Transcript Document

Marissa Hampton RN, BSN, SNNP
and
Gabriela Olivas RN, BSN, SNNP
Objective
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To describe each disease process for immunization
To discuss the origin and history of vaccination,
particularly in Texas
To detail each part of immunization and its
purpose
To provide evidence based practices of
immunization
To identify any long term outcome or management
issues if vaccination is not provided
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Immunization: The method in which a person
becomes protected from a disease process.
Vaccination: Injection of a killed or weakened
infectious organism in order to prevent the
disease.
Vaccine: A product that produces immunity
against the disease.
(Centers for Diseases Control and Prevention [CDC], 2012c)
When bacteria/virus enter the
body, they multiple and attack
healthy cells.
o The immune system fights
invaders and makes memory cells
to recognize them so the body can
fight if ever attacked again.
o Vaccines develop immunity by
imitating infection. This imitation
does not cause illness, but instead
helps the individual to build an
immunity. If exposed again, the
body will use memory cells to
fight the infection.
o
(CDC, 2012b)
(Immunization Action Coalition, 2012)
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Viral disease that is spread via puncture wounds through the skin or
through blood and body fluid secretions
Signs and symptoms:
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High risk individuals:
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Vary with age
Most newly infected patients and infants are asymptomatic
Fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, joint pain,
jaundice
Include sex with an infected partner , injection drug use or needle sticks, an infant born to
an infected mother or contact with blood or open sores of infected person
Acute Hepatitis B: at time of initial infection
Chronic Hepatitis B: Progressive worsening of liver disease; Chronic
patients may continue to have signs and symptoms, further complications
and cause infection in others.
Persons with chronic HBV infection might be asymptomatic, have no
evidence of liver disease, or have a spectrum of disease ranging from
chronic hepatitis to cirrhosis or hepatocellular carcinoma (a type of liver
cancer).
(Texas Department State of Health Services, 2013a)
History United States
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Before 1982: 200,000 to 300,000 people infected including 20,000 children
90 % chance transmission from + mother to infant without prophylaxis
 25 % infected at childhood will die from cirrhosis
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No method for pre exposure prophylaxis
1984: Advisory committee on immunization practices (ACIP)
recommends testing for high risk individuals
1988: ACIP recommends screening pregnant women for Hepatitis B
1991: ACIP recommends comprehensive strategy: prenatal screening,
prophylaxis treatment of infants from + mothers, universal childhood
vaccination
Texas
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1991: Texas implemented recommendations from CDC into state law
Vaccination is required prior to day care and school admission in Texas
(Morbidity and Mortality Weekly Report, 2002)
(Wasley, Kruszon-Moran, Kuhnert, Simard, Finelli, McQuillan,& Bell, 2012)
(Texas Department State of Health Services, 2013a)
Heptavax-B, Recombivax HB, Engerix-B
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Indication and Use: Immunization against infection caused by all known subtypes of
hepatitis B virus in individuals
Actions: Promotes immunity by inducing the production of specific antibodies to the virus
Dosage:
 Infants born to hepatitis B surface antigen(HBsAg)-positive mothers: First does
within the first 12 hours of life even if premature and regardless of birth weight
(hepatitis immune globulin should also be administered at the same tie/different
site); second dose at 1-2 months of age; third dose at 6 months. Check anti-HBs and
HBsAg at 9-15 months of age. IF anti-HBs and HBsAg are negative, reimmunize with
3 doses 2 months apart and reassess.
 Infants born to HBsAg-negative mothers: First dose prior to discharge; however, the
first dose may be given at 1-2 months of age. Another dose given 1-2 months later,
and a final dose at 6 months of age. A total of 4 doses of vaccine may be given if a
“birth dose” is administered and a combination vaccine is used to complete the
series.
 Infants born to mothers whose HBsAg status is unknown at birth: first dose within
12 hours of birth even if premature, regardless of birth weight; second dose
following 1-2 months later, and a final dose at 6 months of age. If the mother’s blood
HBsAg test is positive, the infant should receive hepatitis immune globulin as soon
as possible (no later than 1 week
(Cunningham, Eyal & Gomella, 2013)
United States
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1990-2004: Hepatitis B rates have declined by 94% in children due to
screening, universal vaccination and prophylaxis, if needed.
Texas
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1991- 2012: Steady decline of Hepatitis B rates in Texas
In 2012 , 170 reportable cases of acute Hepatitis B, lowest rates in history.
 Overall decline was greatest among children and adolescents under 18 years.
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(Texas Department State of Health Services, 2013a)
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Treatment
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No specific therapy for acute HBV infection.
Treatment is supportive.
Interferon is the most effective treatment for chronic HBV
infection and is successful in 25% to 50% of cases.
Hepatitis B complications
•
Fulminant hepatitis, hospitalization, cirrhosis,
hepatocellular carcinoma, death
Female patient from Cambodia with a
heptoma due to chronic Hepatitis B
infection.
(CDC, 1995c)
(CDC, 2012a)
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Leading cause of gastroenteritis in infants and children
under age 5
Prior to vaccination 4 out 5 children will be infected by
age 5
Transmitted Fecal- Oral Route
Signs and Symptoms
Fever, vomiting, diarrhea, abdominal pain, loss of appetite,
dehydration.
 Dehydration may be severe; may cause electrolyte imbalance, shock
and death

