Swanson – Immunizations

Swanson’s Family Medicine 2017
Ch. 100 Immunizations 508
Lani K. Ackerman

1. Hepatitis B, DTaP, PCV13, IPV, and Hib  should be given to this child, just enough as is recommended routinely at 2 months of age. His vaccination should not have been withheld because of a mild upper respiratory infection. Rotavirus vaccine may not be initiated because the child is older than 14 weeks 6 days, and the maximum age for the third dose is 8 months. PCV13, not PPSV23, should be given routinely to infants and young children. Hepatitis B is usually given at birth, 2, and 6 months, but it is given to this child to replace the missed 2-month vaccine.

2. According to the catch-up immunization schedule, no vaccine may be given at an interval of less than 4 weeks. All of his previously given vaccines (DTaP, Hib, PCV13, and IPV) may be given at the visit in 4 weeks except for his third hepatitis B vaccine, which requires a minimum interval of 8 weeks between doses 2 and 3, and age older than 24 weeks.

3. A mild upper respiratory infection is not a contraindication to vaccination, and late vaccination is not a predictor of more severe adverse reactions. This child should follow routine vaccination schedules once he has “caught up.” MMR cannot be given before 12 months.

4. Vaccination against hepatitis B is routinely recommended for all children born in the United States. The recommended schedule for hepatitis B immunization is birth, 1-2 months, and 6-18 months. If an infant’s mother is hepatitis B surface antigen (HBsAg) positive, the infant must be given HBIG with the birth dose of the vaccine within 12 hours to prevent transmission of Hep B. The second dose should be given 1-2 months after the birth dose (minimum 4-week interval), and the third dose must be given at older than 24 weeks, generally at 6-12 months. For infants who are given a combined vaccine, giving an additional dose at 4 months of age is not a problem. The perinatal hepatitis B program has been successful in dramatically decreasing transmission from mother to infant through routine screening and appropriate treatment at birth.

5. The first dose is routinely given at 2 months and may not be given after 14 weeks and 5 days of age. Two oral rotavirus vaccines are now available, RV1 (2-dose at 2 and 4 months) and RV5 (3-dose at 2, 4, 6 months) . Rotavirus is the most common cause of severe gastroenteritis in infants and young children worldwide. There is an association with intussusception, however, and the risk of 0.79/100,000 is minimal compared to 40,000 fewer hospitalizations for diarrheal illnesses after the first dose. Although breastfeeding is protective and decreases severity, the vaccine is recommended for breast-fed and bottle-fed infants, and infants in lowand high-risk countries.

6. There are three true contraindications to the administration of childhood immunizations: (1) an anaphylactic reaction to a vaccine; (2) an anaphylactic reaction to a vaccine constituent, contraindicating the use of vaccines containing that substance; and (3) moderate or severe illness with or without a fever. Mild acute illness with or without a fever is not a contraindication. Convulsions, encephalopathy, collapse, or shock-like state within 48 hours of receipt of any vaccine is a cause for concern and may be considered a contraindication to further vaccination. Such episodes, which had been related to the whole-cell DTP vaccine, are extremely rare with the acellular DTaP vaccine. For live attenuated vaccines, known immunodeficiency and pregnancy are also contraindications.

7. Vaccination against Hib is recommended as a 2 or 3 dose primary series (depending on the type of vaccine) and a booster dose at 12-15 months. PRPOMP, a 2-dose primary series at 2 and 4 months has a more rapid immune response after the first dose, and is recommended for use in Alaskan natives and American Indians. PRP-T is given in 3 doses at 2,4, and 6 months. Both require a booster at 12-18 months. For unvaccinated healthy children 15 months and older, only one Hib dose is required. Meningitis caused by this organism usually occurs between the ages of 1 month and 4 years. Other significant infections caused by H. influenzae include acute epiglottitis, pneumonia, septic arthritis, cellulitis, osteomyelitis, pericarditis, and bacteremia. Hib immunization has dramatically decreased Hib meningitis and invasive disease, but not otitis media, which is due to nontypable strains. For healthy children 15 to 59 months of age without previous immunization, only one dose of Hib vaccine is recommended.

8. Three vaccinations are given for the first time at 12 to 15 months of age: MMR, varicella, and hepatitis A. They can be administered at the same time, but if not, at least a 4-week interval needs to separate varicella and MMR. Hepatitis A was previously given at 2 years, but it is now recommended to be given at 12 months, followed by a booster dose 6 to 12 months later.

9. By the time a child reaches 7 years of age, five doses of DTaP should have been administered. DTaP is given at 2, 4, 6, and 12 to 18 months and at 4 to 6 years of age.

10. Tdap—tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine—is given routinely to adolescents ages 11 or 12 years who finished their primary series (5 doses of DTaP). Tdap is now also recommended for children >7 years who did not complete their primary series. If more than one “catch-up” dose is required, Td should be used for subsequent doses. Adolescents aged 13 to 18 years who missed the 11or 12-year booster dose should also receive a single dose of Tdap if they have completed the childhood DTaP series. Subsequent Td boosters are recommended every 10 years. Tdap is recommended during the third trimester of pregnancy (27-36 weeks preferred) for each pregnancy in order to decrease transmission to infants under 2 months of age, the group with the highest rate of mortality and morbidity from pertussis. Tdap is now approved even for adults over age 65 years, and every adult should be given this vaccine once in place of one Td booster. Caretakers/relatives in contact with young infants who have not received Tdap previously should get a single dose of Tdap as soon as possible.

