VaccinationsVaccinations-James Baugh, MD--James Baugh, MD-

PertussisPertussis Non invasive airway disease caused by Bordetella pertussis Non invasive airway disease caused by Bordetella pertussis Induces paroxysmal cough Induces paroxysmal cough Possible complications: pneumonia, seizure, apnea, encephalopathy, Possible complications: pneumonia, seizure, apnea, encephalopathy,

death death Duration of 6 to 10 weeks Duration of 6 to 10 weeks 270,000 cases prevaccine era, with 10,000 deaths annually270,000 cases prevaccine era, with 10,000 deaths annually 7,867 cases in 2000 with 17 infant fatalities7,867 cases in 2000 with 17 infant fatalities adolescents and adults=greatest source of outbreaks (booster doses adolescents and adults=greatest source of outbreaks (booster doses

needed in this population)needed in this population) many infant fatalities under 2 months--?maternal immunizationmany infant fatalities under 2 months--?maternal immunization and/or and/or

birth immunizationbirth immunization Contraindications: immediate anaphylaxis history to any vaccine Contraindications: immediate anaphylaxis history to any vaccine

components or encephalopathy within 7 days of vaccinationcomponents or encephalopathy within 7 days of vaccination Tdap for age 11 years and every 10 years thereafterTdap for age 11 years and every 10 years thereafter

DiphtheriaDiphtheria Corynebacterium diphtheriae bacterium (activated Corynebacterium diphtheriae bacterium (activated

by corynebacteria phages) by corynebacteria phages) Produces membranous nasopharyngitis with Produces membranous nasopharyngitis with

airway obstructionairway obstruction ToxinToxin damaging to myocardial and peripheral damaging to myocardial and peripheral

nerve cells nerve cells Case fatality 3-23%Case fatality 3-23% Contraindications: anaphylaxis to any vaccine Contraindications: anaphylaxis to any vaccine

componentscomponents

TetanusTetanus

Clostridium tetani bacterium induced infection Clostridium tetani bacterium induced infection mediated by potent myoneuronal junction binding mediated by potent myoneuronal junction binding toxintoxin

Inducing long lasting severe muscle spasms and Inducing long lasting severe muscle spasms and trismus trismus

Case fatality rate 30% approximatelyCase fatality rate 30% approximately Contraindications: anaphylaxis to any vaccine Contraindications: anaphylaxis to any vaccine

componentscomponents

PolioPolio Enterovirus with 3 serotypes that give nonspecific Enterovirus with 3 serotypes that give nonspecific

illness with low-grade fever and sore throatillness with low-grade fever and sore throat Complications: aseptic meningitis in 4-8% of Complications: aseptic meningitis in 4-8% of

cases andcases and in 0.1-2% of infections, acute in 0.1-2% of infections, acute asymmetric flaccid paralysis secondary to motor asymmetric flaccid paralysis secondary to motor neuron disease.neuron disease.

Contraindications: anaphylaxis to streptomycin, Contraindications: anaphylaxis to streptomycin, neomycin, or polymyxin Bneomycin, or polymyxin B

Paralytic polio in 1/1.5million OPV vaccineesParalytic polio in 1/1.5million OPV vaccinees

Hepatitis BHepatitis B Liver infections caused by DNA hepadnavirus that can lead Liver infections caused by DNA hepadnavirus that can lead

to cirrhosis, liver failure, and hepatic carcinomato cirrhosis, liver failure, and hepatic carcinoma After acute infection, 5% of infants, 70% of 1-5 year olds, After acute infection, 5% of infants, 70% of 1-5 year olds,

and 95% of patients older than 5 years haveand 95% of patients older than 5 years have complete complete recovery and natural immunityrecovery and natural immunity

After acute infection, 1-5% of all cases suffer fulminant After acute infection, 1-5% of all cases suffer fulminant hepatic failure and all others have persistent infection. hepatic failure and all others have persistent infection.

