Immunization and RSV/Palivizumab Clinic Update Advances in preventative care for our pediatric...
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Immunization and Immunization and RSV/Palivizumab RSV/Palivizumab Clinic UpdateClinic Update
Advances in preventative care for our Advances in preventative care for our pediatric populationpediatric population
Immunization UpdateImmunization Update
The ever changing quagmire of pediatric The ever changing quagmire of pediatric immunization schedulesimmunization schedulesChanges and clarifications for the 2000-2001 Changes and clarifications for the 2000-2001 immunization recommendations for Evans immunization recommendations for Evans Army Community HospitalArmy Community Hospital
Basic Immunization Basic Immunization OverviewOverview
Hepatitis B initial vaccination to be given at Hepatitis B initial vaccination to be given at birth birth
Prevnar (pneumococcal conjugate vaccine) Prevnar (pneumococcal conjugate vaccine) currently in use starting at 2 months, soon to currently in use starting at 2 months, soon to be expandedbe expanded
Selective PPD skin testingSelective PPD skin testing
Current Immunization Current Immunization ScheduleSchedule
Birth 2 Months 4 Months 6 Months 12Months
18Months
4-6Yrs.
11-12Yrs.
Hep B 1 DTaP 1IPV 1Comvax 1Prevnar 1
DTaP 2IPV 2Prevnar 2
DTaP 3IPV 3Comvax 2Prevnar 3
MMR 1Prevnar 4PediVaxHib (#3)VarivaxPPD*
DTaP 4(Varivax)
DTaP 5IPV 4MMR 2PPD*
Td(MMR 2)(Hep Bseries)
* PPD only as clinically required or as required by day care programs or school
Hepatitis B changesHepatitis B changes
Current AAP, ACIP and CDC recommendations Current AAP, ACIP and CDC recommendations encourage changing back to thimerisol-free encourage changing back to thimerisol-free Hepatitis B at birth for all infantsHepatitis B at birth for all infants
Comvax (Hib and Hep B) will be given at 2 months Comvax (Hib and Hep B) will be given at 2 months and 6 monthsand 6 months
PediVax Hib at 12 months will provide the third and PediVax Hib at 12 months will provide the third and final Haemophilius influenza B immunizationfinal Haemophilius influenza B immunization
Prevnar AdditionPrevnar Addition
Prevnar (pneumococcal 7-valent conjugate Prevnar (pneumococcal 7-valent conjugate vaccine) has been added to the routine vaccine) has been added to the routine immunization schedule for all 2 month oldsimmunization schedule for all 2 month olds
Catch-up immunizations for other age groups Catch-up immunizations for other age groups will be initiated at the start of the new year…will be initiated at the start of the new year…based on vaccine availabilitybased on vaccine availability
Current Prevnar Current Prevnar RecommendationsRecommendations
VACCINE SCHEDULE FOR INFANTS AND TODDLERS
Dose 1 Dose 2 Dose 3 Dose 4
2 Months 4 Months 6 Months 12-15 Months
May be given asearly as 6 weeks
Dosing interval is 4-8 weeks Should be given at least 2months after third dose
VACCINE SCHEDULE FOR UNVACCINATED CHILDREN 7 MONTHS OF AGE
Age at first dose Total doses Dosing information
7-11 Months 3 2 doses at least 4 wks apart, 3rd dose after 12months of age and 2 months after 2nd dose
12-23 Months 2 2 doses at least 2 months apart.
24 Months to 9years
1 One dose
* PPD only as clinically required or as required by day care programs or school
Tuberculin Skin TestingTuberculin Skin Testing
The TST is the only practical tool for diagnosing The TST is the only practical tool for diagnosing tuberculosis infection in asymptomatic persons. tuberculosis infection in asymptomatic persons. The Mantoux test containing 5 tuberculin units (TU) The Mantoux test containing 5 tuberculin units (TU) of purified protein derivative (PPD), administered of purified protein derivative (PPD), administered intradermally, is the recommended TST. Other intradermally, is the recommended TST. Other strengths of Mantoux skin tests (1 or 250 TU) strengths of Mantoux skin tests (1 or 250 TU) should not be used. Multiple puncture tests are not should not be used. Multiple puncture tests are not recommended because they lack adequate recommended because they lack adequate sensitivity and specificity.sensitivity and specificity.
Tuberculin Skin TestingTuberculin Skin Testing
The AAP recommends a TST for children who are at The AAP recommends a TST for children who are at increased risk of acquiring tuberculosis infection and increased risk of acquiring tuberculosis infection and disease. disease. Routine TST administration, including Routine TST administration, including school-based programs that include populations at school-based programs that include populations at low risk, that has either a low yield of positive results low risk, that has either a low yield of positive results or a large number of false-positive results represents or a large number of false-positive results represents an inefficient use of health care resources.an inefficient use of health care resources. Children Children without risk factors, including children who are without risk factors, including children who are younger than 1 year of age, do not need routine TSTs.younger than 1 year of age, do not need routine TSTs.
