15-18 months and 4-6 years. Vaccines approved for ages 6 weeks and older: Infanrix, Tripedia and

Daptacel DT

Vaccine does not contain pertussis Used in children who can not tolerate pertussis vaccine

(CDC, 2007)

Effects of DTaP VaccineDiphtheriaUnited States Rapid decline in rates since vaccination

Began in 1940 1970-1979: 196 reportable cases 1980-2004: 57 reportable cases

Texas According to Texas Health services website, there

have been no reportable cases in years, but is still considered a reportable rare disease

Child with diphtheria presented with a characteristic swollen neck, sometimes referred to as “bull neck”. (CDC, 1995b)

Effects of DTaPTetanusUnited States Steady decrease since vaccine introduced into routine childhood

vaccination in 1940 2001-2008: 233 cases of reported tetanus, averaging 29 cases

annually. Neonatal tetanus is rare, two cases reported since 1989. Texas Rare. Most reported cases are unvaccinated individuals or those who

have not received booster shot in the following 10 years. Since 2008 only 5 reported cases, one of which was fatal.

(CDC, 2013d)(Texas Department of State Health Services, 2013)

Body rigidity from neonatal tetanus(CDC, 1995d)

Effects of DTaP vaccinePertussis United States

1940: Following introduction of vaccine, rates gradually declined 1980–1990: An average of 2,900 cases per year were reported 2001-2003: Average annual cases began to rise once again

Texas Pertussis rates in Texas historically climbs every 3 to 5 years then sharply

declines. Documented outbreaks occurred in 2005 and 2008. 2012: There were 2,218 reported cases, doubling the 2011 count of 961. 2013: Outbreak of Pertussis continues with 2,652 pertussis cases reported in

Texas. 2000-2012, a total of 43 deaths were attributed to pertussis in Texas, with most

deaths under the age of 1.

(Texas Department of State Health Services, 2013b)(CDC, 2012e)

Pertussis rates: United States 1940-2009(CDC, 2012 e)

Long term outcome and management if untreated

Diphtheria Treatment: Diphtheria antitoxin to neutralize toxins produced by

bacteria. Antibiotics are used, patients are kept in isolation for 48 hours after antibiotic treatment begins.

Complications: Blocked airway, myocarditis, polyneuropathy, Paralysis, Pneumonia or respiratory failure.

Tetanus Treatment: Tetanus is a medical emergency requiring

hospitalization, immediate treatment with human tetanus immune globulin (TIG) , a tetanus toxoid booster, wound care and antibiotics.

Complications: Uncontrolled/involuntary muscular contraction of the vocal cords, fracture, nosocomial infections, pulmonary embolism, aspiration pneumonia, difficulty breathing, death

(CDC, 2011a)(CDC, 2013d)

Long term outcome and management if untreated

Pertussis Complications:

Serious and potentially life-threatening complications in unvaccinated infants:Apnea, pneumonia, seizures, encephalopathy and death

More than half of infants who acquire pertussis and are younger than 12 months of age must be hospitalized.

Hospitalization is common in infants younger than 6 months of age.

Other complications: Anorexia, dehydration, difficulty sleeping, epistaxis, hernias, otitis media, and

urinary incontinence More severe complications include pneumothorax, rectal prolapse, and

subdural hematomas.

(CDC, 2012e)

Haemophilus influenzae type B(Hib)

6 types of Haemophilus influenzae bacteria Haemophilus influenzae bacterium may cause severe

infection; occurs mostly in infants and children younger than five.

Haemophilus influenzae type b (Hib) bacteria causes: Pneumonia, bacteremia, meningitis, epiglottitis, septic arthritis,

cellulitis, otitis media, purulent pericarditis, endocarditis and osteomyelitis.

Transmission occurs through direct contact with respiratory droplets.

Neonates can acquire infection by aspiration of amniotic fluid or contact with genital tract secretions containing the bacteria.

(CDC, 2012d)

Infant with severe vasculitis with disseminated intravascular coagulation (DIC) with gangrene of the hand secondary to Hib septicemia (American Academy of Pediatrics, n.d.).

HibHistory United States Before vaccination era, Hib was the leading cause of

bacterial meningitis in children younger than 5 1930: 1 in 200 children developed Hib

Two thirds in children younger than 18 months. Peak age of occurrence among children 6- 11 months

1980’s: Estimated 20,000 cases of Hib occurred in the US

1985: A pure polysaccharide vaccine (HbPV) was licensed in the U.S. Not effective in children younger than 18 months of age.