Persistent infection: 15-25% develop cirrhosis or hepatic Persistent infection: 15-25% develop cirrhosis or hepatic carcinomacarcinoma

Rare mutant strains have developed that infect vaccinated Rare mutant strains have developed that infect vaccinated individualsindividuals

Contraindications: anaphylaxis to any vaccine componentsContraindications: anaphylaxis to any vaccine components

Streptococcus Streptococcus PneumoniaePneumoniae Implicated in invasive pediatric disease such as Implicated in invasive pediatric disease such as

bacteremia, pneumonia, and meningitisbacteremia, pneumonia, and meningitis ParticularlyParticularly problematic for patients with asplenia, sickle problematic for patients with asplenia, sickle

cell, chroniccell, chronic cardiac, pulmonary disease, renal disease, cardiac, pulmonary disease, renal disease, diabetes, CSF leak, HIV, or immunosuppressiondiabetes, CSF leak, HIV, or immunosuppression

Moderate risk problem for Alaskan or Native American Moderate risk problem for Alaskan or Native American patients, or day care attendees.patients, or day care attendees.

Conjugate vaccineConjugate vaccine Contraindications: anaphylaxis to any vaccine Contraindications: anaphylaxis to any vaccine

componentscomponents

Hemophilus InfluenzaeHemophilus Influenzae

Implicated in several invasive diseases of infants Implicated in several invasive diseases of infants and children: cellulitis, arthritis, pneumonia, to and children: cellulitis, arthritis, pneumonia, to meningitismeningitis

Contraindications: anaphylaxis to any vaccine Contraindications: anaphylaxis to any vaccine componentscomponents

Conjugate vaccineConjugate vaccine

RotavirusRotavirus Infection caused by RNA virus of 7 serotypes (A-Infection caused by RNA virus of 7 serotypes (A-

G), with A most importantG), with A most important Causes non bloody diarrhea, common cause of Causes non bloody diarrhea, common cause of

dehydration in North American infants age 4-24 dehydration in North American infants age 4-24 months; infant death elsewheremonths; infant death elsewhere

Live vaccineLive vaccine Contraindications: anaphylaxis to any vaccine Contraindications: anaphylaxis to any vaccine

componentscomponents

MeaslesMeasles RNA virus producing fever, coryza, cough, RNA virus producing fever, coryza, cough,

conjuctivitis, and erythematous maculopapular conjuctivitis, and erythematous maculopapular rash all with 7-10 day durationrash all with 7-10 day duration

Complications includeComplications include pneumonia, diarrhea, and, pneumonia, diarrhea, and, for 1/1000, encephalitis often with permanent CNS for 1/1000, encephalitis often with permanent CNS injury injury

SSPE (subacute sclerosing panencephalitis) SSPE (subacute sclerosing panencephalitis) possible years after infectionpossible years after infection

Contraindications: anaphylaxis to neomycinContraindications: anaphylaxis to neomycin Can render PPD skin test invalid if PPD given 3 Can render PPD skin test invalid if PPD given 3

days or later after MMRdays or later after MMR

MumpsMumps

RNA virus causing fever, parotitis, RNA virus causing fever, parotitis, sometimes orchitis (adolescence/adult), sometimes orchitis (adolescence/adult), and for 1/1000 encephalitisand for 1/1000 encephalitis

Live virus vaccineLive virus vaccine Contraindications: anaphylaxis to any of Contraindications: anaphylaxis to any of

the vaccine componentsthe vaccine components

RubellaRubella RNA virus causing benign fever/rash syndrome of RNA virus causing benign fever/rash syndrome of

3 days duration; devastating fetal injury in 3 days duration; devastating fetal injury in congenital rubella syndrome—brain, heart, congenital rubella syndrome—brain, heart, hearing, hematopoetichearing, hematopoetic

Live vaccineLive vaccine Contraindications: anaphylaxis to neomycinContraindications: anaphylaxis to neomycin MMR can interfere with PPD response if given 3-MMR can interfere with PPD response if given 3-

30 days after MMR30 days after MMR

VaricellaVaricella VZV infection resulting in generalized pruritic, vesicular rash with VZV infection resulting in generalized pruritic, vesicular rash with

fever of 7-10 days durationfever of 7-10 days duration Complications: bacterialComplications: bacterial superinfection of skin lesions (group A beta superinfection of skin lesions (group A beta

hemolytic streptococcus), pneumonia cerebellar ataxia, encephalitis, hemolytic streptococcus), pneumonia cerebellar ataxia, encephalitis, meningitis, and Reye syndromemeningitis, and Reye syndrome

Fetal embryopathy possible with maternal infection in first trimesterFetal embryopathy possible with maternal infection in first trimester Neonatal infection with peripartum maternal infectionNeonatal infection with peripartum maternal infection Contraindications: (live virus) high dose steroids, HIV with decreasedContraindications: (live virus) high dose steroids, HIV with decreased

