Transcript Immunizations and Vaccine preventable childhood diseases

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Vaccines and
Vaccine Preventable
Communicable Illness
of Childhood
Childhood Immunizations
The introduction of vaccines against childhood diseases such as
measles, mumps, rubella, polio, whooping cough
(pertussis), diphtheria, small pox, haemophilus influenza,
hepatitis b and varicella has greatly improved the quality of
life for both children and adults.
Vaccines need to be administered at specific ages and time
intervals, timing for the first sets of immunizations is
determined by the age in which transplacental immunity
decreases or disappears, and the infant has the ability to
make antibodies in response to the disease.
The effectiveness of vaccines depends on proper storage and
handling. Most vaccines need to be refrigerated and Varivax
(for varicella) needs to be kept frozen. When involved in the
administration of vaccine, the RN is responsible for both the
proper storage and handling
Types of Immunizations
Live attenuated (live virus)
MMR, Varivax
Inactivated (killed virus vaccine)
DTaP, Hib, IPV, Prevnar
Recombinant (genetically rendered)
Hep A, B
Immunoglobulins (IVIG)
Varicella , Measles, RSV, Rabies, Tetanus, Hepatitis A, B, C
2004 Immunization Schedule
Securing a toddler
Pediatric Nursing Responsibilities and
Nursing Interventions in Immunizing children
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Be prepared for life threating reaction when ever immunizing children.
At every visit/encounter child’s immunizations record should be reviewed.
Review child’s allergies (food and medicine) .
Review potential contraindications to each vaccines
Review past immunization history for past reactions
Assess child for anxiety and fear related to administration
Obtain informed consent.
In females of child bearing age (11-50) perform rapid urine HcG (pregnancy
test) before administering Live vaccines (MMR/Varicella).
Parent and patient education about the need for specific vaccinations, risk of not
getting vaccination and getting dieses and potential side effects of vaccine.
Record vaccines administered in patients chart and vaccine record (card)
Give patient and parent current VIS (vaccine information statement) in
APPROPRIATE language before discharge.
Monitor child for 15 minutes post vaccination.
Report all vaccine related reactions using the federal VAERS (vaccine adverse
reaction reporting system) and as per institution policy.
DTaP Vaccine
Diphtheria, acellular pertussis and tetanus
Ages:
2,4,6,15-18 months, 4-6 years with a separate Td
(tetanus booster) at age 11-12 years, Td booster every
10 years for life. Total 5 childhood doses.
Route:
IM
Dose:
0.5ml
Common side effects:
Redness, swelling, pain at injection site. T>100.9,
drowsiness, anorexia.
Serious side effects:
Anaphylaxis, shock or collapse, fever > 102, persistent,
inconsolable crying, seizures, encephalopathy.
Contraindications: Occurrence of a serious side effect after
previous dose, administration of IVIG within past 90
days.
Nursing considerations
DTaP vaccine
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Use the same brand when ever possible.
Carefully question parents if they say the child had previous
reaction to immunizations
Inform parents of increased risk of reaction to does 4 & 5
If child had a serious adverse reaction to any previous dose,
the next doses should be deferred.
Diphtheria
A bacterium that occurs in winter. Sx can be mild – severe with a gradual
onset (1-2days). Low grade fever, malaise, anorexia, Rhinorrhea (with
foul odor), hoarseness, stridor, cervical lymphadenitis, pharyngitis.
There is a characteristic membrane that covers the tonsills, it is a
membranous thick bluish white to grayish black in color, can spread to
the soft & hard palates. Any attempt to remove the membrane results
in significant bleeding.
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Treatment: administration of IV antitoxin within 3 days of onset of sx.
Also PCN G and surgical removal of membrane if occluding airway.
Maternal antibodies last as long as 6 months
Transmission: Contact with infectious nasal or eye
discharge,unpasturized milk can also serve as a mode of transmission.
Incubation:2-7 days
Period of communicability: 2-4 weeks or until 4 days of abx therapy
Complications: produces an endotoxin that causes myocarditis,
peripheral neuropathy and ascending paralysis (similar to Gulliiainbarre syndrome.