(Morbidity and Mortality Weekly Report, 2009)
(CDC, 2011c)
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State of Texas does not currently recommend
immunization against rotavirus
RotaTeq® [RV5]
3 dose series licensed in 2006
 Given at 2, 4, 6 months
 Recommended by ACIP for all infants
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Rotarix® [RV1]
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2 dose series licensed in 2008
Given at 2, 4 months
Recommended by ACIP to replace previous vaccine
(Morbidity and Mortality Weekly Report, 2009)
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For persons with healthy immune systems,
rotavirus gastroenteritis is a self-limited illness,
lasting for only a few days. Treatment is
nonspecific and consists of oral rehydration
therapy to prevent dehydration. About 1 out of
70 children with rotavirus gastroenteritis will
require hospitalization for intravenous fluids.
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(CDC, 2011c)
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Diphtheria
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Tetanus
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Infection caused by Corynebacterium diphtheriae bacteria
Spread by respiratory droplets or contaminated objects
Bacteria invades the respiratory system and produces toxins
Cause weakness, sore throat, fever, swollen glands in the neck, pseudomembrane- build
up of dead tissue that causes difficulty breathing
Toxins damages the heart, kidneys and nerves
Infection caused by bacteria Clostridium tetani.
Enters the body through broken skin, from contaminated objects.
Causes headache, jaw cramping, sudden, involuntary muscle tightening – often in the
stomach (muscle spasms), painful muscle stiffness, difficulty swallowing, seizures, fever,
sweating, high blood pressure and fast heart rate
Pertussis
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Infectious disease caused by the bacterium Bordetella pertussis.
Early symptoms: runny nose, low-grade fever, mild, occasional cough , apnea,
With progression, traditional symptoms appear: Many, rapid coughs followed by a highpitched "whoop“, vomiting, exhaustion after coughing fits. Coughing fits can go on for up
to 10 weeks or more.
(CDC, 2011a)
(CDC, 2013d)
(CDC, 2012d)
History
Diphtheria
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Early 1900s: First prophylaxis was attempted
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1921: toxoid was developed but not used until 1930
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1940: Vaccine was incorporated with tetanus toxoid and pertussis.
Tetanus
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1914- 1919: World War I- passive immunity used for treatment and
prophylaxis
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1920: Inactivating tetanus toxin process
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1924: Development of tetanus toxid; widely used in World War II
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1940’s: Tetanus toxid introduced into routine childhood immunizations
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Tetanus became nationally notifiable; 500-600 cases annually
Pertussis
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1906: First isolated organism
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1940: Development of pertussis vaccine
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200,000 cases reported annually
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4 combination vaccines: DTaP, Tdap, DT, and Td.
DTaP and DT are given to children younger than 7 years of age
 Tdap and Td are given to older children and adults.
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DTaP
Children should get 5 doses of DTaP, one dose at each of the following ages: 2,
4, 6, and 15-18 months and 4-6 years.
 Vaccines approved for ages 6 weeks and older: Infanrix, Tripedia and Daptacel
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DT
Vaccine does not contain pertussis
 Used in children who can not tolerate pertussis vaccine
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(CDC, 2007)
Diphtheria
United States
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Rapid decline in rates since vaccination
 Began in 1940
 1970-1979: 196 reportable cases
 1980-2004: 57 reportable cases
Texas
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According to Texas Health services website, there
have been no reportable cases in years, but is still
considered a reportable rare disease
Child with diphtheria presented
with a characteristic swollen
neck, sometimes referred to as
“bull neck”. (CDC, 1995b)
Tetanus
United States
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Steady decrease since vaccine introduced into routine childhood vaccination
in 1940
2001-2008: 233 cases of reported tetanus, averaging 29 cases annually.
Neonatal tetanus is rare, two cases reported since 1989.
Texas
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Rare. Most reported cases are unvaccinated individuals or those who have not
received booster shot in the following 10 years.
Since 2008 only 5 reported cases, one of which was fatal.
Body rigidity from neonatal tetanus
(CDC, 1995d)
(CDC, 2013d)
(Texas Department of State Health Services, 2013)
Pertussis
 United States
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1940: Following introduction of vaccine, rates gradually declined
1980–1990: An average of 2,900 cases per year were reported
2001-2003: Average annual cases began to rise once again
Texas
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Pertussis rates in Texas historically climbs every 3 to 5 years then sharply declines.