CD4 counts, immunocompromised, pregnancy, anaphylaxis to CD4 counts, immunocompromised, pregnancy, anaphylaxis to neomycinneomycin

Vaccine 95% effective against severe diseaseVaccine 95% effective against severe disease Breakthough cases will be increasing percentage of cases as wild Breakthough cases will be increasing percentage of cases as wild

type virus infectiontype virus infection decreasesdecreases Reduced rate of shinglesReduced rate of shingles 2 vaccine series (age 1 yr and 4/5 years) or after 1 month in older 2 vaccine series (age 1 yr and 4/5 years) or after 1 month in older

children, adolescents, and adultschildren, adolescents, and adults

Hepatitis AHepatitis A Cause of acute hepatitis—likely benign in Cause of acute hepatitis—likely benign in

infants and children; higher risk for infants and children; higher risk for fulminant hepatitis in adults; RNA virusfulminant hepatitis in adults; RNA virus

Highly infectious, but not cause of chronic Highly infectious, but not cause of chronic hepatitishepatitis

2 vaccine series at least 6 months apart2 vaccine series at least 6 months apart Contraindications: anaphylaxis to any Contraindications: anaphylaxis to any

vaccine componentsvaccine components

Human Papilloma VirusHuman Papilloma Virus

Many serotypes, and serotype 16 most Many serotypes, and serotype 16 most virulent in causing venereal warts and virulent in causing venereal warts and cervical cancer riskcervical cancer risk

Vaccine against serotypes 6,11,16,18Vaccine against serotypes 6,11,16,18 Contraindications: anaphylaxis to any Contraindications: anaphylaxis to any

vaccine componentsvaccine components

Neisseria MeningitidesNeisseria Meningitides Bacteria implicated in fulminant sepsis and Bacteria implicated in fulminant sepsis and

meningitis, with high mortality ratemeningitis, with high mortality rate Serotypes A, B, C, Y, W-135Serotypes A, B, C, Y, W-135 Conjugate vaccine to A, C, Y, W-135Conjugate vaccine to A, C, Y, W-135 Contraindication: anaphylaxis to any Contraindication: anaphylaxis to any

vaccine components; surveillance ongoing vaccine components; surveillance ongoing for Guillain-Barrefor Guillain-Barre

InfluenzaInfluenza Acute illness (fever, coryza, body aches) Acute illness (fever, coryza, body aches)

complicated by pneumonia/secondary bacterial complicated by pneumonia/secondary bacterial infection—high risk groups age less than 6 infection—high risk groups age less than 6 months and greater than 65 yearsmonths and greater than 65 years

Orthomyxovirus of three types (A, B,C)Orthomyxovirus of three types (A, B,C) Antigenic drift between HA and NA; antigenic Antigenic drift between HA and NA; antigenic

shift with new HA or NA (type A)shift with new HA or NA (type A) Inactivated (6 months and older) and live vaccine Inactivated (6 months and older) and live vaccine

(age 2-50 years); 2 dose series under age 9(age 2-50 years); 2 dose series under age 9 Contraindication: anaphylaxis to egg proteins, or Contraindication: anaphylaxis to egg proteins, or

vaccine componentsvaccine components

Vaccine ScheduleVaccine Schedule Manipulation of adaptive immune system --> T cell mediated Manipulation of adaptive immune system --> T cell mediated

pathway used in immunization for infants because of immaturity pathway used in immunization for infants because of immaturity of humoral (B cell) systemof humoral (B cell) system

Large proteins (conjugated) required for successful vaccination; Large proteins (conjugated) required for successful vaccination; small antigenicsmall antigenic proteins use humoral systemproteins use humoral system

Immune serum globulin interferes with immuneImmune serum globulin interferes with immune response (dose response (dose dependent); should not be given less than 14 days afterdependent); should not be given less than 14 days after live live virus immunizationvirus immunization

If immune globulin given, must wait up to 11 months (Kawasaki If immune globulin given, must wait up to 11 months (Kawasaki syndrome treatment) for live virus vaccine syndrome treatment) for live virus vaccine

Maternal antibody interference is same rational for waiting to Maternal antibody interference is same rational for waiting to vaccinate infants until 12 months of age.vaccinate infants until 12 months of age.