Membrane of Diphtheria
Pertussis (aka: whooping cough)
Most common in children under 6 mths of age
Occurs frequently in medical workers and adults that are immunosuppressed,
adults have mild illness but spread to unimmunized kids.
Starts with runny nose followed by an irregular, non-productive cough, cough
becomes severe at night and changes into spasms of paroxysmal coughing
followed by inspiratory stridor or “whooping”. The whooping sound is
produced by forceful inhalations and a narrowed glottis.
In the infant sucking on a bottle can trigger the coughing spells.
Is accompanied by flushing, cyanosis, vomiting, profuse drainage from eyes,
nose, mouth.
Dehydration may occur form decreased PO intake.
Paroxysmal coughing may last up to 2 weeks.
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Treatment: erythromycin
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Mode of transmission: Resp droplets and direct contact with nasal/oral/eye
drainage
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Incubation: 7-21 days
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Period of communicability: 1 week after exposure, and up to 5-7 days after
abx tx is started. Is VERY contagious during paroxysmal coughing stage
Cough of Pertussis
Tetanus
An acute, preventable and often fatal
disease caused by an endotoxin
produced by the anaerobic sporeforming, gram + bacillus called
Clostridium tetani.
Clincal manifestations of tetanus
Characterized by painful muscular rigidity, usually of the masseter (mastoid bone) and
neck muscles.
Tetanus spore are found in soil, dust and the gut of humans and animals. Tetanus is
not an invasive organism but enters a susceptible host through an opening in the
skin, usually a puncture wound, burn or crushed injury. Tetanus spore can enter
through a very minor, often unnoticed break in the skin.
In the newborn, infection may occur through the umbilical cord (when child is
delivered in an unsanitary way using a “dirty” instrument to cut the cord).
Substance abusers are particularly susceptible through using contaminated injectable
drug equipment.
Organism multiples and grows rapidly in “unclean” wound and the endotoxin affects
the CNS, there are several forms of Tetanus but the most common form is the
most lethal.
Initial sx: stiff neck, tenderness of the muscles in the jaw & neck, eventually all
voluntary muscles are affected, complete recovery is possible
Mortality is about 30%, infections in the newborn are almost always fatal.
Tetany
Poliomyelitis
3 known types and a “wild-type”.
Polio affects the CNS and causes paralytic disease. Causes fever, headache, decreased deep
tendon reflexes, progressive weakness and paralysis. The paralysis results from damage to
neurons, onset of paralysis may be sudden or gradual (3- 5 days) , is accompanied by
respiratory difficulties leading to resp. distress and resp. failure. Pt will require
intubation/tracheostomy and mechanical ventilation
Less serious infection can be limited to fever, stiffness in neck/back, vomiting and sore throat.
Still occurs world wide, primarily affects children although susceptible immunosuppressed adults
can be infected in caring for infants who receive OPV.
OPV: Oral polio vaccine, live virus vaccine. Virus is excreted in stool. Is no longer used in the US.
Treatment:
None, supportive only
Mode of transmission:
Fecal-oral possibly also respiratory.
Incubation:
7 -10 days
Period of Communicability:
Unknown, pt believed to be infectious for several weeks before sx begin. Shed in
pharyngeal secretions for a few days and in stool for several weeks
Complications of Polio: Permanent motor paralysis, respiratory arrest, myocardial failure, aseptic
meningitis.
Polio Ward – Iron Lungs
Polio Vaccine
 OPV: Oral polio vaccine, live virus NO LONGER USED IN
US.
 IPV: Inactive Polio Vaccine, killed virus.
Ages:
2,4, months, 6-18 months, booster at 4-6
years. Total 4 doses
Route:
SQ
Dose:
0.5ml
Common side effects: swelling and tenderness at injection
site, irritability, tiredness.
Serious side effects: Anaphylaxis
Contraindications: Hypersensitivity to vaccine
components, allergy to neomycin, streptomycin and
polymyxin B.
Measles/ Rubeola
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Caused by mobillivirus. (member of the paramyxovirus family).