1987: First conjugate vaccine licensed in U.S.

(CDC, 2012d)

Hib VaccineHib vaccine Infant primary series is given in 3 doses at 2, 4, 6 months

or 2 doses at 2, 4 months Booster dose is needed at 12 to 15 months. 2 monovalent conjugate Hib vaccines

PRP-OMP (PedvaxHIB) vaccine is 2 doses PRP-T (ActHIB) is 3 doses

2 combination conjugate Hib vaccines DTaP-IPV/Hib: Pentacel Hepatitis B-Hib: Comvax

(CDC, 2012d)

Effects of Hib vaccineUnited States Late 1980’s: Rates of Hib infection decreased

by 99 percent as compared to pre-vaccine era. 1991: Hib infections became nationally

reportable. 1996-2000: 341 confirmed cases of Hib

reported Approximately 22 percent within children less than 5 years old.

Texas Rare in Texas Average of 8 cases reported annually(CDC, 2012)

(Texas Department of State Health Services, 2013)

Long term outcome and management if untreated

Invasive Hib Hospitalization Antimicrobial therapy

Third-generation cephalosporin (cefotaxime or ceftriaxone)

Chloramphenicol in combination with ampicillin Treatment is 10 days.

(CDC, 2012d)

Pneumococcal Disease Streptococcus pneumoniae causes an acute

bacterial infection. Transmission of S. pneumoniae occurs as the result

of direct person-to-person contact via respiratory droplets and by autoinoculation in persons carrying the bacteria in their upper respiratory tract. 

The major clinical syndromes of pneumococcal disease are pneumonia, bacteremia, and meningitis.

The immunologic mechanism that allows disease to occur in a carrier is not clearly understood.

Disease most often occurs when a predisposing condition exists, particularly pulmonary disease.

(CDC, 2012g)

This ventral view of a human brain depicts a purulent basilar meningitis infection due to Streptococcus pneumoniae bacteria. Though S. pneumoniae in a normally occurring floral inhabitant of the human upper respiratory tract, in cases where an individual’s immune system is compromised, it is responsible for causing paranasal sinusitis, middle ear infections (otitis media), and lobar pneumonia, as well as meningitis secondary to these primary respiratory infections (CDC, 1995e).

PneumococcalHistory 1911: First developments in creating a pneumococcal

vaccine 1940: Penicillin development; Vaccine developments

stopped 1960’s: Increased mortality despite antibiotic therapy

Efforts made toward development of vaccine 1977: First Pneumococcal vaccine licensed 1998: 24 cases per year of Pneumococcal Disease, highest

rates in children under 2 years of age 2000: First conjugate pneumococcal vaccine licensedTexas 2005: Texas mandates pneumococcal requirement for

children 5 years and younger (CDC, 2012g)

Pneumococcal 13-velent conjugate vaccine (Prevnar)

Prevnar Protects against: Streptococcus pneumoniae

Indication and use: for active immunization of infants/toddlers against Streptococcus pneumoniae invasive disease caused by the 13 capsular serotypes in the vaccine for all children 2-23 months of age. It is also recommended for certain children 24-59 months of age.

Administered at 2, 4, 6, and 12-15 months of age. Shake well before administration.

Adverse effects: decreased appetite, drowsiness, irritability, fever and injection site local tenderness, redness and edema. Not a treatment of active infection. Use of this vaccine does not replace the use of the 23-valent pneumococcal polysaccharide vaccine in children> 24 month old with sickle cell disease, chronic illness, asplenia, HIV, or those who are immunocompromised.

(Cunningham, Eyal & Gomella, 2013, pg.991)

Effects of Pneumococcal Vaccine

United States 1998-1999: In children 5 and younger,

reported 99 cases per 100,000 of pneumococcal disease

2008: Reported 21 cases per 100,000 in same age group

Texas No information found on reportable cases

for pneumococcal related disease

Long term outcome or management if untreated

What does S.Pneumoniae cause if patient infected?

Causes invasive infections Bacteremia, meningitis, pneumonia, otitis media and sinusitis

Leading cause of bacterial meningitis among children <5 years of age Disease complications:

Bacteremia, meningitis, death Treatment:

Resistance to penicillin and other antibiotics is common. In some areas of the United States, up to 40% of invasive pneumococcal isolates

are resistant to penicillin. Treatment will usually include a broad-spectrum cephalosporin, and often

vancomycin, until results of antibiotic sensitivity testing are available.

