Lecture 3

Question 1

downside of vaccines

Answer 1

 Oral (Salk) Polio vaccine causing polio infection.
 Febrile seizures with flu vaccine
 Allergy to any vaccine

Question 2

antigen theory

Answer 2

 Exposure to many antigens (ie. multiple vaccines) causes autism. - CDC study from 2013 looked at antigen load of children in the first 2 years of life and there were no differences between children with ASD (autism spectrum disorder) and those without the diagnosis.

Question 3

vaccine ingredients

Answer 3

 Thimerosal-Mercury derived additive that was used as a preservative for multi-dose vials of vaccine.
 Since 2003 there have been 9 CDC-funded studies that found no connection between thimerosal and ASD.
 1999-2001- Thimerosal was reduced to trace amounts in all childhood vaccines.

Question 4

vaccines and the law

Answer 4

-In 2016, California passed a SB277 that no longer allowed families who have children in child care, private and public school to decline vaccinations for religious and personal beliefs.
 Children who are home schooled do not have to be vaccinated.
 Vaccination records are checked at: entrance to child care, kindergarten and 7th grade.
 Not all vaccines on the childhood vaccination schedule are required.
 Required vaccinations: DTaP, HiB (younger), Polio, MMR, VZV, Hep B, Tdap (older)
 Shotsforschool.org
-In 2011, AB499 was passed that allowed minors 12-17 to consent for vaccinations against STI’s:
 Hep B, HPV

-Need to know which ones are required for school, but don’t need to know specific ones for 7th grade, etc.

Question 5

catch-up schedule

Answer 5

-For those who are receiving vaccines out of the “traditional” interval.
 Delayed start
 New immigrant
 Lapse in care

• Available at www.cdc.gov. Should be reviewed carefully if have a patient who needs vaccines off-schedule. There are MANY rules.
• Full schedules can be repeated safely.

Question 6

active vaccines

Answer 6

 individual is stimulated to develop immunologic defenses against future natural exposure
 may be either:
-live (attenuated) – side effects occur ≥7d later, or (common side effects include fever and rash)
-killed (inactivated) – side effects occur in <48 hours (common side effects include fever and site reactions)

Question 7

passive vaccines

Answer 7

 individual exposed or at risk of exposure is given an immuno-modulator: such as a preformed human or animal antibody (HBIG, VZIG are examples)

Question 8

vaccine risk/benefit

Answer 8

	Risks
•	precautions
•	contraindications
•	misconceptions
	Benefits
•	Individual and society benefits

Question 9

vaccines can still be given in the presence of:

Answer 9

 minor illness
 fever
 most common allergies (cats, weeds, pollen, drug rash)

Question 10

precautions and contraindications for vaccines

Answer 10

 precaution
• moderate or severe illnesses with or without fever
 contraindications
• anaphylactic reaction to a vaccine (contraindicates further doses of that vaccine)
• anaphylactic reaction to a vaccine constituent (contraindicates the use of vaccines containing that substance (e.g., neomycin, eggs))

Question 11

vaccine schedule

Answer 11

-2-6 months (dose after 12 mos.)
	DTaP 1,2,3,(4)
	Hib 1,2,3,(4)
	IPV 1,2,3
	HBV 1,2,3
	RV 1,2,3
	PCV-13 1,2,3,(4)

-influenza annually starting at 6 months of age

-starting at 12 months
 HAV 1,2
 MMR, VZV

-at 4-6 years
 DTaP, IPV, MMR, VZV

-adolescence
 Tdap, MCV, HPV

Question 12

immunizations

Answer 12

-Required documentation
 manufacturer, lot number, date - mark the date that the vaccine was given
 name & business address of the health care professional administering the vaccine
 vaccine information statement (VIS) - version date & date provided
 site, route, expiration date of vaccine

-Clinically significant adverse events are reported to the Vaccine Adverse Event Reporting System (VAERS)

Question 13

abbreviations

Answer 13

o DTaP – diphtheria-tetanus-acellular pertussis (under 7 years)
o Tdap – tetanus-diphtheria-acellular pertussis (7 yo or over)
o Td – diphtheria-tetanus
o DT – diphtheria-tetanus (under 7 years when pertussis is contraindicated, ex. seizures)
o IPV – inactivated polio vaccine
o OPV – oral polio vaccine
o HAV – hepatitis A vaccine
o HBV – hepatitis B vaccine
o PCV-13 – 13-valent pnuemococcal conjugate vaccine
o Hib – conjugate H. influenzae type b vaccine
o MMR – measles-mumps-rubella
o VZV – varicella zoster vaccine
o MCV – meningococcal conjugate vaccine
o HPV – human papilloma virus vaccine

