Immunizations Flashcards
(109 cards)
1
Q
What are parents concerns about immunizations usually about?
A
- Fear of harm
- Vaccines being unnecessary
- Mistrust
- Aversion to government mandates
- Unfounded speculation about links to autism in past 10-15 years
2
Q
When should immunization records be checked?
A
Each office well child check, sometimes even acute sick visits
appropriate vaccines should be administered at this time if due
3
Q
In the US, every infant requires how many doses of vaccines by the age 18
A
- more than 25 doses
- Protect against 14 or more childhood diseases
- If combo vaccines, 18 from birth to 4
4
Q
Who recommends childhood immunization standards in the US?
A
- Advisory Committee on Immunization Practices of the CDC and Prevention (ACIP)
- American Academy of Pediatrics (AAP)
- American Academy of Family Physicians (AAFP)
5
Q
What are the 2 main types of vaccines?
A
Active and passive
6
Q
What is the MOA of a active vaccination?
A
Induces immunity by vaccination with a vaccine or toxoid (inactivated toxin)
7
Q
What is the MOA of passive immunization?
A
Transplacental transfer of maternal antibodies and administration of antibody, either as immunoglobulin or monoclonal antibody
8
Q
Types of active vaccines
A
- Live attenuated (LIVING)
- Inactivated or killed viruses
- Recombinant
- Reassortant
- Immunogenic Components of Bacteria
- Toxoids
9
Q
What is a live attenuated virus vaccine?
A
- Vaccine created by reducing the virulence of a pathogen, although still viable (live) vaccine
- Replicates in body after given
- Usually induces immunity through 1 dose
- Susceptible to vaccine failure due to circulating antibodies, including maternal residual antibodies in infants
10
Q
What are examples of live attenuated vaccines?
A
- MMR
- Varicella
- IN influenza (Flumist)
- Rotavirus (oral)
- OPV-oral polio virus
11
Q
Cautions with live attenuated vaccinations?
A
- Giving blood products and immunoglobulin can diminish response to live virus vaccines if administered before recommended interval (generally 3 months), may inhibit immune response
- Live vaccines not administered simultaneously should be separated by at least 4 weeks to reduce risk of interference
- Rare use in immunocompromised patients, elderly, infants, and pregnancy
12
Q
What are inactivated or killed vaccines?
A
- Virus particle grown in culture and then killed using method such as heat, radiation, or chemicals
13
Q
What are the inactivated or killed virus vaccines?
A
- Polio
- Hepatitis A
- Flu shot
14
Q
What is a recombinant vaccine?
A
- Engineered virus or bacteria that harmless DNA encoded antigen is inserted to stimulate immune response
15
Q
What are recombinant vaccines?
A
- Hepatitis B
- HPV
16
Q
What are reassortant vaccines?
A
- Human-Bovine reassortant
- Vaccine made by combining antigens from several strains of same virus
- Considered live as well
17
Q
Which vaccine is reassortant?
A
- Rotavirus (Rotateq) oral vaccine
18
Q
What are immunogenic components of bacteria?
A
- Use of bacterial surface components to obtain immunity
- Protein polysaccharide conjugate
19
Q
What are the immunogenic components of bacteria vaccines?
A
- Pertussis
- HIB
- Meningococcal conjugate
- Pneumococcal conjugate
20
Q
What is a toxoid vaccine?
A
Bacterial toxin whose toxicity has been inactivated or suppressed either by chemical or heat
21
Q
What are the toxoid vaccines?
A
- Diphtheria
- Tetanus
22
Q
How are most vaccines administered?
A
IM or SQ, a few are oral
23
Q
What are the preferred sites of IM immunization administration in infants up to age 3-4? Children and adults 5+?
A
infants–>3-4: anterolateral aspect of the thigh
5+: deltoid
24
Q
Can multiple vaccines be administered at the same time?
A
Yes, at anatomically separate sites, different limbs or separated by >1 inch
25
What are the oral vaccines?
* OPV
* Rotavirus
26
What are the IM vaccines?
* DTap, DT, Td
* Hep B
* IPV
* Hib
* PCV-7
27
What are the SQ vaccines?