Documented outbreaks occurred in 2005 and 2008.
2012: There were 2,218 reported cases, doubling the 2011 count of 961.
2013: Outbreak of Pertussis continues with 2,652 pertussis cases reported in Texas.
2000-2012, a total of 43 deaths were attributed to pertussis in Texas, with most deaths
under the age of 1.
Pertussis rates: United
States 1940-2009
(CDC, 2012 e)
(Texas Department of State Health Services, 2013b)
(CDC, 2012e)
Diphtheria
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Treatment: Diphtheria antitoxin to neutralize toxins produced by bacteria.
Antibiotics are used, patients are kept in isolation for 48 hours after antibiotic
treatment begins.
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Complications: Blocked airway, myocarditis, polyneuropathy, Paralysis,
Pneumonia or respiratory failure.
Tetanus
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Treatment: Tetanus is a medical emergency requiring hospitalization,
immediate treatment with human tetanus immune globulin (TIG) , a tetanus
toxoid booster, wound care and antibiotics.
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Complications: Uncontrolled/involuntary muscular contraction of the vocal
cords, fracture, nosocomial infections, pulmonary embolism, aspiration
pneumonia, difficulty breathing, death
(CDC, 2011a)
(CDC, 2013d)
Pertussis
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Complications:
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Serious and potentially life-threatening complications in
unvaccinated infants:
Apnea, pneumonia, seizures, encephalopathy and death
More than half of infants who acquire pertussis and are younger
than 12 months of age must be hospitalized.
Hospitalization is common in infants younger than 6 months of
age.
Other complications:
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Anorexia, dehydration, difficulty sleeping, epistaxis, hernias, otitis media,
and urinary incontinence
More severe complications include pneumothorax, rectal prolapse, and
subdural hematomas.
(CDC, 2012e)
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6 types of Haemophilus influenzae bacteria
Haemophilus influenzae bacterium may cause severe infection;
occurs mostly in infants and children younger than five.
Haemophilus influenzae type b (Hib) bacteria causes:
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Pneumonia, bacteremia, meningitis, epiglottitis, septic arthritis, cellulitis, otitis
media, purulent pericarditis, endocarditis and osteomyelitis.
Transmission occurs through direct contact with respiratory
droplets.
Neonates can acquire infection by aspiration of amniotic fluid or
contact with genital tract secretions containing the bacteria.
(CDC, 2012d)
Infant with severe vasculitis with disseminated intravascular coagulation
(DIC) with gangrene of the hand secondary to Hib septicemia (American
Academy of Pediatrics, n.d.).
History United States
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Before vaccination era, Hib was the leading cause of
bacterial meningitis in children younger than 5
1930: 1 in 200 children developed Hib
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Two thirds in children younger than 18 months.
Peak age of occurrence among children 6- 11 months
1980’s: Estimated 20,000 cases of Hib occurred in the US
1985: A pure polysaccharide vaccine (HbPV) was licensed in
the U.S.
 Not effective in children younger than 18 months of age.
1987: First conjugate vaccine licensed in U.S.
(CDC, 2012d)
Hib vaccine
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Infant primary series is given in 3 doses at 2, 4, 6 months or 2
doses at 2, 4 months
Booster dose is needed at 12 to 15 months.
2 monovalent conjugate Hib vaccines
PRP-OMP (PedvaxHIB) vaccine is 2 doses
 PRP-T (ActHIB) is 3 doses
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2 combination conjugate Hib vaccines
DTaP-IPV/Hib: Pentacel
 Hepatitis B-Hib: Comvax
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(CDC, 2012d)
United States
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Late 1980’s: Rates of Hib infection decreased by 99
percent as compared to pre-vaccine era.
1991: Hib infections became nationally reportable.
1996-2000: 341 confirmed cases of Hib reported
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Approximately 22 percent within children less than 5 years old.
Texas
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Rare in Texas
Average of 8 cases reported annually
(CDC, 2012)
(Texas Department of State Health Services, 2013)
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Invasive Hib
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Hospitalization
Antimicrobial therapy
 Third-generation cephalosporin (cefotaxime or
ceftriaxone)
 Chloramphenicol in combination with ampicillin
 Treatment is 10 days.
(CDC, 2012d)
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Streptococcus pneumoniae causes an acute bacterial
infection.
Transmission of S. pneumoniae occurs as the result of
direct person-to-person contact via respiratory droplets
and by autoinoculation in persons carrying the bacteria
in their upper respiratory tract.
The major clinical syndromes of pneumococcal disease
are pneumonia, bacteremia, and meningitis.
The immunologic mechanism that allows disease to
occur in a carrier is not clearly understood.
Disease most often occurs when a predisposing
condition exists, particularly pulmonary disease.
(CDC, 2012g)
History
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1911: First developments in creating a pneumococcal vaccine
1940: Penicillin development; Vaccine developments stopped
1960’s: Increased mortality despite antibiotic therapy
 Efforts made toward development of vaccine
1977: First Pneumococcal vaccine licensed