(CDC,2012g)

Poliomyelitis Enterovirus Enters through the mouth Implants and replicates in the

gastrointestinal tract Migrates to the nervous system to

destroy motor neurons Excreted in feces

(CDC, 2012f)

PoliomyelitisHistory United States First outbreaks recorded in 1843 Epidemic outbreaks for the next century 1952: Outbreaks peaked in the U.S.

More than 21,000 paralytic cases reported 1955: Introduction of inactivated polio vaccine (IPV)

Following introduction of vaccine rates declined dramatically 1961: Introduction of oral polio vaccine (OPV) 1979: Last reported case of polio

(CDC, 2012f)

Poliomyelitis vaccine Two types of polio vaccines: oral and inactive Inactivated Polio Vaccine (IPV)

Highly effective in producing immunity to poliovirus 90% immune after 2 doses 99% immune after 3 doses Duration of immunity not known with certainty Only effective treatment recommended against polio Vaccinations due at 2, 4 months, between 6-18 months and at age 4. May be given as a combination vaccine

Oral Polio Vaccine(OPV) Highly effective in producing immunity to poliovirus. Approximately 50% immune after 1 dose. More than 95% immune after 3 doses. Immunity probably lifelong Shed in stool for up to 6 weeks following vaccination OPV not used due to increased risk for vaccine associated paralytic polio. 

(CDC, 2012f)

Effects of Poliomyelitis vaccineUnited States 1955: Dramatic decrease in rates after IPV introduced 1960: 2,525 reported cases of paralytic polio 1961: Introduction of OPV introduction 1965: 61 reported cases of paralytic polio 1979: Last reported case of polio, found in Midwestern

statesTexas Reportable in Texas, but has not occurred in years 1970: Last reported cases of polio affected 22 children, all under age of 4.

Poliomyelitis - United States, 1940-1995

(CDC, 2012f)(Texas Department of Heath Services, 2013)

Long-term outcome or management if untreated

Disease is rare Response to polio infection is variable Up to 95 % of cases maybe asymptomatic Paralytic polio

Symptoms last 1-7 days Fever, loss of superficial reflexes, initially increased deep tendon reflexes, severe muscle aches and spasms in the limbs or back. Paralysis is commonly asymmetrical, strength returns 3 types depending on level of involvement: Spinal, Bulbo, Bulbospinal

Maybe fatal in 2-3 percent of infant cases Non paralytic polio

Symptoms will last 2 to 10 days stiffness of the neck, back, legs, usually following several days after “minor illness” Infant with affected lower

limb from Poliomyelitis infection

(CDC, 1995a)(CDC, 2012f)

Influenza Single stranded RNA virus Acquired via droplets, invades respiratory system and

replicates Incubation period is 1- 4 days Symptoms

“Classic” symptoms abrupt onset of fever, myalgia, sore throat, nonproductive cough, headache and fever.

3 strains: Type A- moderate to sever illness, all ages Type B- mild illness, primarily children Type C- rare

(CDC, 2013c)

InfluenzaHistory United States Children 0–4 years of age, hospital rates vary from 100

to 500 per 100,000 healthy children Hospitalization rates for children 24 months of age and

younger are comparable to rates for persons 65 and older.

1940: Trivalent inactivated influenza vaccine (TIV) is available Contains three inactivated viruses: type A (H1N1), type A (H3N2), and type

B 2003: First live attenuated influenza vaccineTexas Texas follows current recommendations for annual flu vaccine

Influenza vaccine Vaccine protects against influenza Spread by air, direct contact 2 initial doses

First dose at 6 months Second dose at 28 days after first dose Once a year immunizations thereafter

Contraindications: Infants with moderate-to-severe illness with or without a fever People with a history of Guillain-Barré Syndrome that occurred after

receiving influenza vaccine Special Considerations regarding egg allergy

People who have ever had a severe allergic reaction to eggs may be advised not to get vaccinated.

People who have had a mild reaction to egg—that is, one which only involved hives—may receive a flu shot with additional precautions.

(CDC, 2013c)

Effects of Influenza vaccineUnited States Reporting season for influenza: October to May Vaccine effectiveness depends on the strains and patient

health status With similar strains, vaccines are up to 90% effective in protecting

individuals

Texas Influenza peaks in January/February Individual cases of influenza are not tracked

Long term outcome and management if untreated

Most people who get influenza will recover in a few days to less than two weeks.