* Measles
* Yellow fever
28
What is the intradermal vaccine?
BCG
29
What are current vaccines at birth?
Hep B
30
What vaccines are given at 2 months?
* Pediarix: Dtap/HBV/IPV
* HIB
* Prevnar
* Rotavirus
31
What vaccines are given at 4 months?
* Pediarix
* HIB
* Prevnar
* Rotavirus
32
What vaccines are given at 6 months?
* Pediarix
* HIB
* Prevnar
33
What vaccines are given at 12 months?
* MMR
* Varicella (or MMRV)
* Hep A
34
What vaccines are given at 15 months?
* Dtap
* Prevnar
35
What vaccines are given at 18 months?
* HIB
* Hep A
36
What vaccines are given at 4 years?
* Dtap
* IPV (Kinrix)
* MMR
* Varivax (Proquad)
## Footnote
Very DIM between 4-6 pm
37
What vaccines are given at 9 years?
HPV series
38
What vaccines are given at 11 years?
* Tdap
* Meningitis
39
What vaccines are given at 16 years?
Meningitis #2
(Menactra repeat dose)
40
What vaccines are given at 17 years?
* Meningitis B vaccine- booster in one month
* Flu and COVID (throughout)
41
What are state laws that require immunizations for school entry associated with?
* Increased rates of immunization
* Decreased rates of vaccine-preventable diseases
* Every state requires some immunizations for school entry (typically pre-K, kindergarten, 7th grade, 11th grade, college)
* However, some exemption that parent can elect for
42
What are exemptions to state laws that may be present?
* Medical exemptions: children with valid CI to vaccine or vaccine component
* Religious: religious belief that opposes immunizations
* Philosophical: personal, moral, or philosophical belief against some or all immunizations
43
What laws do most states have regarding exemptions?
* All states allow medical exemptions
* Nearly all allow religious exemptions (not WV)
* Nearly 1/2 allow philosophical
* WV does not allow nonmedical exemptions (maybe now with new bill)
44
Why do parents refuse vaccines?
* Concerns about safety and side effects majority
* Belief that they are not necessary or lack of choice
* Belief that parents know what is best for their child and should have right to make decisions for them
* Lack of trust in government health authorities, organized medicine, public health officials, and pharma companies
* Ethical, moral, or religious objections
45
What are concerns about safety and side effects that parents may have?
* Pain
* Fever
* Guillain-Barre syndrome
* Do not want too many vaccines to overload immune system
* Concerns about safety intensified by negative word of mouth and media messages
46
What objections may be present about vaccines not being necessary?
* Belief that they do not work
* Belief that their child is not at risk or the disease is not dangerous
* Belief that it is better to be naturally infected than vaccinated
47
Why is vaccine refusal a problem?
* Increases risks of outbreaks of vaccine-preventable disease in general population
* May affect individuals who refused due to religious/philosophical reasons
* May affect children too young to be vaccinated
* Could affect people with CI to vaccines
* May affect vaccinated individuals with suboptimal immune response or waning immunity
* Most outbreaks related to religious groups or communities opposed to immunizations
48
How do we approach parental refusal?
* Establish a positive dialogue
* Identify parental concerns
* Provide education targeted to those concerns
* Maintain relationship with family
* Make every effort to follow recommended vaccine schedule
49
How do you establish a positive dialogue to increase vaccinations?
* Begin at first encounter
* Establish/maintain trust
* Acknowledge shared goal of doing what is best for child
* Acknowledge large volume of complex, conflicting information about vaccine benefits and safety
* Offer to help parents gather and interpret best information to make informed decision
* CDC, NIH sites have the proper information
50
How do you identify concerns to increase vaccinations?
* Identify concerns and forces that influence parental concerns
* Through respectful listening
* Once identified, can establish plan for targeted education
* A lot of parents get medical information from Facebook, Instagram, Tik Tok and not provided by medical specialists
51
How can education be targeted to specific parental concerns/beliefs?
* Must address concerns while emphasizing safety and effectiveness and serious disease that could occur
* Vaccine benefits/limitations/safety/adverse events
* Risk of natural infection
* Correct misconceptions
* Discuss the vaccine injection itself and any pain
52
What are alternative schedules?