Occurs primarily in children, late winter early spring. Occurs in
unvaccinated children or children whose immunity is declining
(the teenager or school age child who only rec’d 1 dose).
Many cases are reported from children who immigrate to the
US from countries which do not require vaccination (even
though it is a INS regulation that all who enter the US be
immunized) or received mishandled vaccines (poor response)
Vaccination provides life long immunity in 95% of persons
vaccinated
Measles is a cause of significant cause of infant and child
morbidity in developing countries
Maternal antibodies begin to disappear in the infant at 12-15
months.
Clincal manifestations of Measles
Clincal Manifestations Measles
Children are quite ill during prodromal phase with:
 High fever
 Conjunctivitis
 Cough
 Anorexia
 Small, irregular, bluish-white spots on buccal mucosa
know as “Koplik’s spots”
 Characteristic red, blotchy maculorpapular rash
appears 2-4 days after prodromal phase, rash begins
on face and then spreads to trunk and extremities, Sx
subside in 2-4 days
Koplik’s Spots - Measles
Measles
Treatment:
None, supportive only, abx used for
secondary bacterial infections (which
are very common)
Mode of transmission:
airborne (resp droplets)
Incubation:
8-12 days
Period of communicability:
during prodromal phase, ends 24 days after rash appears.
Complications of Measles:
diarrhea, OM, bronchopneumonia,
laryngealtracheobronchitis,
encephalitis
Mumps/ Parotitis
 A paramyxovirus that occurs world wide in
unvaccinated children., most often in late
winter/early spring.
 Both infection and vaccination provide life long
immunity.
 Maternal antibodies begin to disappear in the
infant 12-15 months.
Clinical manifestations of Mumps
Malaise
Low grade fever
Decrease appetite
Decreased activity level
Unilateral parotid swelling, swelling peaks
around day 3.
 Meningeal signs: stiff neck, headache,
photophobia (in about 15% of pts)
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Unilateral Parotid swelling - Mumps
Mumps
Treatment: none ,supportive only
Mode of transmission: saliva droplets and direct
contact with secretions
Incubation: 12-25 days
Period of communicability: 7 days before swelling till 9
days after swelling subsides (can be as long as 2-3
weeks)
Complications of Mumps: Orchitis (inflammation of the
epidydimis which produces pain on testicular
palpations and unilateral scrotal swelling).
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Sterlity is a rare occurrence
Oophoritis, pancreatitis, aseptic meningitis and
unilateral deafness (permanent)
Rubella/ German Measles
German measles is a mild disease with
a characteristic pink, nonconfluent,
maculorpapular rash that appears on
the face, neck, trunk, legs and
disappears in the same order.
Clincal manifestations Rubella
 Prodromal sx begin 1-5 days before rash
 Low grade fever
 headache
 Malaise
 Sore throat
 Anorexia
 Generalized lymphadenopathy involving the
postaricular, suboccipital and posterior cervical lymph
nodes, common up to 7 days before rash begins.
German Measles is a self limiting disease in children with
very rare side effects. Danger is pregnant women.
Rubella/German Measles
Treatment: None, supportive only
Mode of transmission: Droplets, direst contact with
infected persons, or contact with articles soiled by
nasal secretions
Incubation: 14-21 days
Period of communicability: 7 days before rash until
about 4 days after. Infants with CRS shed virus for
months and should not be cared to by susceptible
persons, strict isolation from pregnant women (or
potentially pregnant women) is required.
Complications of Rubella: Rare but includes arthritis in
the adolescent. Encephalitis. By far the most common
and serious complication is CRS.
CRS: Congenital Rubella Syndrome
If a mother is infected in the first trimester of pregnancy, the fetus can be
severely affected
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spontaneous abortion
Still birth
Fetal death
are all common
10% of infected fetuses die after birth
Multiple congenital anomalies are common, these congenital anomalies are
known as Congenital Rubella syndrome.:
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Severe congenital heart dieses (pulmonary atresia-PA, tricuspid atresia,
hypoplastic left heart syndrome-HLHS)
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IUGR
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Ear defects (causing deafness
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Eye defects (causing congenital cataracts)
Caused by mother not being immunized as a child, rates of CRS are on the rise.