1998: 24 cases per year of Pneumococcal Disease, highest rates in
children under 2 years of age
2000: First conjugate pneumococcal vaccine licensed
Texas
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2005: Texas mandates pneumococcal requirement for children 5
years and younger
(CDC, 2012g)
Prevnar
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Protects against: Streptococcus pneumoniae
Indication and use: for active immunization of infants/toddlers against Streptococcus
pneumoniae invasive disease caused by the 13 capsular serotypes in the vaccine for all
children 2-23 months of age. It is also recommended for certain children 24-59 months of
age.
Administered at 2, 4, 6, and 12-15 months of age. Shake well before administration.
Adverse effects: decreased appetite, drowsiness, irritability, fever and injection site local
tenderness, redness and edema. Not a treatment of active infection. Use of this vaccine
does not replace the use of the 23-valent pneumococcal polysaccharide vaccine in
children> 24 month old with sickle cell disease, chronic illness, asplenia, HIV, or those
who are immunocompromised.
(Cunningham, Eyal & Gomella, 2013, pg.991)
United States
 1998-1999: In children 5 and younger, reported
99 cases per 100,000 of pneumococcal disease
 2008: Reported 21 cases per 100,000 in same age
group
Texas
 No information found on reportable cases for
pneumococcal related disease
What does S.Pneumoniae cause if patient infected?
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Causes invasive infections
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Leading cause of bacterial meningitis among children <5 years of age
Disease complications:
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Bacteremia, meningitis, pneumonia, otitis media and sinusitis
Bacteremia, meningitis, death
Treatment:
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Resistance to penicillin and other antibiotics is common.
In some areas of the United States, up to 40% of invasive pneumococcal isolates are
resistant to penicillin.
Treatment will usually include a broad-spectrum cephalosporin, and often
vancomycin, until results of antibiotic sensitivity testing are available.
(CDC,2012g)
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Enterovirus
Enters through the mouth
Implants and replicates in the gastrointestinal
tract
Migrates to the nervous system to destroy
motor neurons
Excreted in feces
(CDC, 2012f)
History United States
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First outbreaks recorded in 1843
Epidemic outbreaks for the next century
1952: Outbreaks peaked in the U.S.
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1955: Introduction of inactivated polio vaccine (IPV)
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More than 21,000 paralytic cases reported
Following introduction of vaccine rates declined dramatically
1961: Introduction of oral polio vaccine (OPV)
1979: Last reported case of polio
(CDC, 2012f)
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Two types of polio vaccines: oral and inactive
Inactivated Polio Vaccine (IPV)
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Highly effective in producing immunity to poliovirus
90% immune after 2 doses
99% immune after 3 doses
Duration of immunity not known with certainty
Only effective treatment recommended against polio
Vaccinations due at 2, 4 months, between 6-18 months and at age 4.
May be given as a combination vaccine
Oral Polio Vaccine(OPV)
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Highly effective in producing immunity to poliovirus.
Approximately 50% immune after 1 dose.
More than 95% immune after 3 doses.
Immunity probably lifelong
Shed in stool for up to 6 weeks following vaccination
OPV not used due to increased risk for vaccine associated paralytic polio.
(CDC, 2012f)
United States
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1955: Dramatic decrease in rates after IPV introduced
1960: 2,525 reported cases of paralytic polio
1961: Introduction of OPV introduction
1965: 61 reported cases of paralytic polio
1979: Last reported case of polio, found in Midwestern states
Texas
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Reportable in Texas, but has not
occurred in years
1970: Last reported cases of polio
affected 22 children, all under age
of 4.
(CDC, 2012f)
(Texas Department of Heath Services, 2013)
Poliomyelitis - United States, 1940-1995
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Disease is rare
Response to polio infection is variable
Up to 95 % of cases maybe asymptomatic
Paralytic polio
Symptoms last 1-7 days
Fever, loss of superficial reflexes, initially increased
deep tendon reflexes, severe muscle aches and
spasms in the limbs or back.
 Paralysis is commonly asymmetrical, strength returns
 3 types depending on level of involvement:
Spinal, Bulbo, Bulbospinal
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Maybe fatal in 2-3 percent of infant cases
Non paralytic polio
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Symptoms will last 2 to 10 days
stiffness of the neck, back, legs, usually following
several days after “minor illness”
(CDC, 2012f)
Infant with affected lower limb
from Poliomyelitis infection
(CDC, 1995a)
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Single stranded RNA virus
Acquired via droplets, invades respiratory system and replicates
Incubation period is 1- 4 days
Symptoms
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“Classic” symptoms abrupt onset of fever, myalgia, sore throat, nonproductive
cough, headache and fever.
3 strains:
 Type A- moderate to sever illness, all ages
 Type B- mild illness, primarily children
 Type C- rare
(CDC, 2013c)
History United States

