Transcript Immunizations: Fun for Everyone!

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Immunizations: Fun for Everyone!
Jillian Bardsley, PGY-1
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99 Topics: Key Features
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Do not delay immunizations unnecessarily (e.g., vaccinate a
child even if he or she has a runny nose).

With parents who are hesitant to vaccinate their children,
explore the reasons, and counsel them about the risks of
deciding against routine immunization of their children.

Identify patients who will specifically benefit from
immunization (e.g., not just the elderly and children, but also
the immunosuppressed, travellers, those with sickle cell
anemia, and those at special risk for pneumonia and hepatitis
A and B), and ensure it is offered.
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Clearly document immunizations given to your patients.
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99 Topics: Key Features

In patients presenting with a suspected infectious disease,
assess immunization status, as the differential diagnosis and
consequent treatment in unvaccinated patients is different.

In patients presenting with a suspected infectious disease, do
not assume that a history of vaccination has provided
protection against disease (e.g., pertussis, rubella, diseases
acquired while travelling).
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Today’s Learning Objectives
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Indications for vaccinations
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Children
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Elderly
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Special Populations
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Travel
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Contraindications to vaccines
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Common anti-vaccination myths and the truth
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Administration and Documentation
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Presentation and treatment of vaccine preventable illnesses
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Indications for vaccinations
Identify patients who will specifically benefit from
immunization (e.g., not just the elderly and children, but also
the immunosuppressed, travellers, those with sickle cell
anemia, and those at special risk for pneumonia and hepatitis
A and B), and ensure it is offered.
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Children
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Canadian Adults
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Influenza - Annually
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Diptheria, tetanus - Td every 10 years
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Pertussis - One dose in adulthood; ASAP for those in close
contact with infants
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Mumps, Measles - One dose in susceptible adults born after
1970
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Rubella - One does for susceptible adults
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Herpes zoster - 50-59 may be given 1 dose; >60 1 dose
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Varicella - Two doses for susceptible adults
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HPV – 3 doses for adults up to/including age 26
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Pneumococcal 23 - One dose for 65 years or older
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Canadian Adults
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Influenza
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Diptheria, tetanus
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Pertussis
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Mumps, Measles
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Rubella
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Herpes zoster
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Varicella
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HPV
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Pneumococcal 23
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Canadian Adults
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Influenza - Annually
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Diptheria, tetanus - Td every 10 years
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Pertussis
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Mumps, Measles
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Rubella
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Herpes zoster
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Varicella
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HPV
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Pneumococcal 23
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Canadian Adults

Influenza - Annually

Diptheria, tetanus - Td every 10 years

Pertussis - One dose in adulthood; ASAP for those in close
contact with infants

Mumps, Measles
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Rubella
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Herpes zoster
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Varicella
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HPV
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Pneumococcal 23
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Canadian Adults

Influenza - Annually

Diptheria, tetanus - Td every 10 years

Pertussis - One dose in adulthood; ASAP for those in close
contact with infants

Mumps, Measles - One dose in susceptible adults born after
1970

Rubella - One does for susceptible adults
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Herpes zoster
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Varicella
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HPV
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Pneumococcal 23
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Canadian Adults

Influenza - Annually
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Diptheria, tetanus - Td every 10 years

Pertussis - One dose in adulthood; ASAP for those in close
contact with infants

Mumps, Measles - One dose in susceptible adults born after
1970
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Rubella - One does for susceptible adults
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Herpes zoster - 50-59 may be given 1 dose; >60 1 dose
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Varicella
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HPV
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Pneumococcal 23
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Canadian Adults

Influenza - Annually
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Diptheria, tetanus - Td every 10 years

Pertussis - One dose in adulthood; ASAP for those in close
contact with infants

Mumps, Measles - One dose in susceptible adults born after
1970
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Rubella - One does for susceptible adults
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Herpes zoster - 50-59 may be given 1 dose; >60 1 dose
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Varicella - Two doses for susceptible adults
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HPV – 3 doses for adults up to/including age 26
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Pneumococcal 23
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Canadian Adults

Influenza - Annually
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Diptheria, tetanus - Td every 10 years
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Pertussis - One dose in adulthood; ASAP for those in close
contact with infants