Question 14

vaccines of the first 6 months

Answer 14

o Hepatitis B
o Diphtheria, Tetanus and acellular pertussis (DTaP)
o Inactivated Polio (IPV)
o Pneumococcal Conjugate Vaccine (PCV-13)
o Haemophilus Influenza B (Hib)
o Rotavirus

Question 15

transmission of hep B

Answer 15

 blood products
 perinatal
 sexual transmission
 saliva
 infected needles - IV drug use, skin piercing
 household transmission (possibly by saliva) - child-to-child transmission in U.S. limited by vaccine-induced herd immunity

Question 16

clinical manifestations of hep B

Answer 16

-acute hepatitis B infection: ranges from asymptomatic to fulminant hepatitis, anorexia, nausea, jaundice, right-upper quadrant discomfort, age of acquiring disease determines likelihood of developing symptoms (<1% of infants but 30-50% of those infected over age 5 years), extrahepatic manifestations (arthralgia/arthritis, rash, thrombocytopenia, Gianotti-Crosti syndrome (papular acrodermatitis of childhood))

Question 17

chronic hepatitis B infection

Answer 17

 25-50% of children with acute infection under age 5 progress to chronic infection
 2-6% first infected older than 5 progress to chronic infection
 3% of children with chronic hepatitis B progress to cirrhosis
 up to 25% who are chronically infected as children will develop hepatocellular carcinoma

Question 18

treatment for hep B

Answer 18

 none for acute infection

 chronic active hepatitis - anti-virals – lamivudine, interferon-alpha

Question 19

hep B vaccine

Answer 19

• recombinant vaccine
• intramuscular

-schedule
 Birth, 2 months, 4 months (extra), 6-9 months
 infants born to hepatitis B surface antigen positive mothers (mothers screened during pregnancy, HBIG at birth with hepatitis B vaccination)

-Common for people who have received a complete vaccination series to not be immune to Hep B.
 Revaccinate
 No need to check titers

Question 20

Diphtheria sxs

Answer 20

-Acute upper respiratory tract infection Caused by Corynebacterium diphtheriae

-Clinical findings
 pharyngeal diptheria (sore throat, fever, swelling, stridor) - severe form is a membranous pharyngitis
 obstructive tracheolaryngitis
 can cause cutaneous, vaginal, conjunctival or otic infection
 complications (“bull neck,” myocarditis, swelling, respiratory symptoms

• dehydration
• thick exudative membrane over pharynx

Question 21

diphtheria tx

Answer 21

-Last respiratory tract infection in U.S. reported in 2003
-Endemic in countries where immunization is less available
-Treatment
 IV equine anti-toxin
 erythromycin or penicillin
 active immunization

Question 22

tetanus cause and sxs

Answer 22

-Caused by Clostridium tetani toxin

-Blocks inhibitory impulses to skeletal motor neurons
 acts at neurons of the spinal cord and at myoneural junction, causing muscle spasm

-Bacterium itself causes no inflammatory reaction or tissue destruction at wound site (e.g., umbilical stump)
 normal resident of soil and human GI tract
 not transmissible between humans

-Clinical presentation
	Pain at the site of inoculation
	Hypertonicity
	Spasm
	Exaggerated spasms in response to light stimuli

Question 23

tetanus tx

Answer 23

 human tetanus immune globulin (TIG)
• IVIG if TIG is not available
• equine tetanus antitoxin (not available in U.S.)

 treatment of wounds
• wound excision if necrotic tissue is present

 antibiotics
• metronidazole or penicillin

 spasm control
• minimized stimulation
• muscle relaxants
• time (if not fatal, symptoms subside in a few weeks)

-SPASTIC PARALYSIS!!! Botulism is flaccid paralysis

Question 24

pertussis stats

Answer 24

-Adults and adolescents act as reservoir
 prompted start of adolescent vaccination in 2007

-U.S. incidence of disease “re-peaked” in 2004-2005

-Infants infected before primary immunization series are at risk
 reservoir is infected adolescents and adults