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Children 0–4 years of age, hospital rates vary from 100 to
500 per 100,000 healthy children
Hospitalization rates for children 24 months of age and
younger are comparable to rates for persons 65 and older.
1940: Trivalent inactivated influenza vaccine (TIV) is
available
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Contains three inactivated viruses: type A (H1N1), type A (H3N2), and type B
2003: First live attenuated influenza vaccine
Texas

Texas follows current recommendations for annual flu vaccine

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Vaccine protects against influenza
Spread by air, direct contact
2 initial doses
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Contraindications:
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First dose at 6 months
Second dose at 28 days after first dose
Once a year immunizations thereafter
Infants with moderate-to-severe illness with or without a fever
People with a history of Guillain-Barré Syndrome that occurred after
receiving influenza vaccine
Special Considerations regarding egg allergy


People who have ever had a severe allergic reaction to eggs may be
advised not to get vaccinated.
People who have had a mild reaction to egg—that is, one which only
involved hives—may receive a flu shot with additional precautions.
(CDC, 2013c)
United States

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Reporting season for influenza: October to May
Vaccine effectiveness depends on the strains and patient health
status

With similar strains, vaccines are up to 90% effective in protecting individuals
Texas

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Influenza peaks in January/February
Individual cases of influenza are not tracked

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Most people who get influenza will recover in a few days to less
than two weeks.
Symptoms: fever, muscle pain, sore throat, cough , extreme fatigue
Complications: Bronchitis, sinus, ear infections, pneumonia which
can be fatal
Treatment:

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Antiviral medications with activity against influenza viruses, antiviral
prescription drugs can be used for prevention
Influenza vaccine
Two FDA-approved influenza antiviral medications: Oseltamivir
(Tamiflu®) and Zanamivir (Relenza®).
Oseltamivir and Zanamivir are chemically related antiviral medications
that have activity against both influenza A and B viruses.
Antiviral resistance to oseltamivir and zanamivir among circulating
influenza viruses is currently low.
(CDC,
2013c)
Measles

Measles (Rubeola) virus grows in the cells of the throat and lungs.

Spread through droplet and direct contact

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Signs and Symptoms:

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Mild to moderate fever, cough, runny nose, red eyes, and sore throat.
Kopliks spots: Tiny white spots appear inside
the mouth 2 to 3 days after infection.
Complications:


Highly contagious
Diarrhea, pneumonia, otitis media with hearing loss,
death.
Leading cause of blindness in African children