* Parents who only want one or two vaccines at a time, or spread out
* Offer incomplete and delayed protection against life threatening illnesses
* Only consider after other options have failed and family would otherwise refuse entirely
* Increase duration of vulnerability to vaccine preventable disease that continue to cause outbreaks, increase risk of undervaccination
* Require extra visits that may be cumbersome and time-consuming
53
How are alternative vaccine schedules managed?
* Make sure when ill the family tells provider not fully vaccinated
* Draw up a schedule and give copy to parents and keep copy in the chart
* Put in as an actual appointment instead of shot only or on nursing only schedule
54
How are patients with late, interrupted, or catch up immunizations managed?
* Compressed, catch-up, or accelerated immunization schedule provided annually and published for providers
* Can be difficult to follow and understand
55
What should be done if patient presents as a new patient with unknown vaccination status?
* Determine if any records exist, ie request from previous pediatrician
* WV has immunization tracking program called SIIS
* If no record found, presumed unvaccinated and vaccine schedule should be catch-up
56
Immunization rules
1. Children who are behind on immunizations should receive catch-up immunizations as rapidly as feasible
2. Always obtain informed consent for immunizations
3. Infants born prematurely should be immunized, regardless of birth weight, at the same chronologic age and according to the same schedule as infants born at term
4. Exception: premature babies less than 2000 grams (4-6 oz) should delay first HBV to 1 month WCC
57
What does the National Childhood Vaccine Injury Act require health care providers do?
* Provide parents or patients with copies of vaccine information statements prepared by CDC before dose
58
What are general contraindications to vaccination?
* Serious allergic reaction after a previous vaccine dose or to a vaccine component
* Immunocompromised states or pregnancy (for live virus vaccines)
* Moderate or severe acute illness with or without fever
59
Contraindications for live virus vaccines
Severe immunosuppression from
* Congenital immunodeficiency
* HIV
* Leukemia
* Lymphoma
* Cancer therapy
* Prolonged course of high-dose corticosteroids >2 mg/kg/day for over 2 weeks
60
When should HIV infected children receive MMR?
* If do not have evidence of severe immunosuppression, MMR at 12 months of age with second dose 1 month later rather than waiting until 4-6 years for booster
61
What are contraindications to varicella vaccination?
Cellular immunodeficiency
62
When should children with HIV without evidence of severe immunosuppression be given varicella?
* 12 months of age
* 2 doses 3 months apart
63
What are NOT contraindications to immunization?!
* Mild acute illness (with or without fever)
* Convalescent phase of illness
* Recent exposure to infectious disease
* Current antimicrobial therapy
* Breastfeeding
* Mild to moderate local reaction to previous vaccine
* History of penicillin or other non-vaccine allergy
* Receiving allergy extract immunotherapy
64
Where are significant adverse events after vaccination reports made? Who makes this requirement?
* VAERS
* National Childhood Vaccine Injury Act
65
What are the primary objectives of VAERS?
* Detect new, unusual, or rare vaccine adverse events
* Monitor increases in known adverse events
* Identify potential patient risk factors for particular types of adverse events
* Assess safety of newly licensed vaccines
* Determine and address possible reporting clusters
* Recognize persistent safe-use problems and administrative errors
* Provide a national safety monitoring system that extends to the entire general population for response to public health emergencies, such as a large-scale pandemic influenza vaccination program
66
What is the national vaccine injury compensation program?
No-fault system in which persons thought to have suffered an injury or death as a result of administration of a covered vaccine can seek compensation
67
Where should suspected cases of vaccine-preventable diseases be reported?
* State or local health departments
* If any lab tests for traceable disease, reports to local health department to track disease for prophylaxis and prevention
68
What is HPV?
STD that causes anogenital and oropharyngeal disease in males/females
69
Persistent viral infection with high-risk HPV genotypes can cause what?
* Virtually all cancers of the cervix
* High-risk types 16 and 18 approx 70% of all cervical cancers worldwide
* Nearly 90% of anal cancers
70
What vaccines is available in US for HPV? What HPV types does it target?