-20-25 infant deaths per year

-Pre-vaccine: 36,000 deaths per year
 most in the first 6 months of life

-27,550 cases in California in 2010, fewer in 2011
 10 infant deaths

-2164 cases in California in through Aug 10, 2011
 no deaths reported

Question 25

pertussis stages

Answer 25

-prodromal/catarrhal phase – 1-2 weeks  rhinitis, sneezing, cough  apnea may occur especially young infants -paroxysmal phase – 4-6 weeks  10-30 staccato coughs with loud inspiratory “whoop” in older childrens  coughing paroxysms accompanied by cyanosis, sweating, post-tussive vomiting, exhaustion  can be complicated by pneumonia, seizures, encephalopathy (worst in infants under 3 months of age) -convalescent phase – 2 weeks to several months  In Chinese – bai re ke – “100 days’ cough”  may be exacerbated by viral illness -infectious in the first two phases

Question 26

laboratory findings of pertussis

Answer 26

 leukocytosis  lymphocytosis  Charcoal-Lowe media culture - 30-second posterior nasopharynx culture; poor sensitivity in practice  PCR - nasopharyngeal swab

Question 27

pertussis tx

Answer 27

 antibiotics: • azithromycin (drug of choice) (may shorten course of disease in catarrhal phase) • alternate – TMP/SMX (Bactrim) • prevent spread of infection  inpatient monitoring until cyanotic episodes clear  supportive care • oxygen • ventilatory support

Question 28

pertussis vaccine precautions

Answer 28

 temperature of 40.5°C within 48 hours without another identifiable cause  collapse or shock-like state within 48 hours (5 per 100,000)  persistent crying of or over 3 hours within 48 hours (12 per 100,000)  seizure within 3 days (7 per 100,000)

Question 29

pertussis contraindications

Answer 29

 encephalopathy within 7 days of administration of previous dose without another identifiable cause

Question 30

DTaP

Answer 30

 2 months, 4 months, 6 months,  Booster 18 months, 4-6 years  TdaP if over 7 yo and need catch up.  Tdap at 12 yo

Question 31

TdaP

Answer 31

-(the version given after 7 years old) – same vaccine as DTaP but formulation is given -Tdap immunization replaced Td in adolescents  adolescents common reservoir for pertussis  transmission to at risk group of infants reduced if adolescent reservoir is vaccinated  In 2008, adolescent coverage was estimated at 40%  routine dose at 11-12 years of age -adult coverage at <6%  anyone 19-64 years old should receive a booster in lieu of Td

Question 32

poliomyelitis sxs

Answer 32

 headache, low-grade fever, sore throat, muscle weakness • originally inoculates the oropharynx • headache may represent aseptic meningitis  asymmetric, flaccid paralysis • infection of anterior horn of spinal cord • 0.1 to 2.0% of infected  muscle tenderness and hyperesthesia; intact sensation  later - muscle atrophy

Question 33

inactivated polio vaccine

Answer 33

-0.5 mL subcutaneous dose in U.S. ``` -schedule  4 doses  2 months  4 months  6-18 months  4 years ```

Question 34

oral polio vaccine (OPV)

Answer 34

-Live virus vaccine -Used in other countries  easy to administer  cheap -Vaccination can be spread to the unvaccinated by fecal-oral route  may cause infection in immunocompromised -Risk of conversion to wild-type polio  1/760,000

Question 35

pneumococcus

Answer 35

-Streptococcus pneumoniae is the most common cause of invasive bacterial infection in children (14% mortality)  sepsis  meningitis – 3300 cases/year pre-vaccine  pneumonia – 100k-135k hospitalizations/year pre-vaccine - also most common cause of otitis media and sinusitis in children (6 million cases of OM/year pre-vaccine) - most infection occurs in children less than 2 years of age

Question 36

pneumococcal conjugate vaccine

Answer 36

o vaccination with PCV-7 (heptavalent) began in 2000 o heptavalent pneumococcal vaccine effective in preventing serious bacterial infection (pneumonia, meningitis, bacteremia) o 99% reduction between 1999 and 2006 in invasive disease due to 7 serotypes o 76% reduction in all invasive disease o invasive disease by penicillin-resistant types has fallen - especially among children younger than 2 years of age o simultaneous reduction in disease in older children and adults o overall rates of pneumococcal otitis have not changed o pneumonia with empyema remained a problem o vaccination with 13-valent pneumococcal vaccine started in 2010