Related to vitamin A deficiency in malnourished
children.
(CDC, 2009a)
(CDC, n.d)
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Mumps virus is a paramyxovirus in the same group as parainfluenza and Newcastle
disease.
Up to half of people who get mumps have very mild or no symptoms, and therefore do
not know they were infected with mumps.
Disease symptoms: swollen salivary glands, fever, headache, tiredness, muscle pain
The virus is acquired by respiratory droplets and direct contact.
It replicates in the nasopharynx and regional lymph nodes. After 12 to 25 days a viremia
occurs, which lasts from 3 to 5 days. During the viremia, the virus spreads to multiple
tissues,including the meninges, and glands such as the salivary, pancreas, testes, and
ovaries. Inflammation in infected tissues leads to characteristic symptoms of parotitis
and aseptic meningitis.
Most mumps transmission likely occurs before the salivary glands begin to swell and
within the 5 days after the swelling begins. Therefore, CDC recommends isolating
mumps patients for 5 days after their glands begin to swell.
Currently, there is no specific treatment for mumps. Supportive care should be given as
needed.
(CDC, 2010)
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Rubella, also known as German Measles, or 3 day measles
Rubella is a viral illness caused by a togavirus of the genus Rubivirus and is
characterized by a mild, maculopapular rash.
Respiratory transmission of rubella virus, replication of the virus is thought to occur in
the nasopharynx and regional lymph nodes. A viremia occurs 5 to 7 days after exposure
with spread of the virus throughout the body. Transplacental infection of the fetus
occurs during viremia. Fetal damage occurs through destruction of cells.
The incubation period of rubella is 14 days, with a range of 12 to 23 days. Symptoms are
often mild, and up to 50% of infections may be subclinical or inapparent.
The signs and symptoms of rubella are often so mild that they're difficult to notice,
especially in children. If signs and symptoms do occur, they generally appear between
two and three weeks after exposure to the virus. They typically last about two to three
days and may include: Mild fever of 102 F, headache, stuffy or runny nose, inflamed red
eyes, enlarged, tender lymph nodes at the base of the skull, the back of the neck and
behind the ears, fine, pink rash that begins on the face and quickly spreads to the trunk
and then the arms and legs, before disappearing in the same sequence, and aching joints,
especially in young women

(CDC,2009b)
History: United States
Measles
 1954: Measles virus isolated from human tissue
 1963: First live attenuated vaccine licensed
 Prevaccine era


500,000 reported cases annually, 500 of which were
fatal
Epidemic cycles noted every 2 to 3 years
Texas
 1958: 85,862 reportable cases of measles
History United States
Mumps
 Prevaccine Era: Mumps was cause of
frequent outbreaks in military




1934: mumps discovered
1945: Virus isolated
1948: Short lasting vaccine developed




Most common cause of aseptic meningitis
and sensorineural deafness in childhood
Mumps infection with
characteristic swollen neck
region due to an enlargement
of the boy’s salivary glands
(CDC, 2005)
Used until 1970’s
1964: 212,000 reported cases of mumps
1967:Development of live attenuated mumps vaccine
1968: Nationally reportable disease
History: United States
Rubella
 1940: Widespread Rubella infection
 1941: 78 cases of congenital cataracts from infants born
to mothers with rubella infection early in pregnancy
 1962: Rubella isolated
 1964-1965: 12.5 million reported cases



20,000 newborns with congenital rubella syndrome causing
deafness, blindness and mental retardation
2,100 neonatal deaths
1969: First rubella vaccine licensed
Pictured at top right: Infant with blueberry spots from Congenital Rubella Syndrome (CDC, 1978)
(CDC, 2012)





Vaccine protects against measles, mumps, rubella; live virus vaccine
2 Doses: first dose given 12-15 months, second dose given between 4-6 years old
Measles and Mumps vaccine is prepared in chick embryo fibroblast tissue culture. MMR
and MMRV are supplied as a lyophylized (freeze-dried) powder and are reconstituted
with sterile, preservative-free water. The vaccines contain a small amount of human
albumin, neomycin, sorbitol, and gelatin.
MMR adverse effects: fever, rash and joint symptoms (Joint pain attributed to measles
and rubella vaccine)
Contraindications: Women known to be pregnant or attempting to become pregnant
should not receive rubella vaccine. Although there is no evidence that rubella vaccine
virus causes fetal damage, pregnancy should be avoided for 4 weeks (28 days) after
rubella or MMR vaccination. Persons with immunodeficiency or immunosuppression,
resulting from leukemia, lymphoma, generalized malignancy, immune deficiency
disease, or immunosuppressive therapy should not be vaccinated.