Mumps, Measles - One dose in susceptible adults born after
1970
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Rubella - One does for susceptible adults
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Herpes zoster - 50-59 may be given 1 dose; >60 1 dose
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Varicella - Two doses for susceptible adults
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HPV – 3 doses for adults up to/including age 26
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Pneumococcal 23 - One dose for 65 years or older
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Special Populations
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Asplenia/Sickle Cell: PneuC-13, PneuP-23, MenC-ACYW,
MenB, Hib
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Sickle Cell patients also need Hep A& B (repeat transfusions)
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Cardiorespiratory disease: PneuC-13, PneuP-23
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MSM: PneuC-13, PneuP-23, HepA, HepB
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At risk for liver disease: PneuC-13, PneuP-23, HepA, HepB
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Diabetes: PneuC-13, PneuP-23
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Phew…..
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Contraindications to Vaccines
Do not delay immunizations unnecessarily (e.g., vaccinate a child
even if he or she has a runny nose).
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Anaphylaxis to a vaccine component
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For inactivated vaccines, within 3 months of
immunosuppressive therapy
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For live vaccines, within 1-3 months of immunosuppressive
therapy
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Breastfeeding for BCG, smallpox, yellow fever
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Anaphylaxis to Eggs?
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MMR and MMRV okay (have trace egg)
Inactivated influenza only okay if prepared to deal with
anaphylaxis
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Vaccine-Specific Contraindications
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Lives vaccines
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Live attenuated influenza
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Rotavirus
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Tetanus
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Vaccine-Specific Contraindications
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Lives vaccines ->immunocompromised, pregnant, active
untreated TB
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Live attenuated influenza ->severe asthma/active wheeze
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Rotavirus ->congenital GI malformation, hx of
intussusception
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Tetanus ->GBS within 6 weeks of earlier Tetanus
vaccination
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Not Contraindications to Vaccination
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Acute illness, febrile or non-febrile
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Bleeding disorder
The following after immunization…..
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Extensive limb swelling
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Hypotonic-hyporesponsive episodes (pertussis)
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Febrile seizure
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2% chance of febrile seizure in a child with past seizures when
receiving MMR, does not increase risk of epilepsy
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Syncope after immunization (HPV)
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Inconsolable crying after immunization (pertussis)
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Oculo-respiratory syndrome (primary influenza)
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Common Anti-Vaccination Myths
With parents who are hesitant to vaccinate their children,
explore the reasons, and counsel them about the risks of
deciding against routine immunization of their children.
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Autism!
2.
My baby’s system can’t handle all those antigens!
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THE TOXINS!!! Aluminum!
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Formaldehyde!
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Thimerosal/mercury!
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You are injecting my baby with fetus cells!
7.
We have herd immunity so my baby is safe!
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Autism!
1.
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My baby’s system can’t handle all those antigens!
2.
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There is 10 times more in your baby’s body at any given time than in a
vaccine. It also is found in APPLES!
Thimerosal/mercury….?!
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It’s only in the influenza vaccine. Hasn’t been in other routine
childhood vaccinations since the 90s. Was never in MMR.
You are injecting my baby with fetus cells!
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7.
Similar concentration in breast milk.
Formaldehyde?!
4.
6.
Can counter 10 000 antigens at any given moment; get more exposure
crawling on the floor than with multiple injections
THE TOXINS!!! Aluminum!
3.
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False! MANY studies contradict this.
No! (We remove them first)
We have herd immunity so my baby is safe!
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Nope! And most outbreaks are starting with imported cases.
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Documentation and Technique
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Date, site, vaccine name, expiry and lot number
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Site:
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Minimum Needle length
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<1 year/not walking: Anterolateral thigh
> 1year: Deltoid
Young babies: 5/8ths
Infants and adults: 1 inch
Administration
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With a few exceptions, all vaccines are IM (90 degrees)
MMR, varicella are subcutaneous (45 degrees, aim for fat tissue)
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Vaccine-Preventable Illnesses
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In patients presenting with a suspected infectious disease,
assess immunization status, as the differential diagnosis and
consequent treatment in unvaccinated patients is different.