Symptoms: fever, muscle pain, sore throat, cough , extreme fatigue Complications: Bronchitis, sinus, ear infections, pneumonia which

can be fatal Treatment:

Antiviral medications with activity against influenza viruses, antiviral prescription drugs can be used for prevention

Influenza vaccine Two FDA-approved influenza antiviral medications: Oseltamivir (Tamiflu®)

and Zanamivir (Relenza®). Oseltamivir and Zanamivir are chemically related antiviral medications that

have activity against both influenza A and B viruses. Antiviral resistance to oseltamivir and zanamivir among circulating influenza

viruses is currently low.

(CDC, 2013c)

MMRMeasles Measles (Rubeola) virus grows in the cells of the throat and

lungs. Spread through droplet and direct contact

Highly contagious Signs and Symptoms:

Mild to moderate fever, cough, runny nose, red eyes, and sore throat. Kopliks spots: Tiny white spots appear inside the mouth 2 to 3 days after infection.

Complications: Diarrhea, pneumonia, otitis media with hearing loss, death.

Leading cause of blindness in African children Related to vitamin A deficiency in malnourished children.

(CDC, 2009a)(CDC, n.d)

MMR Mumps virus is a paramyxovirus in the same group as parainfluenza and

Newcastle disease. Up to half of people who get mumps have very mild or no symptoms, and

therefore do not know they were infected with mumps. Disease symptoms: swollen salivary glands, fever, headache, tiredness, muscle

pain The virus is acquired by respiratory droplets and direct contact. It replicates in the nasopharynx and regional lymph nodes. After 12 to 25 days

a viremia occurs, which lasts from 3 to 5 days. During the viremia, the virus spreads to multiple tissues,including the meninges, and glands such as the salivary, pancreas, testes, and ovaries. Inflammation in infected tissues leads to characteristic symptoms of parotitis and aseptic meningitis.

Most mumps transmission likely occurs before the salivary glands begin to swell and within the 5 days after the swelling begins. Therefore, CDC recommends isolating mumps patients for 5 days after their glands begin to swell.

Currently, there is no specific treatment for mumps. Supportive care should be given as needed.

(CDC, 2010)

MMR Rubella, also known as German Measles, or 3 day measles Rubella is a viral illness caused by a togavirus of the genus Rubivirus and is

characterized by a mild, maculopapular rash. Respiratory transmission of rubella virus, replication of the virus is thought to occur

in the nasopharynx and regional lymph nodes. A viremia occurs 5 to 7 days after exposure with spread of the virus throughout the body. Transplacental infection of the fetus occurs during viremia. Fetal damage occurs through destruction of cells.

The incubation period of rubella is 14 days, with a range of 12 to 23 days. Symptoms are often mild, and up to 50% of infections may be subclinical or inapparent.

The signs and symptoms of rubella are often so mild that they're difficult to notice, especially in children. If signs and symptoms do occur, they generally appear between two and three weeks after exposure to the virus. They typically last about two to three days and may include: Mild fever of 102 F, headache, stuffy or runny nose, inflamed red eyes, enlarged, tender lymph nodes at the base of the skull, the back of the neck and behind the ears, fine, pink rash that begins on the face and quickly spreads to the trunk and then the arms and legs, before disappearing in the same sequence, and aching joints, especially in young women

(CDC,2009b)

MMRHistory: United StatesMeasles 1954: Measles virus isolated from human

tissue 1963: First live attenuated vaccine licensed Prevaccine era

500,000 reported cases annually, 500 of which were fatal

Epidemic cycles noted every 2 to 3 yearsTexas 1958: 85,862 reportable cases of measles

MMRHistory United StatesMumps Prevaccine Era: Mumps was cause of frequent outbreaks in military

Most common cause of aseptic meningitis and sensorineural deafness in childhood

1934: mumps discovered 1945: Virus isolated 1948: Short lasting vaccine developed

Used until 1970’s 1964: 212,000 reported cases of mumps 1967:Development of live attenuated mumps vaccine 1968: Nationally reportable disease

Mumps infection with characteristic swollen neck region due to an

enlargement of the boy’s salivary glands

(CDC, 2005)

MMRHistory: United StatesRubella 1940: Widespread Rubella infection 1941: 78 cases of congenital cataracts from infants born

to mothers with rubella infection early in pregnancy 1962: Rubella isolated 1964-1965: 12.5 million reported cases

20,000 newborns with congenital rubella syndrome causing deafness, blindness and mental retardation

2,100 neonatal deaths 1969: First rubella vaccine licensedPictured at top right: Infant with blueberry spots from Congenital Rubella Syndrome (CDC, 1978)

(CDC, 2012)

MMR vaccine Vaccine protects against measles, mumps, rubella; live virus vaccine 2 Doses: first dose given 12-15 months, second dose given between 4-6 years

old Measles and Mumps vaccine is prepared in chick embryo fibroblast tissue

culture. MMR and MMRV are supplied as a lyophylized (freeze-dried) powder and are reconstituted with sterile, preservative-free water. The vaccines contain a small amount of human albumin, neomycin, sorbitol, and gelatin.