(CDC, 2011b)
United states
Measles

Post vaccine era



1978: Measles Elimination program



55,626 reported cases, 123 deaths
1991: Intensive efforts made to vaccinate preschool aged children


Goal: To eradicate indigenous measles by Oct. 1, 1982
1983: Resurgence of Measles outbreak among children less than five


Decrease in measles by 98 percent
No further 2-3 cyclic events
Vaccination levels increased from 70% in 1990 to 91% in 1997
Since 1993: Fewer than 500 cases reported annually
2008: Total of 140 reported cases

91% of cases were reported in unvaccinated individuals
Texas

Due to vaccination, reportable cases have decreased by 99.9% in Texas. Nearly all cases

Reportable cases since 2000: all reported cases have occurred due to unvaccinated
individuals from foreign countries where measles are prevalent

2011:6 reportable cases

2012:0 Reported cases

2013: 21 reported cases of measles, in North Texas, from an unvaccinated traveler who
was returning home.
History: United States
Mumps



Rapid decline after mumps vaccination implements
1983-1985: 3000 reported cases annually
Cyclic resurgence of mumps outbreak

in 2006 and 2009
Texas

Averages 20 cases of mumps a year
(CDC, 2011b)
(Texas Department of State Health Services, 2013)
United States
Rubella



Rapid decline in rates following vaccine licensure
1983 less than 1,000 cases annually
1990-1991: Outbreak of congenital rubella syndrome with 25
and 33 cases respectively.
Texas


No reported cases since 2004
No reported congenital cases since 1998.
Rubella and Congenital Rubella
Syndrome in the United States from
1966- 2009
(CDC, 2011b)
(Texas Department of State Health Service, 2013)



Live measles vaccine provides permanent protection and may prevent disease if given
within 72 hours of exposure. Immune globulin (IG) may prevent or modify disease and
provide temporary protection if given within 6 days of exposure. The dose is 0.25
mL/kg body weight, with a maximum of 15 mL intramuscularly. The recommended
dose of IG for immunocompromised persons is 0.5mL/kg of body weight (maximum 15
mL) intramuscularly. IG may be especially indicated for susceptible household contacts
of measles patients, particularly contacts younger than 1 year of age (for whom the risk
of complications is highest).
Most people with mumps recover fully. However, mumps can occasionally cause
complications, and some of them can be serious. Complications may occur even if a
person does not have swollen salivary glands (parotitis) and are more common in people
who have reached puberty. These complications include orchitis in males who have
reached puberty, encephalitis, meningitis, oophoritis, mastitis in females who have
reached puberty, and temporary or permanent deafness
When rubella infection occurs during pregnancy, especially during the first trimester,
serious consequences can result. These include miscarriages, fetal deaths/stillbirths, and
a constellation of severe birth defects known as congenital rubella syndrome (CRS). The
most common congenital defects are cataracts, heart defects and hearing impairment.



(CDC, 2009a)
(CDC, 2009b)
(CDC, 2010)

Acute infectious disease caused by varicella zoster
virus (VZV).
VZV is a DNA virus
 Member of the herpes virus group



Enters respiratory tract and then replicates in
lymph nodes
Primary infection: chicken pox
Incubation is 10- 14 days
 signs and symptoms: head then truncal lesions, pruritic


Secondary infection: shingles
Recurrent disease
 Unilateral pain and paresthesia

(CDC, 2013e)
United States

Prevaccine era: Endemic






Virtually all persons had acquired by adulthood
Approximately 4 million cases per year
1981: was removed from the reportable list
Highest age specific incidence was in children 1-4- 40 %
1995: Varivax, first live attenuated vaccine licensed in US for
infants 12 months and older
2005: Combination MMR and Varicella vaccine available
Texas

Continues to report disease



Two doses of the vaccine are about 98%
effective at preventing chickenpox.
Varicella given at 12-15 months, then second
dose is administered from age 4-6
Most people who get chickenpox vaccine will
not get chickenpox. But if someone who has
been vaccinated does get chickenpox, it is
usually very mild. They will have fewer
blisters, are less likely to have a fever, and will
recover faster.

After one dose of single-antigen varicella
vaccine:
97% of children 12 months to 12 years developed
detectable antibody titers.
 More than 90% of vaccine responders maintain
antibody for at least 6 years



Risk of Varicella increase with out vaccination
Primary


Chicken pox: Self limiting disease
Secondary

Recurrent disease
(CDC,2013e) ;
Characteristic primary varicella
lesions in unvaccinated individual
(CDC, 2013a)





