Immunizations (Vacunas)

N430

Why Immunize?
Vaccines work! Vaccines have caused a significant decrease in the incidence of infectious disease in the 20th century

Vaccines have caused a significant decrease in human suffering from disease

A Picture is Worth a 1000 Words

P O

L
I O

Polio
Before Immunizations:
50,000 cases of polio per year in US alone

After Immunizations:
NO POLIO IN WESTERN HEMISPHERE (2003 Nigerias northern state of Kano suspended immunizations re-emergence of polio there)

Smallpox...

Examples of:

Immunization Effectiveness
Smallpox... Before Immunizations:
Until mid 1900s smallpox the most devastating disease the world had ever known.

WHO declared it eradicated in 1980 after immunizations given worldwide.

Today, present only as a terrorism threat Not a new idea British forces gave smallpox contaminated blankets to Indians in French/Indian wars to weaken Native American resistance to colonial expansion!

Vaccine Effectiveness:
2007 Study Study objective was to compare the morbidity and mortality rates from before and after the widespread implementation of vaccination recommendations.
Roush SW, Murphy TV, Vaccine-Preventable Disease Table Working Group. Historical comparisons of morbidity and mortality for vaccine preventable diseases in the United Statees. JAMA. 2007; 298:2155-2163.

Vaccine Effectiveness: 2007 Study

92% decrease in the # of cases of disease 99% decrease in the # of deaths prevented by vaccines recommended before1980
includes diptheria, mumps, pertussis, tetanus, poliovirus, measles, rubella)

80% decline in cases and deaths attributable to hepatitis A, Hib and Varicella S. pneumoniae cases decreased by 34% & deaths declined by 25%

Diptheria
An acute infection of the upper respiratory tract caused by a toxinproducing bacteria Skin lesions, Bull Neck, Airway Swelling
Causes inflammatory response with airway swelling!

Immunizations for Diptheria

The D in DTaP & d in Tdap
Schedule:
2 mos, 4 mos, 6 mos, 15-18 mos, 4-6 yrs Required for kindergarten entry in Ks.
1 booster @ 11-12 yrs (Tdap)

Tetanus
Caused by a bacilli that produces a neurotoxin following contamination of a wound by soil with animal manure or animal bite Toxin reaches the CNS & results in intense muscle contractions paralysis.

Pt. remain fully conscious & lucid as paralysis progresses

Immunizations for Tetanus

The T in the DTaP & the T in the Tdap Schedule: Same as diptheria
REQUIRED for kindergarten entry in KS. 1st booster @ 11-12

Pertussis

Pertussis..(Whooping Cough)
Highly contagious infection of the respiratory tract Characterized by severe bronchitis and/or bronchiolitis with a whoop cough. Cough lingers 4-6 wks. Most severe in infancy as airway passages are so small.

Immunization for Pertussis

The P in DTaP & the p in Tdap Schedule: Same as diptheria & tetanus
Required for kindergarten entry

Measles (Rubeola)
Immunization developed in 1962

Measles (Rubeola)
Viral infection
Lasts 7-10 d. Contagious 5days after exposure to 5days after rash appears
High fever (up to 105), hacky cough, conjunctivitis, lethargy, reddish brown maculopapular rash, photophobia, Kopliks Spots

Measles Immunization
The 1st M in MMR Schedule:
1st dose @ 12-15 mos. 2nd dose @ 4-6 yrs.

Required for kindergarten entry. Has not changed in YEARS!

Mumps
Viral Infection
Primarily involves parotid salivary gland Most common complication is nerve deafness usually unilateral

Mumps Immunization
The 2nd M in MMR

Schedule: Same as Measles

1st dose @ 12-15 mos. 2nd dose @ 4-6 yrs.