Vaccine ScheduleVaccine Schedule   Primary series followed by booster dose (MMR is Primary series followed by booster dose (MMR is

exception)exception) All vaccinations are IM except MMR, and meningococcal All vaccinations are IM except MMR, and meningococcal

vaccines whichvaccines which are subcutaneousare subcutaneous Schedule changes: Schedule changes:

Hepatitis B third dose defined as after 24 weeks of age Hepatitis B third dose defined as after 24 weeks of age Tdap booster advised between ages 11-12 yearsTdap booster advised between ages 11-12 years Influenza schedule now for all infants ages 6-59 months Influenza schedule now for all infants ages 6-59 months

annuallyannually Combination vaccines: Combination vaccines:

Pediarix (DPT/IPV/Hep B) is for primary series onlyPediarix (DPT/IPV/Hep B) is for primary series only Act HIB (DPT/Hib) for booster onlyAct HIB (DPT/Hib) for booster only

Vaccine ScheduleVaccine Schedule Multiple simultaneous vaccinations OK, caution Multiple simultaneous vaccinations OK, caution

with PPD 3 days or more after MMR (invalid with PPD 3 days or more after MMR (invalid response)response)

Vaccine components i.e. Hib vaccine--use one Vaccine components i.e. Hib vaccine--use one manufacturer for primary series, booster dose manufacturer for primary series, booster dose interchangeable interchangeable

Adverse events require monitoring/documenting; if Adverse events require monitoring/documenting; if severe, contact VAERS severe, contact VAERS 1-800-822-7967 or www.vaers.com to record1-800-822-7967 or www.vaers.com to record

Anaphylaxis treatment must always be available: Anaphylaxis treatment must always be available: Epinephrine 1:1000 (aqueous) 0.01ml/kg IM and Epinephrine 1:1000 (aqueous) 0.01ml/kg IM and oxygenoxygen

Special SchedulesSpecial Schedules International travel:International travel:

contact contact www.mdtravelhealth.comwww.mdtravelhealth.com (possibly requires (possibly requires early MMR,early MMR, hepatitis A, typhoid fever vaccine)hepatitis A, typhoid fever vaccine)

Hepatitis A given to any hepatitis B carriers and Hepatitis A given to any hepatitis B carriers and possible international travel possible international travel

Bone marrow/Stem Cell transplantBone marrow/Stem Cell transplant Immunoglobulin givenImmunoglobulin given

Vaccine RiskVaccine Risk 95% of people have no side effects; vaccine efficacy very 95% of people have no side effects; vaccine efficacy very

high; vast number of vaccineshigh; vast number of vaccines without problemswithout problems Polio--wild type contamination as well as Simian virus 40 Polio--wild type contamination as well as Simian virus 40

contaminationcontamination RSV--exaggerated fatal immune responseRSV--exaggerated fatal immune response Influenza 1976--multiple cases of Guillain Barre disease Influenza 1976--multiple cases of Guillain Barre disease

(10 fold increase)(10 fold increase) MMR and yellow fever vaccine contamination--small MMR and yellow fever vaccine contamination--small

amounts of reverse transcriptaseamounts of reverse transcriptase evident (retrovirus-evident (retrovirus-avian), but no evidence of infectivityavian), but no evidence of infectivity

Rotavirus virus--intussusceptions in infantsRotavirus virus--intussusceptions in infants

Perceived RiskPerceived Risk Not substantiated by science: Not substantiated by science:

MMR--autism and inflammatory bowel disease MMR--autism and inflammatory bowel disease Hepatitis B and multiple sclerosis Diabetes type I Hepatitis B and multiple sclerosis Diabetes type I Thimerosal toxicityThimerosal toxicity

Educate with handouts (required) to include Educate with handouts (required) to include risks of disease (omission of vaccine), risks of disease (omission of vaccine), and and adverse events of vaccine (including death)adverse events of vaccine (including death)

Educational web site from Children's Hospital Educational web site from Children's Hospital Philadelphia--www.vaccine.chop.eduPhiladelphia--www.vaccine.chop.edu

StorageStorage

All vaccines kept at 2-8degrees C except All vaccines kept at 2-8degrees C except Varivax, OPV, and intranasal influenza (frozen)Varivax, OPV, and intranasal influenza (frozen)

MMR--shield from lightMMR--shield from light

RecordingRecording What vaccine, date, name of manufacturer, lot What vaccine, date, name of manufacturer, lot

number, signature of person adminstrating number, signature of person adminstrating vaccinevaccine

Personal vaccination card--state recorded registryPersonal vaccination card--state recorded registry