Review – Kaplan Pediatrics: Immunizations

See Also: CDC All About Immunizations

Classification of Vaccines 

 Vaccine Rules

• 2 or more doses are usually required for stimulation of an adequate and persisting antibody response
• A lapse in schedule does not require reinstitution of the entire series.
• For unknown or uncertain immunization status
  • the child should be considered to be disease-susceptible, and immunizations should be initiated without delay
  • all vaccine(s) must be documented on a formal immunization record, regardless of country.
• No reduced dose or divided dose should be administered, including to babies born prematurely or at low birth weight (exception: first dose hepatitis B).
• Active immunization of people who recently received gamma globulin
  • Live virus vaccine may have diminished immunogenicity when given shortly before or during the several months after receipt of immunoglobulin (Ig) so live vaccine is delayed (3–11 months).

Myths on vaccines

• Evidence does not support the hypothesis that the MMR causes autism, associated disorders, or inflammatory bowel disease.
• No causal relationship between multiple immunizations and increased risk of immune dysfunction and type 1 diabetes.
• No causal relationship between hepatitis B vaccine administration and demyelinating neurologic disorders
• No causal relationship between meningococcal vaccination and Guillain- Barré.
• Preservative thimerosal (Hg-containing) not causative of any problems (has now been removed)

No contraindications for: 

• A reaction to a previous DTaP of temperature <105°F, redness, soreness, and swelling
• A mild, acute illness in an otherwise well child
• Concurrent antimicrobial therapy
• Prematurity—immunize at the chronological age
• A family history of seizures
• A family history of sudden infant death syndrome
• Fever, per se, is not a contraindication.
  • but based on the physician’s assessment and on specific vaccines  
  • If moderate or serious illness, the child should not be immunized until recovered
• Documented egg allergy is not a contraindication to the MMR. MMR does not contain significant amounts of egg cross-reacting proteins.
• Influenza vaccine (and yellow fever) does contain egg protein and on rare occasions may induce a significant immediate hypersensitivity

Post-exposure Management

Measles

 Varicella

• Give vaccine to susceptible immunocompetent household contacts as soon as possible and VZIG to all immunocompromised, susceptible pregnant women, and children age < 12
• VZIG also for susceptible pregnant women, newborn whose mother had the onset of chicken pox within 5 days before delivery to 48 hours after delivery, and certain hospitalized premature infants

Hepatitis

• Hepatitis B: after exposure in non-immune patient, give hepatitis B Ig plus vaccine; repeat vaccine at 1 and 6 months.
• Hepatitis A: if not vaccinated or received one dose of vaccine within the past 4 weeks, give immunoglobulin within 2 weeks of exposure

Mumps and Rubella

• Not protected by postexposure administration of live vaccine
• Recommended for exposed adults who were born in the United States in or since 1957 and who have not previously had or been immunized against either; except pregnancy

ROUTINE VACCINATION

Hepatitis B

• First dose should be given soon after birth, before hospital discharge, with a total of 3 doses by 18 months of age if mother is HBsAg negative.
• The infant born to a hepititis B surface antigen (HBsAg)-positive mother should receive the first dose of hepatitis B virus (HBV) plus hepatitis B Ig at 2 different sites within 12 hours of birth; all 3 doses should be given by 6 months of age (treat same as exposure).
• All children and adolescents not immunized should begin the series during any visit

DTaP

• All DTaP contain acellular pertussis.
• The rates of local reactions, fever, and other common systemic reactions are substantially lower with acellular pertussis vaccines than with whole-cell vaccine (but may still occur). Use DT if there has been a serious reaction and also for any catch-up after age 7 (i.e., no full dose pertussis after age 7).
• Total of five doses is recommended before school entry, with the final given at preschool age, 4–6 years.
• Pertussis booster (Tdap) vaccine is now recommended during adolescence, regardless of immunization status; is also recommended even if one has already had pertussis
• Tdap (childhood tetanus) is given at age 11–12, and then Td (adult tetanus) every 10 years.

Tetanus

Tetanus Prophylaxis in Wound Management

Definition of abbreviations: TIG, tetanus immune globulin; Td, tetanus and diptheria vaccine.

*All other wounds = increased risk of tetanus: dirt, saliva, feces, avulsions, frostbite, puncture, crush, burns, and missiles.

†Unless >10 years from last dose.

‡Unless >5 years from last dose.

IPV

• “Inactivated” is now only available in US.
• Four doses of IPV, with the last at preschool age, 4–6 years
• Any child up to 18 years of age should receive all doses, if behind.
• Any child who has received OPV from another country should complete schedule in United States with IPV.

HiB Conjugated Vaccine

• Not cover nontypeable Haemophilus
• Primary series consists of 3 doses or 4 (depending on brand)
• An additional booster dose at 12–15 months of age, regardless of  types of primary series
• If immunization behind until 15–59 months of age, then give 1 catch-up dose by age 5 years in normal children
• Invasive disease does not confirm immunity; patients still require vaccines if age appropriate, i.e., <5 years of age.

Pneumococcal Vaccines

• Pneumococcal conjugate vaccine (PCV13)
  • Purified polysaccharides of 13 serotypes conjugated to diphtheria protein
  • Routine administration as a four-dose series for all children age 15 months and younger
  • If no dose given yet between 15–59 months of age, then there are catch-up doses
• 23-valent pneumococcal polysaccharide vaccine (PS23)—given as additional protection to the PCV13 in some high-risk children (e.g., functional/anatomic asplenia) >2 years of age

 Varicella

• Recommended at 12 months of age or older for healthy people who have not had varicella illness, with second dose at 4–6 years of age
• Catch-up dosing: Two doses for children 12 years and younger, and two doses (separated by 4–8 weeks) for >12 years (seroconversion is higher after two doses in this age range)
• May still have breakthrough varicella; milder than unimmunized, rarely spread
• Has been associated with the development of herpes zoster after immunization (rare)
• Most people over 18 years of age, even without a reliable history of varicella infection, will still be immune.

MMR

• Live attenuated vaccine: issues as above for varicella
• First dose given at 12–15 months of age
• Second dose given at preschool age, 4–6 years
• Catch-up with 2 doses

Hepatitis A Vaccine

• For all >1 year of age (12–23 months)
• Two doses, 6 months apart
• Also routinely for chronic liver disease, homosexual and bisexual men, illegal drug users, clotting-factor disorders, and risk of occupational exposure
• Can give with other vaccines

Meningococcal Conjugate Vaccine (MCV4)

• Administer MCV4 to
• At 11–12-year-old visit and a booster at age 16
• All college freshmen living in dormitories if not vaccinated

 Influenza Vaccine

• Inactivated influenza vaccine (typical flu shot)
  • Administered IM
  • Caution in egg allergy
  • Annually during flu season for children greater than 6 months of age (A strains, B strains, and H1N1)
• Live influenza vaccine
  • Administered intranasally
  • Contraindicated in the immunocompromised
  • Only to healthy people 2–49 years of age who are not pregnant and do not have certain health conditions

Rotavirus Vaccine

• Oral live attenuated vaccine
• Given at ages 2, 4, 6 months
• Essentially no catch-up if behind (no dose after age 8 months)
• Safe, highly effective (no intussusception; M & M from disease reduced significantly)

Human Papilloma Virus Vaccine (HPV)

• Quadrivalent vaccine (6, 11, 16, 18) or bivalent vaccine (16, 18) to girls at the age 11-12 visit (through age 26) for cervical cancer prevention
• Quadrivalent vaccine (6, 11, 16, 18) to boys age 11–12; for genital warts caused by HPV 6,11.
• Can give in both males and females as early as age 9