Hepatitis A, caused by infection with the Hepatitis A virus (HAV),
which is nonenveloped RNA virus that is classified a
picornavirus; it has an incubation period of approximately 28 days
(range: 15–50 days).
HAV replicates in the liver and is shed in high concentrations in
feces from 2 weeks before to 1 week after the onset of clinical
illness
Primarily transmitted by the fecal-oral route, by either person-toperson contact or consumption of contaminated food or water.
Disease symptoms: there may be no symptoms, fever, headache,
weakness, vomiting, jaundice, joint pain
Disease complication: chronic liver infection, liver failure, liver
cancer
(CDC, 2013b)
History

“Historically children age 2 through 18 years of age have had the highest
rates of Hepatitis A” during the mid 1990s (CDC, 2012)

1940: Differentiated from Hepatitis B

1966: Hepatitis A became a nationally reportable case

1971: 59,606 reported cases of Hepatitis A; Largest in US history

1979: Hepatitis A was isolated

1989: Last large nationwide epidemic

1995: First licensed vaccine against Hepatitis B

1999: ACIP recommends routine vaccination, implemented by states, of
children ages 2 and older

2006: ACIP revised recommendations and advised children 12 months
and older should receive vaccine
Texas

2005: Requires vaccination for children attending daycare setting (HB
1316, 2005)

2009: All school aged children are required to have 2 doses of Hepatitis A
vaccine
(CDC, 2012)
(Sims, 2009)





Vaccine protects against Hepatitis A
Vaccine given at 12-23 months, and 6 months after first
dose
Two single-antigen Hepatitis A vaccines, HAVRIX®
(manufactured by GlaxoSmithKline) and VAQTA®
(manufactured by Merck & Co., Inc), are currently
licensed in the United States. A combination vaccine,
TWINRIX® (manufactured by GlaxoSmithKline),
contains both HAV (in a lower dosage; see table) and
Hepatitis B virus antigens.
All are inactivated whole virus vaccines.
Adverse effects of vaccination: soreness where the shot
was given, headache, loss of appetite, tiredness
(CDC, 2013b)
United States



1995: Hepatitis A rates begin to decline
1998: Lowest rates of Hepatitis A
2002: Rates of children with Hepatitis A have reached similar rates
of other age groups
Texas


Rates have declined due to childhood immunizations
2012: 134 cases of Hepatitis A reported
 Lowest rate since reporting began
(CDC, 2012)
(Texas Department of State Health Services, 2013)
Hepatitis A- United States 1966-2009



Clinical illness usually does not last longer than 2 months, although 10%–
15% of persons have prolonged or relapsing signs and symptoms for up
to 6 months. Virus may be excreted during a relapse.
Antibody produced in response to HAV infection persists for life and
confers protection against reinfection
What occurs if you have not received the vaccine and are exposed? Until
recently, an injection of immune globulin (IG) was the only recommended
way to protect people after they have been exposed to Hepatitis A virus.
In June 2007, U.S. guidelines were revised to allow for Hepatitis A
vaccine to be used after exposure to prevent infection in healthy persons
aged 1–40 years. Persons who have recently been exposed to HAV and
who have not been vaccinated previously should be administered a single
dose of single-antigen Hepatitis A vaccine or IG (0.02 mL/kg) as soon as
possible, within 2 weeks after exposure
(CDC, 2013b)



American Academy of Pediatrics. (n.d.) [Infant with severe vasculitis with disseminated
intravascular coagulation (DIC) with gangrene of the hand secondary to Hib septicemia.]
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[photograph]. Retrieved from http://phil.cdc.gov/phil/details.asp?pid=130



Centers for Disease Control and Prevention[CDC]. (n.d.). Measles. [photograph].
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deformity of her right lower extremity due to polio caused by the poliovirus, an enterovirus member.]
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[photograph]. Retrieved from http://phil.cdc.gov/phil/details.asp?pid=5325





Centers for Disease Control and Prevention[CDC]. (1995c). [This female Cambodian patient presented with
a distended abdomen due to a hepatoma resulting from chronic hepatitis B infection.] [photograph].
Retrieved from http://phil.cdc.gov/phil/details.asp
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http://phil.cdc.gov/phil/details.asp
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produced by Clostridium tetani exotoxin, called “neonatal tetanus”.] [photograph]. Retrieved from
http://phil.cdc.gov/phil/details.asp?pid=6374
Centers for Disease Control and Prevention[CDC]. (1995e). [This ventral view of a human brain
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Retrieved from http://phil.cdc.gov/phil/details.asp?pid=6548
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visstatements/dtap.html

Centers for Disease Control and Prevention [CDC]. (2011a). Diphtheria vaccination. Retrieved
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
Centers for Disease Control and Prevention [CDC]. (2013b). Hepatitis A: an information for
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









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

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


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