Rubella:
aka German Measles, 3 day measles

Rubella
(German Measles, 3 day measles)

Rubella
Caused by rubella virus Maculopapular rash beginning on face & rapidly spreading to entire body. Rash disappears by 4th day. Usually mild in children

Rubella
(German Measles, 3 day measles)

Rubella
About 20% of individuals who have had rubella develop type 1 diabetes.
Pediatrics in Review 2008; 29; 374

Dangerous in pregnant women: leads to serious and significant birth defects

Congenital Rubella Syndrome

(when infants are born with rubella from mom)

Common Triad of Symptoms: Cataracts/congenital glaucoma, and/or retinopathy Congenital heart disease

Loss of hearing.

Congenital Rubella Syndrome

Also: Purpura (circular type of bruising) Splenomegaly

Jaundice
Microcephaly with, mental retardation, Meningoencephalitis,
Ends of long bones look like celery stalks

Bone disease--------->

Rubella Vaccine
Immunization: the R in MMR Schedule: Same as Measles & Mumps
Again 2 doses of vaccine 12-15 months 4-6 yrs

More about MMR...

A live vaccine
Should not be given to:
Pregnant women Children who are moderately to severely ill Immune compromised Anyone who has had life threatening reaction to gelatin or the antibiotic neomycin

Emerson Iron Lung or Negative pressure Ventilator allowed person with polio to breathe with loss of normal muscle control
Donated to CDC Museum by family of Barton Herbert who used it from 1950s until death in 2003

Poliomyelitis (polio)
Caused by polio virus Subclinical in 95% of cases S & S:
Initially fever, myalgia, sore throat, and headache for 2-6 days Several symptom free days are then followed by return of fever & HA, stiff neck, spinal rigidity & nausea

Polio
Poliomyelitis (polio)
Most people dont knowmild cases resolve completely More severe cases result in asymmetric paralysis which affects swallowing, speech, and cardiorespiratory function Paralysis usually complete by the time temperature resolves Most improvement of muscle paralysis will take place within 6 months after that, a permanent disability

Immunization for Polio: IPV

Now available as injectible only
Used to be oral (OPV): was a live vaccine which caused disease in 1:1,000,000 cases. Paralysis in 1:10,000,000 children. Never used anymore.

Injectible is a killed vaccine.

Immunization for Polio: IPV

Schedule:
Primary series of 4 shots: 2 mos, 4 mos, 6-18 mos., & 4-6 yrs. No booster required

Note:
See note on schedule for fine detaild of when to use the different brands Pedvax, Comvax, Hiberix,

Haemophilus influenzae type b (Hib

Disease)

Hib
Name of a bacteria that causes different types of disease processes Is NOT the name of a disease itself

Most common cause of bacterial meningitis & epiglottitis before immunization*** Can also cause cellulitis, septic arthritis, pneumonia, & bacteremia

Hib Infections

Cellulitis

Hib Immunization
Schedule:
4 doses
2 mos, 4 mos, 6 mos, 12-18 mos
The most dramatic impact on disease of any recent vaccine***!

Hib meningitis and epiglottitis are rarely seen today.

Hep B
Liver damage with Hep B

Hep B
What you already know
Caused by a virus that attacks the liver Can cause life long infection with cirrhosis, liver cancer, liver failure and death Transmitted through blood/body fluids More than 2 billion persons worldwide Of those, 350 million remain life long carriers

Hep B what you might not know

Hepatitis B in Children
Infant & children @ highest risk of developing lifelong infection.
25% of kids who become infected with hepatitis B virus are expected to die of related liver disease as adults 12,000 infants born to hepatitis B infected mothers were infected each year before vaccine

Hep B Immunization
Schedule:
3 shot series Ideally: Birth, 1-2 mos., & 6 mos. MUST be 24 wks before 1st dose and 3rd dose Can be given in 4 doses with combination vaccines:

Hep A
A viral disease Transmission by fecal-oral route Possibility for epidemic outbreaks from contaminated food or water

Hep A
Fever, anorexia, vomiting, HA, abdominal pain Jaundice follows these sxs within 5-10 days Darkening of the urine & stools become light or clay colored Hepatomegaly Self-limiting, acute illness Death rare