Tuberculin Skin TestingTuberculin Skin Testing
Previous immunization with bacille Calmette-Guérin Previous immunization with bacille Calmette-Guérin (BCG) is not a contraindication to TST skin testing.(BCG) is not a contraindication to TST skin testing.
Current guidelines from the CDC, American Current guidelines from the CDC, American Thoracic Society, and the AAP accept 15 mm or Thoracic Society, and the AAP accept 15 mm or greater of induration as a positive TST result for any greater of induration as a positive TST result for any person. Interpretation of 5 mm or more or 10 mm or person. Interpretation of 5 mm or more or 10 mm or more induration from a TST is outlined in the Red more induration from a TST is outlined in the Red Book.Book.
Children for whom Children for whom immediateimmediate TST is indicated: TST is indicated:
Contacts of persons with confirmed or suspected Contacts of persons with confirmed or suspected infectious tuberculosis; including children identified as infectious tuberculosis; including children identified as contacts of family members or -associates in jail or contacts of family members or -associates in jail or prison during the last 5 yearsprison during the last 5 years
Children with radiographic or clinical findings Children with radiographic or clinical findings suggesting tuberculosis diseasesuggesting tuberculosis disease
Children immigrating from endemic countriesChildren immigrating from endemic countries Children with travel histories to endemic countries Children with travel histories to endemic countries
and/or significant contact with indigenous persons from and/or significant contact with indigenous persons from such countriessuch countries
Children who should have Children who should have annual TST :annual TST :
Children infected with HIV or living in Children infected with HIV or living in household with HIV-infected persons.household with HIV-infected persons.
Incarcerated adolescentsIncarcerated adolescents
Children who should be Children who should be tested every 2–3 years:tested every 2–3 years:
Children exposed to the following persons: Children exposed to the following persons: HIV-infected, homeless, residents of nursing HIV-infected, homeless, residents of nursing homes, institutionalized adolescents or homes, institutionalized adolescents or adults, users of illicit drugs, incarcerated adults, users of illicit drugs, incarcerated adolescents or adults, and migrant farm adolescents or adults, and migrant farm workers; foster children with exposure to workers; foster children with exposure to adults in the preceding high-risk groups are adults in the preceding high-risk groups are includedincluded
Considerations for TST at 4–6 Considerations for TST at 4–6 and 11–16 years of age:and 11–16 years of age:
Children whose parents immigrated (with unknown Children whose parents immigrated (with unknown TST status) from regions of the world with high TST status) from regions of the world with high prevalence of tuberculosis; continued potential prevalence of tuberculosis; continued potential exposure by travel to the endemic areas and/or exposure by travel to the endemic areas and/or household contact with persons from the endemic household contact with persons from the endemic areas (with unknown TST status) should be an areas (with unknown TST status) should be an indication for a repeated TSTindication for a repeated TST
Children without specific risk factors who reside in Children without specific risk factors who reside in high-prevalence areashigh-prevalence areas
Interpretation of TST Results:Interpretation of TST Results: Induration >5 mmInduration >5 mm
Children in close contact with known or suspected Children in close contact with known or suspected contagious cases of tuberculosis disease:contagious cases of tuberculosis disease:• Households with active or previously active cases if Households with active or previously active cases if
treatment cannot be verified as adequate before treatment cannot be verified as adequate before exposure, treatment was initiated after the child’s exposure, treatment was initiated after the child’s contact, or reactivation of latent tuberculosis infection is contact, or reactivation of latent tuberculosis infection is suspectedsuspected
Interpretation of TST Results:Interpretation of TST Results: Induration >5 mmInduration >5 mm
Children suspected to have tuberculosis disease:Children suspected to have tuberculosis disease:• Chest radiograph consistent with active or previously Chest radiograph consistent with active or previously
active tuberculosisactive tuberculosis• Clinical evidence of tuberculosis disease†Clinical evidence of tuberculosis disease†
Children receiving immunosuppressive therapy‡ or Children receiving immunosuppressive therapy‡ or with immunosuppressive conditions, including HIV with immunosuppressive conditions, including HIV infectioninfection
Interpretation of TST Results:Interpretation of TST Results: Induration >10 mmInduration >10 mm
Children at increased risk of disseminated Children at increased risk of disseminated disease:disease:• Young age: younger than 4 years of ageYoung age: younger than 4 years of age• Other medical conditions, including Hodgkin Other medical conditions, including Hodgkin
disease, lymphoma, diabetes mellitus, chronic disease, lymphoma, diabetes mellitus, chronic renal failure, or malnutritionrenal failure, or malnutrition