Question 37

pneumococcal conjugate vaccine schedule

Answer 37

```  2 months  4 months  6 months  12-15 months o 0.5 ml intramuscular dose o for children up to 59 months of age previously vaccinated with PCV-7, one dose of PCV-13 is recommended ```

Question 38

Haemophilus influenzae type B

Answer 38

o Cause of many serious bacterial infections in early childhood and infancy in prevaccine days (prior to mid-80’s) ``` o Classic infections of Hib  meningitis - severe, associated strongly with hearing loss  acute epiglottitis  pneumonia, often multilobar  septic arthritis  cellulitis (often facial) ``` o Treatment  third-generation cephalosporin

Question 39

Hib vaccination

Answer 39

o Vaccination Schedule (Can be 3 or 4 vaccines depending on brand)  4 dose: 2 months, 4 months, 6 months, 15 months  3 dose: 2 months, 4 months, 12-15 months  very effective in reducing severe infection rate (meningitis from Hib has virtually disappeared, Hib cellulitis is now extremely rare, epiglottitis is now extremely rare)  depending on which clinic you work in, it may be given in 4 or 3 doses  she won’t test on Hib whether it is 4 doses or 3  after 5 years of age, if you have a kid that is unvaccinated, they don’t need the vaccine

Question 40

Rotavirus epidemiology

Answer 40

 most common cause of severe diarrhea in infants and children  nearly every child is infected by 5 years of age  age of severe infection - 4 months to 36 months

Question 41

rotavirus baseline disease burden

Answer 41

 20-60 deaths per year  47,000-60,000 inpatient visits  600,000 outpatient visits  3.2 million home care  associated with 2.5% of all childhood hospitalizations  autumn in southwest & Mexico, moving to northeast by spring

Question 42

rotavirus pathogenesis

Answer 42

 fecal-oral transmission  viral shedding 7 days after onset of symptoms  1-2 day incubation period  typically 3-8 days of symptoms - up to 21 days of symptoms

Question 43

rotavirus infection

Answer 43

 virus invades small intestine villi  villous atrophy  malabsorption of carbohydrates  combination secretory and malabsorptive diarrhea - recovery of absorptive capacity appears much slower in small infants

Question 44

rotavirus sxs

Answer 44

 fever (+/-)  abdominal pain  diarrhea  vomiting

Question 45

rotavirus diagnosis

Answer 45

 fever (+/-)  abdominal pain  diarrhea  vomiting

Question 46

rotavirus tx

Answer 46

 hydration - oral hydration usually sufficient, IV hydration (possibly isolated to emergency department, severe cases or those that cannot tolerate oral intake are hospitalized, particularly important in small infants) -correction of electrolyte abnormalities

Question 47

rhesus rotavirus tetravalent vaccine

Answer 47

-association between vaccination with RRV-TV and intussusception • one case of intussusception for every 4,670 to 9,474 infants who received RRV-TV • risk too high for United States • removed from market after availability from 12/98 to 6/99

Question 48

rotavirus vaccines available

Answer 48

-Two available live, oral vaccines  minimum interval between doses – 4 weeks  dosing for either should not begin after 15 weeks of age  dosing for either must be complete by 8 months, 0 days of age  pentavalent human-bovine reassortant rotavirus vaccine (Feb 2006) - three oral doses o 2, 4, 6 months of age o first dose given between 6 and 12 weeks of age  live human attenuated rotavirus vaccine (Apr 2008) - two dose regimen o 2 & 4 months of age o The later you give this, the higher the risk of intussusception

Question 49

efficacy of pentavalent rotavirus vaccine

Answer 49

 not associated with intussusception- however still comes with warning • risk would have to be at most 1/100,000 to escape detection in surveillance currently  marked reduction in • hospitalizations - 95.8% • emergency department visits - 93.7% • office visits - 86%

Question 50

measles

Answer 50

o Also known as Rubeola o Starts with prodrome of fever and malaise. Progresses to cough, coryza and conjunctivitis. o 2 days prior to rash Koplik’s spots can occur in the mouth. These are bluish, grey spots on the buccal. o 2-4 days after fever patient will develop an erythematous, blanching full body rash.

Question 51

complications of measles

Answer 51

 Diarrhea  Pneumonia- number one cause of mortality from measles  Encephalitis and Acute disseminated encephalomyelitis (ADEM)

Question 52

mumps

Answer 52

o Viral illness o Starts with flu-like symptoms: fever, malaise, headache. Progresses to parotitis (inflammation of the salivary glands) and in some cases orchitis (inflammation of the testis) or oopheritis (inflammation of the ovaries). o Disease is generally self-limited o Orchitis generally ocurs in post-pubertal males. 30-50% of those who develop orchitis later develop testicular atrophy. o Severe cases can lead to encephalitis. Was a leading cause of viral encephalitis induced deafness prior to MMR vaccine. o One dose of MMR is 78% effective at preventing Mumps infection. 2 doses is 88% effective.