Hep A
2007ACIP placed on recommended list for children for the first time Schedule:
2 doses: 1st @ 1-2 yr 2nd 6 mos later

Chicken Pox (Varicella)

NOT ALWAYS INNOCENT

Varicella (Chicken Pox)

Highly contagious viral infection Can be VERY serious Caused by exposure to varicella or herpes zoster viruses
Incubation period: 10-20 days Virus lingers in latent form in sensory ganglia & can reappear at a later time as herpes zoster (shingles) in 10-15% of individuals

Varicella
S & S: Mild fever & mild malaise Crops of red macules that rapidly become tiny vesicles with surrounding erythema. Process occurs over 24 hrs. Vesicles then slowly crust over. New crops occur for about 5 days, then stop. Can occur in the anus, vagina and respiratory tractvaricella pneumonia

Varicella Immunization: Varivax

Schedule:
Given @ 12 months Booster @ 4-6 years

Pneumococcal Infection: streptococcus pneumoniae

The most common cause of bacterial respiratory disease, including otitis media and sinusitis. More than 20 serotypes
Now 2 vaccines available One against 7 serotypes One against 13

Some concern emerging that serotype replacement is going on since vaccine emergence of different serotypes than previously known

Pneumococcal Infection: streptococcus pneumoniae

Streptococcus pneumoniae is also the bacteria that we are seeing increasing antibacterial resistance to
Pneumococcal disease begins as early as the 2nd month of life & becomes progressively more common as maternal antibodies decline

Pneumococcal Immunization:
Schedule: PPV
Single Dose 2-6 yrs. High risk population if PCV missed

Schedule PCV: 4 doses: 2 mos, 4 mos, 6 mos, & 12-15 mos.

Meningococcal Infection Not always meningitis

Meningococcal Infection
Meningococci causative organisms are classified into 9 groups or serotypes of bacteria
Serogroup A is the most likely form of meningitis to cause epidemic spread Most commonly causes meningitis

Meningococcal Infection
Infants less than one year of age have greatest risk, but are too young to immunize
College freshman exposed to communal living for the first time (in dorm setting) also have increased risk

Meningococcal Vaccines
Meningococcal conjugate vaccine (MCV4)
Recommended at 11-12 year exam
2 shot series given 8 weeks apart Booster @ age 16

If given between 13-15:

2 shot series given 8 weeks apart Booster is needed @ age 18

MCV4) form can be given age 2-10 with certain hi-risk criteria

Rotavirus

Rotavirus
Viral infection that causes severe diarrhea, mostly in babies and in young children Often accompanied by vomiting and fever. Almost ALL children in the US are infected with rotavirus before their 5th birthday.

Each year, Rotavirus is responsible for:

> than 400,000 doctor visits 55,000-70,000 ER visits 20-60 deaths

Rotavirus Vaccine
An oral vaccine not an injection Now comes in 2 forms: Rotateq & Rotarix 98% of kids who get vaccine are protected form severe diarrhea; 70% do not get the virus at all after vaccine
Do not start the series later than 14 wks, 6 days. Do not administer a dose later than 8 mos, 0days.

Rotavirus Vaccine
Schedule : 3 doses
2 months 4 months 6 months

Note*******
If doses of Rotarix (a brand name) are given @ 2 and 4 months, the 3rd dose isnt needed

Influenza
Infection of the respiratory tract caused by Influenza A or B
Especially dangerous in young children Characterized by high fever, difficult cough, malaise & extreme fatigue Often accompanied by respiratory distress especially in young asthmatics

Influenza Vaccine
Recommended annually for: All Children > 6 mos. of age Anyone with close contacts for infants 0-5 months
Children aged 6 mos -9 yrs. receiving 1st dose:
0.25 ml. dose with 2nd dose 4 wks. later

Children who have had before:

0.5 ml dose

HPV (human papilloma virus)

Genital HPV: sexually transmitted disease
100 types in all/40 types that are sexually transmitted Can infect both men & women with genital warts Young women are most at risk due to immaturity of the cervix that makes it more vulnerable to HPV

Some types can cause cell changes that can cause cervical cancer

HPV (human papilloma virus)

Most people who get it dont know it and actually clear infection on their own. At least 50% of sexually active men have had it by age 50; 80% of women by age 50. Can cause genital warts. Can cause cervical dysplasia & cervical cancer. This is the focus of the vaccine.