Mostly seen in Hispanic immigrant populations (immigrant being the key)
Congenital Rubella Syndrome
MMR Vaccine
(measles/mumps & rubella)
A combination LIVE vaccine
Ages:
12- 15 months, 4-6 years
(Total 2 doses)
Route: SQ
Dose:
0.5ml
Common side effects: Elevated temperatures 1-2 weeks after immunization,
redness/pain at injection site, joint pain.
Serious side effects: anaphylaxis, encephalopathy, thrombocytopenia, purpura,
chronic arthritis.
Contraindications:
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Allergy to neomycin or gelatin
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Severely impaired immune system (HIV/AIDS, cancer tx) or other
immunosuppressant medications or treatments
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MMR cannot be given to any child with a history of cancer (accept order for
MMR only from a Pediatric Hematologist/Oncologist)
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Children with HIV can get MMR.
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Cannot be given within 3 months of blood or blood product transfusion
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Cannot be given to pregnant women
Nursing Considerations before administration:
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Allergy status
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Urine HcG for all women capable of being pregnant
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Question pt/parents about immunosuppression
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Vaccine is a powder that must be mixed with diluting solution before
administration – becomes clear yellow solution.
Haemophilus Influenza Type B
A bacteria which has several serotypes.
Occurs in spring and summer. Most
commonly affects infants and children in
day care settings, LBW children, children
with chronic illnesses.
Invasive HiB disease was a major source of
mortality and morbidity before routine
vaccination was implemented (1987).
Clincal manifestations of
HiB disease
HiB starts as a viral URI, the organism can pass though out the
nasal mucosa to directly invade the blood stream, It causes
several sever invasive illnesses:
 Meningitis
 Epiglottis it
 Pneumonia
 Septic arthritis
 Om
 Bronchitis
 Pericarditis
HiB disease is a leading cause of sepsis in the newborn.
Treatment is ampicillin, however 1/3 of strains are
resistant. Rifampin may be given to unimmunized contacts.
HiB Disease
Mode of transmission: Direct person to person
contact or droplet inhalation, frequently
colonized in nasal secretions.
Incubation: unknown.
Period of communicability: 3 days from the
onset of symptoms
Haemophilus Influenza Type B
vaccine (HiB)
Ages:
2, 4, 6, 12- 15 months (4 doses
total)
Route:
IM
Dose:
0.5 ml
Common side effects: pain, redness or
swelling at injection site
Serious side effects: anaphylaxis
Nursing considerations:
 prior reaction to HiB vaccine
 Use same preparation/manufacturer (if possible)
Hepatitis B
Hep A, B, C, D , E and G.
Hep
Hep
Hep
Hep
Hep
Hep
A – HBV
B – HCV
C – HCV
D- HDV
E – HEV
G- HGV
Most contagious form, fecal-oral route
blood and blood products
blood and blood products, sexual transmission
only present with Hep B most common in IVDU/hemophiliacs
non A non B fecal-oral route
transfusions and organ transplants
Hepatitis is an acute inflammation of the liver. Acute viral Hepatitis (A,B,C,D,E,G)
is the most common cause of hepatitis. . Hepatitis can also be caused by
drugs (`including alcohol) chemicals and autoimmune liver disease . It is a
significant cause of morbidity and mortality in world wide.
The changes in the liver tissue results in varying degrees of swelling, infiltration
of the liver cells by mononuclear cells with subsequent degeneration,
necrosis and fibrosis of the liver. Hepatitis can be self limiting and complete
regeneration of liver cells can occur but it is unknown which case of
Hepatitis will do so.
Hepatitis - acuity levels
Fulminate Hepatitis: severe, acute disease
with massive destruction of the liver which
results in rapid liver failure followed by
death 1-2 weeks after infection, usually
caused by Hep B accompanied by Hep D.
Most common cause is toxic reactions to
drugs.