Gardasil 9
* 6, 11, 16, 18, 31, 33, 45, 52, 58
71
What is the recommended gardasil schedule?
* Ages 11 or 12, can start at 9
* Catch up recommended 13-26 with option up to 45
* Before 15: 2 doses 0 and 6-12 months later
* After 15: 0, 1-2 months, and 6 months
* Immunocompromised: get all 3 doses
72
When is the optimal time to get the HPV vaccine?
Before sexual debut
73
Do you still immunize patients with gardasil if they have already been exposed/might have infection?
* Non treat or accelerate clearance of preexisting vaccine type HPV infections
* Those sexually active should still be vaccinated
* History of genital warts, +HPV test, abnormal cervical, vaginal, vulvar, or anal cytology indicate prior HPV infection --> still vaccinate because may not be same type
74
Why are gardasil vaccination rates low?
* Lack of sexual activity
* Parents believe vaccines promote sexual activity
* Parents don't think it is needed
* Lack of knowledge about disease
* Perceived influence by pharmaceutical industry
75
What are the 2 types of meningococcal vaccinations?
* Meningitis ACWY (Menactra, Menveo, Menquadfi)
* Meningitis B (Trumenba or Bexsero)
76
When is meningitis ACWY given?
* Required before 7th and 12th grade
* Given 1 dose @ 11-13 year, then 16-18 years
77
When is meningitis B given?
* 1 dose @ age 16-18, second dose either 1 month apart or 6 months apart (depending on vaccine)
* High risk for bacterial meningitis in college dorms and army recruits
* Many colleges and universities require proof of updated vaccine
78
When is flu vaccine recommended?
* Annually children 6 months of age and up
* Children 6 months to 8 years require 2 doses first time they receive flu vaccine with single annual doses thereafter
79
When can flumist be given?
* age 2
* Live attenuated, sometimes not as effective but improves vaccine rates
80
Contraindicatioins to the inactivated flu vaccine
* Children under 6 months of age
* History of severe allergic reaction to influenza virus or any component of the vaccine
81
How should flu vaccination be managed if egg allergy?
* Majority cultured from chicken embryos
* Recommended to receive age-appropriate flu vaccine even if allergic with staff prepared for reaction
* Observe for greater than or equal to 30 minutes for signs of reaction
82
What are guidelines for flu vaccine with egg allergy according to the CDC?
* Egg allergy, hives only: any influenza vaccine appropriate for age and health status annually
* Egg allergy with symptoms other than hives: any influenza vaccine appropriate for age and health status annually in medical setting under supervision of health care provider who can recognize and manage severe allergic reactions
83
Precautions with dead flu vaccine
* Should be withheld from children with moderate to severe acute illness until symptoms resolve
* Minor illnesses with or without fever are not excluded
84
What are contraindications to live attenuated flu vaccine?
* Children under 2
* Children of any age with asthma and children 2-4 with history of recurrent wheezing
* Children who are close contracts of severely immunocompromised individuals
85
What is the measles virus?
* Acute infection
* Fever
* Cough
* Coryza
* Conjunctivitis
* Rash
* Severe complications: encephalitis and death
86
What is the mumps virus?
* Acute viral syndrome
* Parotid swelling
* Self-limited usually
* Associated with orchitis, aseptic meningitis, and encephalitis
87
What is rubella virus?
* German Measles
* Mild infection with rash
* Severe teratogen causing hearing loss, cardiac disease, cataracts, neurodevelopmental defects if occurs in early life
88
What type of vaccine is MMR?
Live attenuated
89
What are the 2 MMR vaccine formulations?
* MMR and MMRV (varicella)
90
When is MMR recommended? Why?
* MMR @12-15 months
* MMRV @4-6 years
* Increased risk of febrile seizures when MMRV administered <4 years
## Footnote
Has led to 99% reduction in measles since 1963!
91
If one person has measles, how many close contacts will likely become infected?
90%!
92
Contraindications to MMR
* Hypersensitivity
* Pregnancy - do not get pregnant for at least 28 days after MMR administration d/t theoretical risk of rubella
* Immunodeficiency
## Footnote
DOES NOT CAUSE AUTISM!!