Interpretation of TST Results:Interpretation of TST Results: Induration >10 mmInduration >10 mm
Children with increased exposure to tuberculosis Children with increased exposure to tuberculosis disease:disease:• Born or whose parents were born in high-prevalence Born or whose parents were born in high-prevalence
regions of the worldregions of the world• Frequently exposed to adults who are HIV-infected, Frequently exposed to adults who are HIV-infected,
homeless, users of illicit drugs, residents of nursing homeless, users of illicit drugs, residents of nursing homes, incarcerated or institutionalized persons, and homes, incarcerated or institutionalized persons, and migrant farm workersmigrant farm workers
Travel and exposure to high-prevalence regions of Travel and exposure to high-prevalence regions of the worldthe world
Interpretation of TST Results:Interpretation of TST Results: Induration >15 mmInduration >15 mm
Children 4 years of age or older without any Children 4 years of age or older without any risk factorsrisk factors
Treatment of latent Treatment of latent tuberculosis infectiontuberculosis infection
Isoniazid daily for 9 monthsIsoniazid daily for 9 months Other regimens as noted in the Red BookOther regimens as noted in the Red Book
RSV/Palivizumab RSV/Palivizumab ClinicClinicUpdateUpdate
Advances in preventative care for our Advances in preventative care for our pediatric populationpediatric population
Respiratory Syncytial Virus Respiratory Syncytial Virus EpidemiologyEpidemiology
100% of infants by 2 yrs infected with RSV100% of infants by 2 yrs infected with RSV 40 % of infants with bronchopulmonary 40 % of infants with bronchopulmonary
dysplasia (BPD) hospitalized with RSV by 1 dysplasia (BPD) hospitalized with RSV by 1 year oldyear old
90,000 hospitalizations with 2% (4,500) deaths 90,000 hospitalizations with 2% (4,500) deaths annually annually
Risk of development of asthma after RSV Risk of development of asthma after RSV infectionsinfections
Prior Treatment OptionsPrior Treatment Options
Mostly supportive with oxygen Mostly supportive with oxygen supplementation and respiratory assistancesupplementation and respiratory assistance
Antiviral agent ribavirin only approved Antiviral agent ribavirin only approved treatmenttreatment• Efficacy and use are controversialEfficacy and use are controversial
Prophylactic infusions with Respiratory Prophylactic infusions with Respiratory Syncytial Virus Immune Globulin (RSV-IGIV, Syncytial Virus Immune Globulin (RSV-IGIV, Human)Human)
Introduction of PalivizumabIntroduction of Palivizumab
First monoclonal antibody for the prevention First monoclonal antibody for the prevention of diseaseof disease
Prophylaxis results in:Prophylaxis results in:• 55% decrease in hospitalization due to RSV55% decrease in hospitalization due to RSV• 78% decrease in RSV hospitalization for infants 78% decrease in RSV hospitalization for infants
without BPDwithout BPD• 39% decrease in RSV hospitalization for infants 39% decrease in RSV hospitalization for infants
with BPDwith BPD
Introduction of PalivizumabIntroduction of Palivizumab
Prophylaxis results in:Prophylaxis results in:• Fewer total RSV hospital daysFewer total RSV hospital days• Fewer RSV hospital days on supplemental Fewer RSV hospital days on supplemental
oxygenoxygen• Lower incidence of ICU admissionLower incidence of ICU admission
Safe and well tolerated with no significant Safe and well tolerated with no significant reported adverse effectsreported adverse effects
Palivizumab RegimenPalivizumab Regimen
Monthly administration of medicationMonthly administration of medication Dose of 15 mg/kg by intramuscular injectionDose of 15 mg/kg by intramuscular injection Provided during anticipated high RSV Provided during anticipated high RSV
season:season:• October through MarchOctober through March
High-Risk Infant Inclusion High-Risk Infant Inclusion CriteriaCriteria
Infants with CLD up to 2 yrs with medical Infants with CLD up to 2 yrs with medical intervention within 6 monthsintervention within 6 months
Infants born up to 28 wk EGA without CLD if less Infants born up to 28 wk EGA without CLD if less then 12 months at onset of RSV seasonthen 12 months at onset of RSV season
Infants born between 28-32 wk EGA if less then 6 Infants born between 28-32 wk EGA if less then 6 months at onset of RSV seasonmonths at onset of RSV season
Infants born between 32-35 wk EGA if less then 6 Infants born between 32-35 wk EGA if less then 6 months at onset of RSV season and increased risk months at onset of RSV season and increased risk factor for infectionfactor for infection
High-Risk Infant Inclusion High-Risk Infant Inclusion CriteriaCriteria
Selected factors that increase RSV disease severity:Selected factors that increase RSV disease severity:• prematurityprematurity• chronic lung diseasechronic lung disease• male sexmale sex• congenital heart diseasecongenital heart disease• low socioeconomic statuslow socioeconomic status• T-cell immunodeficiency T-cell immunodeficiency
EACH Synagis ClinicEACH Synagis Clinic
Held monthly from October to March Held monthly from October to March (anticipated)(anticipated)
Located in Carson Care ClinicLocated in Carson Care Clinic Contact Janet Meuth or LTC Chandler with Contact Janet Meuth or LTC Chandler with
patient informationpatient information
QuestionsQuestions
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