HPV Vaccine Gardacil/Cervarix

HPV Available for young women & young men for the 1st time last year Schedule is changed this so that both males and females are on the same schedule: At 11-12 years: Initiate 3 shot
series

HPV Vaccine Gardacil/Cervarix

HPV 2 different forms of the vaccine:
HPV (Gardacil)4 for males HPV 2(Cervarix) or HPV 4for females

Schedule is changed this so that both males and females are on the same schedule.
At 11-12 years: Initiate 3 shot series

Common Side Effects of Most Vaccines

Common Side Effects of Most Immunizations

Dont Be Concerned: Its ok!
Low grade fever Irritability for 24-48 hrs. Pain @ injection site Knot @ injection site Rash with varicella vaccine

Vaccine Myths
Myth # 1: Vaccines are not safe
Studies repeatedly show extraordinary safety Side effects limited and non-threatening

Vaccine Myths
Myth # 1: Vaccines are not safe
Strictly regulated by FDA:
Guidelines change as new knowledge is gained Old DTP: caused rare event of seizures, persistent crying, high fever..withdrawn OPV withdrawn Thimerosol containing immunizations withdrawn because of rare and isolated intussusception cases (1st Rotavirus vaccine)

Vaccine Myths
Myth # 1: Vaccines are not safe
We have to keep our focus...Risk associated with disease much more than immunizations

Issues that come up after distribution contribute to parental concern

Vaccine Myths
Myth # 2: Vaccines weaken the immune system, so it is better to naturally acquire the disease

Much evidence that vaccines strengthen the immune system

Vaccine Myths
Myth # 2: Vaccines weaken the immune system, so it is better to naturally acquire the disease
Immune system capable of responding to an extremely high # of antigens. Study: Offit & colleagues predicted that infants could respond to 10,000 vaccines at one time! (Pediatrics. 2002;109: 124-129)

Vaccine Myths
Myth # 2: Vaccines weaken the immune system because of so many antigens, so it is better to naturally acquire the disease
All vaccines together have less than 150 antigens...smallpox disease alone has 200

Vaccine Myths
Myth # 3: MMR Causes Autism
First, what is autism? (now called ASD)
Autism is a neurodevelopmental disorder characterized by severe deficits in social interaction, language, communication & play, as well as behavioral problems. Usually identified around 18 mos. of age. A gene has been identified for this disorder

Vaccine Myths
Myth # 3: MMR Causes Autism
1993 Andrew Wakefield (& colleagues) wrote a paper that implied a series of events that led to the development of autism after MMR This series of events included: development of IBD, loss of intestinal barrier function, & entrance into the bloodstream of encephalopathic proteins

MMR Causes Autism Myth Critical Flaws In Study!

Small sample in study No blinding in the study Exposed & control group did not come from same population Different controls were used for different techniques in the study Subsequent studies using molecular amplification techniques failed to detect measles virus genes in a single inflammatory bowel disease patient Diagnostic criteria were not defined

MMR Causes Autism Myth Critical Flaws In Study!!!

GI symptoms were observed AFTER sxs of autism present. The autistic children were reported to have low levels of IgA, when levels reported were actually in normal range using pediatric reference.
Intestinal nodular hyperplasia reported in study is actually a variant of normal in young children

Vaccine Myths
MMR & Autism: Retractions
10 out of 12 authors of study retracted the suggestion of link to Autism We wish to make it clear that in this paper no causal link was established between MMR vaccine and autism as the data were insufficient. Lancet vol. 363, number 9411, 3/6/04

The Power of the Internet!