93
Why is the myth "immunizations are 100% effective" not true?
* EX: MMR is only 88% effective
* Can get mild chickenpox
* Flu vaccine 2015 was only 23% effective
93
Why is the myth "I got the flu from the flu shot" not true?
* May have mild flu symtpoms, very mild runny nose, headache, low grade fever
* Can still get flu if vaccine does not match current subtypes
* Does not give you the flu, it is killed
94
Dispute the MMR autism claim
* Andrew Wakefield published report on 12 children who developed autism after MMR vaccine
* Actually, children carefully selected and some research funded by lawyers acting for parents against vaccine manufacturers
* Fraud for financial compensation
* Wakefield and his colleagues lost licenses in 2010
* Multiple studies have now shown that there is no association
95
What happened during Disneyland outbreak?
* Traveler from overseas with measles visited while infectious
* 147 people infected across states, 131 in california
* researchers determined due to kids not getting vaccinated
96
To establish herd immunity, how many individuals need to be vaccinated?
* 50-95% of population
97
What happened in 2019 with measles?
* Jan - December 2019, 1,274 cases confirmed in 31 states
* Majority among people not vaccinated
* More likely to spread and cause outbreaks in US communities where groups of people are unvaccinated
* Declining vaccination rates have led to increased outbreaks
98
What is prophylaxis?
* Antibiotics
* Immunoglobulin or monoclonal antibodies
* Vaccine
* Used post-exposure, perinatal exposure, and pre-exposure for those at increased risk
99
What is primary prophylaxis?
* Prevent infection before a first occurance
100
What is secondary prophylaxis?
Prevent recurrence after a first exposure
101
Who should receive prophylaxis for meningococcus
* Primary to all contacts of index cases N.meningitidis should be administered ASAP
* Household contacts especially young children, child care or nursery school contacts in last 7 days, direct exposure to secretions through kissing or sharing toothbrushes or eating utensils
* Also recommended for those who frequently sleep or eat in same dwelling or passengers seated directly next to for airline flights longer than 8 hours
* Chemoprophylaxis not recommended for casual contacts with no history of direct exposure to oral secretions, indirect contact with index patient or medical staff without direct exposure
102
What is used for meningococcus prophylaxis?
Rifampin BID for 2 days, ceftriaxone once and ciprofloxacin once are recommended regimen
103
Prophylaxis for tetanus
* Postexposure wound treatment with cleansing using soap and water, removal of foreign body and debridement
* Vaccination (toxoid) of person with incomplete immunization and tetanus immunoglobulin for contaminated wounds, puncture wounds, avulsions, crushing, burns, or frostbite
104
Who receives prophylaxis for rabies
* No benefit after symptoms appear
* RIC and rabies vaccine
* Any healthy-appearing domestic animal responsible for unprovoked bite should be observed for 10 days for signs of rabies without immediate treatment of victim
* Prophylaxis if animal rabid or suspected to be
* Captured wild animal should be euthanized without period of observation and brain examined for rabies
* If not captured, rabies should be presumed and prophylaxis administered
* Following exposure to bat for persons who might be unaware or unable to relate that bite or direct contact has occured (mentally disabled, sleeping child, unattended infant)
105
What animals are high risk for rabies?
* Skunks
* Raccoons
* Foxes
* Woodchucks
* Bats
Most other carnivores regarded as rabid unless proved negative by testing
106
What is used for rabies prophylaxis?
* Cleansing with soap and water and virucidal agent such as iodine
* Rabies immunoglobulin 20 U/kg administered as full dose of RIG infiltrated SQ into area around wound if possible, rest in arm
* Rabies vaccines day 0, 3, 7, 14 and 28 if immunocompromised
107
Prophylaxis for pertussis (whooping cough)
* Post exposure antimicrobial prophylaxis with azithromycin
* Treat with antibiotics and monitor for symptoms for 21 days after exposure
108
Where can you get prophylaxis for traveling abroad?
At health department ie cholera, yellow fever, BCG
Check CDC website for more info