11. Routine adolescent vaccines include Tdap, meningococcal, and HPV vaccine. If the patient is up to date on vaccines, the hepatitis B series should be complete.

12. The HPV vaccine is now available as a bi-valent vaccine (against types 16 and 18, which cause 70% of cervical cancers) for females, and a quadrivalent vaccine, (against types 6 and 11 as well) for females and males, recommended in a three-dose schedule at 0, 1-2, and 6 months. The routine vaccination with HPV is recommended for girls and boys aged 11 or 12 years; the vaccination series can be started as young as 9 years; a catch-up vaccination is recommended for girls and boys age 13-18 years who have not been fully vaccinated. A history of sexual activity is not a contraindication to vaccination; however, the vaccine is most effective if given prior to sexual activity.

13. According to the ACIP, all children older than 6 months should receive seasonal influenza vaccination. Influenza vaccine, available as a quadrivalent or trivalent inactivated vaccine and a quadrivalent live activated vaccine, is recommended for all children and adolescents older than 6 months. As of the 2014-15 season, live active influenza virus (LAIV) is now recommended as preferred for healthy children aged 2 to 8 years who have no contraindications (asthma, wheezing, egg allergy). Children younger than 8 years receiving the seasonal influenza vaccine for the first time should receive two doses at least 4 weeks apart unless they have received at least one flu vaccine since July 1, 2010. If a child can eat scrambled eggs, he or she is likely able to take the vaccine, but those with anaphylaxis to eggs should not. Children do suffer from influenza, and the highest mortality rate is among the very young and very old. Vaccination of pregnant mothers is now recommended to protect the mother as well as provide immunity to infants under 6 months of age.

14. All of the above. Belief that vaccinations are not safe, belief that the disease is not dangerous, and belief that the provider or clinic does not have the patient’s best interest at heart are all reported as health belief systems leading to vaccine hesitancy. Vaccine hesitancy leading to vaccine delay or refusal has become an increasing problem in the United States. The very success of immunizations has resulted in many parents never having seen the disease and thus doubting the need for protection from it. Educating parents about safety monitoring by the CDC through the Vaccine Adverse Event Reporting system (VAERS), Vaccine Safety Data link (VSD), and Clinical Immunization Safety Assessment (CISA) may be helpful. Many resources are available to physicians to assist in giving parents accurate information about vaccines, as well as to document those parents who refuse vaccination (see below).

15. Reassuring parents that, despite extensive research, no association between thimerosal-containing vaccines and autism has ever been found may be helpful in their understanding about vaccine safety. The Institute of Medicine has produced an excellent resource for clinicians, with the associations between potential reactions or safety issues and those for which no association was found. Vaccines can, of course, have side effects, but these are minimal compared to the risk of the disease. Making threats to parents, or not allowing them to come for routine care, has not been shown to be effective in encouraging immunization.

16. The current large increase in measles cases, as well as outbreaks in the last 2 years, has been related to pockets of lack of immunization due to religious or other objections, as well as importation of the disease. Though waning pertussis immunity after introduction of the acellular pertussis vaccine has played a role in the increase of cases, parental delay and refusal of immunization is another factor causing the increase in pertussis cases.

Summary of Immunizations

Physicians have more data than ever before to reassure patients that vaccinations are safe and effective, yet large pockets of unimmunized children continue to lead to outbreaks of vaccine preventable disease. Vaccine hesitancy is a complex problem that leads to delayed or refused immunization; efforts to address this concern continue to challenge physicians but remain critical to ensure continued protection from vaccine-preventable diseases (Figure 100-1). Immunization of children continues to be one of the most cost-effective measures of modern medicine.

Updated schedules are available at http://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html. (Accessed on 8/3/15)

1. Which of the following vaccines are recommended for children who have sickle cell disease (functional splenectomy) or splenectomy, but not for routine vaccinations?
   1. PCV13 (pneumococcal conjugate vaccine) and PPSV23 (pneumococcal polysaccharide)
   2. Hep B and Hib vaccine
   3. PPSV23 (pneumococcal polysaccharide) and meningococcal vaccine
   4. Hib vaccine and meningococcal vaccine

2. An immunosuppressed child presents at 12 months of age. Which vaccinations likely will be contraindicated?
   1. DTaP and IPV
   2. Hib and MMR
   3. MMR and varicella
   4. Hep A and Hep B

3. Which vaccinations (or tests) should be given in the following order to avoid compromising immunologic response?
   1. PCV13 prior to PPSV23 (with minimum 8 weeks apart)
   2. MMR after TB skin test (PPD)
   3. MMR after varicella
   4. Hib after DTaP

Suggested Reading

American Academy of Pediatrics. Addressing common concerns of vaccine-hesitant parents. http://www2.aap.org/ immunization/ pediatricians/ pdf/ vaccinehesitant% 20parent_final.pdf (Accessed on 8/3/15)

American Academy of Pediatrics. Documenting parental refusal to have their children vaccinated. http://www2.aap.org/ immunization/pediatricians/pdf/refusaltovaccinate.pdf (Accessed on 8/3/15)

Institute of Medicine. Adverse effects of vaccines: evidence and causality. Washington, DC: The National Academy Press; 2011. AAFP. Childhood Immunization schedule. 2015 (Accessed on 8/3/15). http://www.aafp.org/patient-care/immunizations/schedules/child-schedule.html.

May include immunization schedules and catch-up schedules from http://www.cdc.gov/vaccines/schedules/ hcp/imz/child-adolescent.html (Accessed on 8/3/15).