The Truth About MMR & Autism

Multiple Large Population Studies:
Prevalence of autism between MMR & control equal No clustering of autism cases after immunizations One group of researchers compared with 12 large well designed large population studies found absolutely NO LINK!
Pediatric Annals. January 2009 Pediatrics. 2004

Unvaccinated Children
Who are they?
Caucasian children
Parents are married Parents have college degree with annual income> $75,000

Unvaccinated Children
Why?
Concerns regarding safety withdrawal of vaccines has contributed to this Distrust of medical community Have never seen these diseases, so they dont understand the real risk... Gain information from unproven sources
Power of the Internet!

Under- Vaccinated Children

Who are they? Research tells us they are predominately:
African-American Young, unmarried mothers No college degree Poverty level Urban residence

Under -Vaccinated Children

Why?
Lack of resources
Transportation issues Lack of knowledge Have not seen these diseases

Cost of Immunizations$$$$$$$
1985: It cost $45 to give a child ALL of their recommended vaccines throughout their childhood There were 62.5 million children

Total Cost: $2,812 million dollars

Cost of Immunizations
1995: It rose to $155 to give a child all of their immunizations. There are 69.5 million children Total Cost: $10,772.5 million dollars

Cost of Immunizations
2006: It is still risingto $837
This does not include the new HPV vaccine. If that vaccine is included, the cost increased to $1200.
(Abramson JS. Immunizations in 2007. Presented at the 19th Annual Infectious Diseases in Children Symposium. Nov. 18-19, 2006. New York City

There are 73.8 million children Total cost is now 88,560 million dollars

Current Costs of Immunizations

2012 CDC Vaccine Price List (Updated 9-10-2012)
Vaccine DTaP Cost Per Dose $25.29 Number of Doses 5 Total Cost $126.45

IPV
Hib Rotavirus Hep B Hep A

$26.66
$25.47 $72.34 $23.20 $30.36

4
4 3 3 2

$106.44
$101.88 $217.02 $69.60 $60.72

Pneumococcal
MMR Varivax Influenza

$120.95
$52.07 $87.10 $10.70

4
2 2 19

$483.80
$104.14 $174.20 $203.30

Current Costs of Immunizations

2012 CDC Vaccine Prize List (Updated 9-10-2012)
Vaccine Cost Per Dose Number of Doses Total Cost of Vaccine

HPV quadrivalent form

TdaP

$130.27
$37.35

3
1

$390.81
$37.35

Meningococcal

$110.72

$221.44

Total Cost Per Child Birth 18 yrs.

$2297.15

It has risen more than $1000 PER CHILD in 6 years!

Retrieved 9-16-2012 http://www.cdc.gov/vaccines/programs/vfc/awardees/vac cine-management/price-list/index.html

Current Costs of Immunizations

2012 projected census findings:
76.1 million children

Based on this statistic, it will cost $174,813.12 million dollars to immunize every child in the country.

Who Pays?????
In the past

Vaccines for Children Has Tried

Government program through Medicaid

40% of children are eligible for this program

Vaccines require significant documentation of usage and management An expensive program for taxpayers

Who Pays?????
In the past

Private Sector: 45% of cost was here, either by insurance or by the parent who pays or a combination of both Lost in the Shuffle!: 15% was being lost in the confusion and were not receiving their vaccines
Stephenson, M. Pediatricians Taking the Hit As New Immunizations Added to the Schedule. Infectious Diseases In Children. January, 2007: p. 50

The new health care bill

The Affordable Care Act A much stronger emphasis on prevention practices
Cost is and will be significant Great for kids and parents

How can you, the nurse, help?

Be informed about immunizations Be able to discuss the diseases Be able to give information about the vaccine myths as you encounter them. Know reputable web sites to provide objective information Know what resources are available in your community Never miss an opportunity to catch up a vaccine!

Reliable Internet Resources

www.healthfinder.gov www.hon.ch/HONcode/ www.immunize.org www.cdc.gov