MMR adverse effects: fever, rash and joint symptoms (Joint pain attributed to measles and rubella vaccine)

Contraindications: Women known to be pregnant or attempting to become pregnant should not receive rubella vaccine. Although there is no evidence that rubella vaccine virus causes fetal damage, pregnancy should be avoided for 4 weeks (28 days) after rubella or MMR vaccination. Persons with immunodeficiency or immunosuppression, resulting from leukemia, lymphoma, generalized malignancy, immune deficiency disease, or immunosuppressive therapy should not be vaccinated. 

(CDC, 2011b)

Effects of MMR vaccineUnited statesMeasles Post vaccine era

Decrease in measles by 98 percent No further 2-3 cyclic events

1978: Measles Elimination program Goal: To eradicate indigenous measles by Oct. 1, 1982

1983: Resurgence of Measles outbreak among children less than five 55,626 reported cases, 123 deaths

1991: Intensive efforts made to vaccinate preschool aged children Vaccination levels increased from 70% in 1990 to 91% in 1997

Since 1993: Fewer than 500 cases reported annually 2008: Total of 140 reported cases

91% of cases were reported in unvaccinated individualsTexas Due to vaccination, reportable cases have decreased by 99.9% in Texas. Nearly all cases Reportable cases since 2000: all reported cases have occurred due to unvaccinated

individuals from foreign countries where measles are prevalent 2011:6 reportable cases 2012:0 Reported cases 2013: 21 reported cases of measles, in North Texas, from an unvaccinated traveler who

was returning home.

Effects of MMR vaccineHistory: United StatesMumps Rapid decline after mumps vaccination implements 1983-1985: 3000 reported cases annually Cyclic resurgence of mumps outbreak

in 2006 and 2009Texas Averages 20 cases of mumps a year

(CDC, 2011b)(Texas Department of State Health Services, 2013)

Effects of MMR vaccineUnited StatesRubella Rapid decline in rates following vaccine licensure 1983 less than 1,000 cases annually 1990-1991: Outbreak of congenital rubella syndrome

with 25 and 33 cases respectively.Texas No reported cases since 2004 No reported congenital cases since 1998.

Rubella and Congenital Rubella Syndrome in the United States from 1966- 2009

(CDC, 2011b)(Texas Department of State Health Service, 2013)

Long term outcome and management if untreated

Live measles vaccine provides permanent protection and may prevent disease if given within 72 hours of exposure. Immune globulin (IG) may prevent or modify disease and provide temporary protection if given within 6 days of exposure. The dose is 0.25 mL/kg body weight, with a maximum of 15 mL intramuscularly. The recommended dose of IG for immunocompromised persons is 0.5mL/kg of body weight (maximum 15 mL) intramuscularly. IG may be especially indicated for susceptible household contacts of measles patients, particularly contacts younger than 1 year of age (for whom the risk of complications is highest).

Most people with mumps recover fully. However, mumps can occasionally cause complications, and some of them can be serious. Complications may occur even if a person does not have swollen salivary glands (parotitis) and are more common in people who have reached puberty. These complications include orchitis in males who have reached puberty, encephalitis, meningitis, oophoritis, mastitis in females who have reached puberty, and temporary or permanent deafness

When rubella infection occurs during pregnancy, especially during the first trimester, serious consequences can result. These include miscarriages, fetal deaths/stillbirths, and a constellation of severe birth defects known as congenital rubella syndrome (CRS). The most common congenital defects are cataracts, heart defects and hearing impairment.