Question 53

Rubella

Answer 53

o Also known as “German Measles” o Symptoms include a low grade fever, lymphadenopathy and pinpoint rash that starts on the face and progresses down to trunk and then generalizes. o Arthralgias can also be present. o Congenital Rubella: “blueberry muffin” rash, cataracts, deafness, cardiac defects. o 90% of women who contract rubella in the first 3 months of pregnancy will give birth to a baby with congenital rubella syndrome.

Question 54

MMR

Answer 54

o Live Vaccine o 2 shot series: 12 mo and 4 yrs o There is a combo vaccine with VZV. This is best given for the second dose so as to prevent febrile seizures. o **Note about live vaccines - they need to be given at least a month apart.

Question 55

VZV

Answer 55

o Varicella aka Chicken Pox o Viral illness that cases fever, malaise, sore throat, and vesicular rash. o Rash is characterized as ”dew drop on a rose petal”- Clear fluid on an erythematous base. o You should see lesions of various stages. o Illness is mild in young children, but can be more dangerous in adolescents and adults.

Question 56

VZV complications

Answer 56

 Encephalitis  Bacterial Superinfections  Pneumonia  Reye’s Syndrome: • Nausea, vomiting, headache, delirium, and coma • Precipitated by Salicylate (Aspirin) usage in children with viral illness  Shingles- recurrence of varicella later in life

Question 57

VZV congenital and neonatal

Answer 57

o Congenital Varicella  Cicatricial skin lesions that are in a dermatomal distribution (The virus has invaded the dermatome and so you get a skin lesion in that dermatome)  Limb abnormalities  CNS abnormalities- microcephaly, seizures, cortical atrophy or intellectual disability  Cataracts, choreoretinitis o Neonatal Varicella  Can range from mild disease with rash to generalized infection with encephalitis, hepatitis and pneumonia

Question 58

hepatitis A

Answer 58

o One of the most common vaccine preventable illnesses in the US. o Recent outbreak in San Diego prominent in the homeless community and those who use IV and non-IV drug use. Multiple outbreaks in other states now. (see next slide) o Viral illness transmitted through fecal-oral route. o Generally an acute, self-limited disease. However 20 people died in the San Diego outbreak. o Vaccine: 2-dose series given 6 months apart. Generally given at 12 and 18 months.

Question 59

HPV

Answer 59

o Human Papilloma Virus is known to cause several cancers including cervical, anal and throat cancer. o Since 2017 the only HPV vaccine in the US is HPV-9 that protects against the key cancer causing strains: 16 and 18 as well as strains 31, 33, 45, 52, and 58. This coverage protects against 90% of the viral causes of cervical cancer. o Recommended for both males and females. o Initiation of vaccine should start prior to exposure to HPV. (KEY!!) o Regimen is either 2 dose or 3 dose depending on age:  9yo-14yo: 2 doses 6 months apart  15yo-26yo*: 3 doses: 1-2 months between dose 1 and 2 and 6 months between dose 1 and 3. o *Insurance may not cover it for males over 22 yo or anyone over 26 yo.

Question 60

meningococcus

Answer 60

o Vaccines available for serogroups ACYW and B of Neisseria meningiditis. o Serogroups C and W have the highest case fatality. o Serogroup B one of the most common. o Meningococcal meningitis is a rapidly progressing, devastating illness that can lead to epidemics. o Features of N. meningiditis infection include: signs of meningitis (headache, neck/back pain, altered consciousness), fatigue, purpuric rash, and shock.

Question 61

meningococcal vaccine

Answer 61

o Vaccination is indicated for teenagers (11yo-18yo) and anyone 2 months or older who would be at increased risk for meningococcal meningitis (Ex. Travelers to the Meningitis Belt or The Hajj). o Post-exposure prophylaxis is needed even for those who are vaccinated and have close contact with someone who has the disease. o Routine Vaccination Series: 1st dose 11yo-12yo and 2nd at 16yo.  Menactra, Menveo

Question 62

meningococcus B

Answer 62

o Trumenba and Bexsero were introduced in 2014 and 2015 against N. meningiditis serogroup B. o Serogroup B is linked to 60% of cases among children <5 yo. o Incidence is 1.6 per 100,000 from 2007-2016. In 2016 there were 370 cases of meningitis. o Given the low incidence Men B is not a “routine” required vaccine in the US. o It is routine in may European countries given the increased incidence. In 2011, there were 750 cases of Men B alone in England.