In patients presenting with a suspected infectious disease, do
not assume that a history of vaccination has provided
protection against disease (e.g., pertussis, rubella, diseases
acquired while travelling).
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Diptheria
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Vaccine is the detoxified toxin of Corynebacterium diptheriae
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Presentation: Gradual URTI with development of mucosal
pseudomembranes (tightly adherent, bleed with scraping)
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Complications: Local mucosal respiratory tract infection which
can cause respiratory failure due to extensive
pseudomembranes ; toxin causes myocarditis, CNS and renal
damage
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Case fatality: 5-10%
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Diagnosis: Clinical vs. Culture on Tindale’s media vs. Toxin
PRC
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Treatment: Antitoxin, 2 weeks of IV erythromycin followed by 2
weeks of oral Penicillin G
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Pertussis
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Inactivated acellular Bordetella pertussis
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Presentation: 2 week URI followed by long-lasting
paroxysmal cough with large inspiratory component, emesis
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Complications: Infants – Pneumonia, apneic episodes
****Adults that are in contact with a infants need a booster
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Diagnosis:
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Clinical
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Culture/PCR if <2 weeks vs. Serology if > 4 weeks
Treatment: Azithromycin (5d)
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Polio
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Inactivated poliovirus
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Oral vaccination works better but caused polio in
immunocompromised contacts via fecal-oral route
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Presentation: Viral URTI, asymmetrical weakness
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Complications: Meningitis/encephalitis, severe
neck/back/muscle pain, respiratory failure
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Asymmetric acute flaccid paralysis: Decreased tone affecting legs >
arms, proximal > distal; one muscle group or quadriplegia; 2/3 with
paralysis will no redevelop strength
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Case fatality 5-10%
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Diagnosis: CSF PCR
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Treatment is supportive
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All patients travelling to an endemic country should have a
booster
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Haemophilus influenza B
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Gram-negative coccobacilli
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Presentation/Complications: Rapid evolution of periorbital
and limb cellulitis leading to necrosis, meningitis, epiglottitis
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Diagnosis: Clinical, varied per presentation
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Treatment: Amoxicillin, 2nd or 3rd generation cephalosporin,
azithromycin
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Mumps, Measles, Rubella
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Live attenuated viral particles
Mumps:
Presentation: 48 hours of myalgias, URTI sx then parotitis for 10
days
Complications: Orchitis (40%), deafness
Diagnosis: Clinical, elevated amylase, leukopenia with relative
lymphocytosis vs. Serolgoy
Treatment: Supportive, symptom-directed
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Measles
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Presentation:
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Viral prodrome with coryza, conjunctivitis, cough and fever
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Koplik spots (pathognomonic)
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Maculopapular rash with 4 days of first fever (maculopapular,
cephalocaudal spread, blanchable early on)
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Complications: Encephalitis (1:1000, 25% have sequaelae,
15% die), blindness, immunosuppression
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Case Fatality: 1:3000
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Diagnosis: Clinical (public health will confirm with PCR)
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Treatment: Supportive, Vitamin A to diminish ocular sequelae
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Rubella
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Presentation: Subclinical, rash, malaise
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Complications: Infection in 1st trimester leads to congenital
rubella syndrome (85%)
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60% hearing impairment
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45% heart defect
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Infancy: Cataracts, microcephaly, low birth weight, mental
retardation, hepatosplenomegaly, purupura
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Late Onset: Hearing loss, mental retardation, DM, thyroid
dysfunction, progressive panencephalitis
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The familiars
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Rotavirus
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Pneumococcus
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Meningococus
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Tetanus
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Hepatitis B
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Varicella
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Human Papillomavirus
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Rubella
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Presentation: Rash, Malaise
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Complications: Infection in 1st trimester leads to congenital
rubella syndrome (85%)
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SAMP
A 24 year old daughter of Jenny McCarthy comes into your
office. Her boss told her she needs vaccines.
PMHx: LSIL, Hereditary spherocytosis with splenectomy
planned next month
Allergies: Eggs
SocHx: Daycare worker in infants room, contemplating
pregnancy. Hobbies include gardening, scrap metal collecting
and foreign travel.
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What vaccines does she need to protect the children at
work?
2.
What vaccines does she require because of her
splenectomy? When should she get these?
3.
The patient would like to minimize the number of vaccines
she gets. How would you address MMRV?
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References:
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Canadian Immunization Guide
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http://www.phac-aspc.gc.ca/publicat/cig-gci/
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Kim DK, Bridges CB, Harriman KH, on behalf of the Advisory Committee
on Immunization Practices. Advisory Committee on Immunization
Practices Recommended Immunization Schedule for Adults Aged 19
Years or Older: United States, 2016*. Ann Intern Med. 2016;164:184-194.
doi:10.7326/M15-3005
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Immunize.ca
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http://immunize.ca/en/publications-resources/questions/additives.aspx
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Immunization Lecture, MMMD, Faculty of Medicine, University of
Toronto; Dr. S Moss, MD, FRCP, FAAP (Nov 14, 2012)
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Ontario MOHLTC Website
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http://www.health.gov.on.ca/en/pro/programs/immunization/schedule.aspx
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