(CDC, 2009a) (CDC, 2009b) (CDC, 2010)

Varicella Acute infectious disease caused by varicella

zoster virus (VZV). VZV is a DNA virus Member of the herpes virus group

Enters respiratory tract and then replicates in lymph nodes

Primary infection: chicken pox Incubation is 10- 14 days signs and symptoms: head then truncal lesions,

pruritic Secondary infection: shingles

Recurrent disease Unilateral pain and paresthesia(CDC, 2013e)

VaricellaUnited States Prevaccine era: Endemic

Virtually all persons had acquired by adulthood Approximately 4 million cases per year

1981: was removed from the reportable list Highest age specific incidence was in children 1-4- 40 % 1995: Varivax, first live attenuated vaccine licensed in US

for infants 12 months and older 2005: Combination MMR and Varicella vaccine availableTexas Continues to report disease

Varicella Vaccine Two doses of the vaccine are about 98%

effective at preventing chickenpox. Varicella given at 12-15 months, then

second dose is administered from age 4-6 Most people who get chickenpox vaccine

will not get chickenpox. But if someone who has been vaccinated does get chickenpox, it is usually very mild. They will have fewer blisters, are less likely to have a fever, and will recover faster.

Effects of Varicella Vaccine After one dose of single-antigen varicella

vaccine: 97% of children 12 months to 12 years

developed detectable antibody titers. More than 90% of vaccine responders

maintain antibody for at least 6 years

Long-term management and outcome

Risk of Varicella increase with out vaccination Primary

Chicken pox: Self limiting disease Secondary

Recurrent disease

(CDC,2013e) ; Characteristic primary varicella lesions in unvaccinated individual

(CDC, 2013a)

Hepatitis A Hepatitis A, caused by infection with the Hepatitis A virus (HAV),

which is nonenveloped RNA virus that is classified a picornavirus; it has an incubation period of approximately 28 days (range: 15–50 days).

HAV replicates in the liver and is shed in high concentrations in feces from 2 weeks before to 1 week after the onset of clinical illness

Primarily transmitted by the fecal-oral route, by either person-to-person contact or consumption of contaminated food or water.

Disease symptoms: there may be no symptoms, fever, headache, weakness, vomiting, jaundice, joint pain

Disease complication: chronic liver infection, liver failure, liver cancer

(CDC, 2013b)

Hepatitis AHistory “Historically children age 2 through 18 years of age have had the highest

rates of Hepatitis A” during the mid 1990s (CDC, 2012) 1940: Differentiated from Hepatitis B 1966: Hepatitis A became a nationally reportable case 1971: 59,606 reported cases of Hepatitis A; Largest in US history 1979: Hepatitis A was isolated 1989: Last large nationwide epidemic 1995: First licensed vaccine against Hepatitis B 1999: ACIP recommends routine vaccination, implemented by states, of

children ages 2 and older 2006: ACIP revised recommendations and advised children 12 months and

older should receive vaccineTexas 2005: Requires vaccination for children attending daycare setting (HB 1316,

2005) 2009: All school aged children are required to have 2 doses of Hepatitis A

vaccine

(CDC, 2012)(Sims, 2009)

Hepatitis A vaccine Vaccine protects against Hepatitis A Vaccine given at 12-23 months, and 6 months after first

dose Two single-antigen Hepatitis A vaccines, HAVRIX®

(manufactured by GlaxoSmithKline) and VAQTA® (manufactured by Merck & Co., Inc), are currently licensed in the United States. A combination vaccine, TWINRIX® (manufactured by GlaxoSmithKline), contains both HAV (in a lower dosage; see table) and Hepatitis B virus antigens.

All are inactivated whole virus vaccines. Adverse effects of vaccination: soreness where the shot

was given, headache, loss of appetite, tiredness(CDC, 2013b)

Effects of Hepatitis A vaccine

United States 1995: Hepatitis A rates begin to decline 1998: Lowest rates of Hepatitis A 2002: Rates of children with Hepatitis A have reached

similar rates of other age groupsTexas Rates have declined due to childhood immunizations 2012: 134 cases of Hepatitis A reported

Lowest rate since reporting began

Hepatitis A- United States 1966-2009

(CDC, 2012)(Texas Department of State Health Services, 2013)

Long term outcome and management if untreated

Clinical illness usually does not last longer than 2 months, although 10%–15% of persons have prolonged or relapsing signs and symptoms for up to 6 months. Virus may be excreted during a relapse.

Antibody produced in response to HAV infection persists for life and confers protection against reinfection

What occurs if you have not received the vaccine and are exposed? Until recently, an injection of immune globulin (IG) was the only recommended way to protect people after they have been exposed to Hepatitis A virus. In June 2007, U.S. guidelines were revised to allow for Hepatitis A vaccine to be used after exposure to prevent infection in healthy persons aged 1–40 years. Persons who have recently been exposed to HAV and who have not been vaccinated previously should be administered a single dose of single-antigen Hepatitis A vaccine or IG (0.02 mL/kg) as soon as possible, within 2 weeks after exposure

(CDC, 2013b)

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