Sub acute or chronic hepatitis: progressive
destruction of liver cells, can be present for
years as an asymptomatic infection but will
eventually result in cirrhosis and liver
failure. Liver tumors after ~ 20 years.
Hepatitis - Jaundice and Ascites
Hepatitis
Most hepatitis B infections are acquired in childhood either
from the mother (Perinatal) or as an adolescent (sexual
transmission and IV drug use),
Route of transmission from mom-fetus - if the mother is a
carrier or has an active infections, the virus will cross the
placental barrier late in pregnancy or during labor, when
the child ingests amniotic fluid or via breast milk. Most
women who pass Hep B to their fetus are unaware of
their status.
The infection can lie dormant for 2-3 decades and in their
30’s or 40’s the hepatitis can become active and can lead
to cirrhosis, liver failure, and liver cancer.
Hepatitis B is the number one cause of liver failure in the
world, number one reason for liver transplants in the US,
and number one cause of liver tumors in young adults.
Clincal Manifestations of Hep B
Insidious onset
Jaundice
Anorexia
Malaise
Nausea
Abnormalities in LFT’s
(SGOT/SGPT/Bilirubin)
 Prodromal sx’s: rash, arthritis, “aches &
pains”
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Treatment
Treatment for Hep B: No specific treatment, supportive
 Rest
 Hydration
 Nutritional support (high calorie, high protein, high carbohydrate,
low fat diet )
 Vitamin supplementation
 No Alcohol or drugs metabolized by the liver
Hospitalization when sx are severe or clotting factors are altered
More importantly treatment involves early detection, monitoring,
recognition of chronic liver disease and the prevention of spread.
Treatment with Monolclonal antibodies ,a-interferon, antiviral agents:
Ribavirin have shown some success.
Hepatitis B Vaccine
Ages: birth- 2months, 2 - 4months, 6 – 18 months
Route:
IM
Dose:
0.5ml
Total doses - 3
Common side effects: Pain/redness at injection site,
headache, photophobia, altered LFT’s
Serious side effects: Anaphylaxis, glean – Barrie type
illness with progressive muscle weakness.
Nursing considerations: all pregnant women should be
screened before birth (or immediately following
birth), if mom is HbsAG+, vaccine must be given to
infant within 12 hours, followed by HBIG to prevent
transmissions to infant.
Prevents liver cancer caused by Hep B.
Varicella (chicken pox)
Cause by varicella- zoster virus, a herpes
virus-6. Occurs in late fall, winter and
spring. Maternal antibodies disappear 2-3
months after birth.
The onset of symptoms is acute, mild fever,
malaise, and irritability occur before rash.
Rash begins as a maculae on a
erythematosus base and progresses to a
papule, then a clear filled vesicle. Lesions of
all stages can be present at one time.
Treatment of Varicella
None, care is supportive. Oral and IV acyclovir (retroviral) is
used for immunocompromised children ONLY.
Most children with varicella recover fully with only supportive
care (prevention of dehydration, reduction of fever,
prevention of secondary bacterial skin infections).
In an immunosuppressed child, prompt recognition and
aggressive treatment with VZIG must begin immediately to
prevent varicella pneumonia.
Children infected prenatal or postnatal have a very poor
prognosis
Varicella lesions
Varicella lesions
Varicella
Mode of transmission: Direct contact with lesions,
airborne spread of secretions
Incubation: 14-21 days
Period of communicability: up to 5 days before the
onset of rash and until ALL lesions are crusted over.
The incubation period may be extended in
immunocompromised children.
Complications of Varicella: In the healthy immune
competent child complications are rare but can
include: secondary bacterial infections, hepatitis,
pneumonia thrombocytopenia, Glomerulonephritis,
Reye syndrome, encephalitis
In the immunosuppressed child the results can be
catastrophic
Varivax – Varicella vaccine
Age:
12-18 months
Route:
SQ
Dose:
0.5ml
Total doses - 2
Storage and handling: Must be kept frozen
and used within 30 minutes, cannot be refrozen
Common side effects: pain/redness at
injection site, fever up to 38.8 (102),
generalized rash, sub acute varicella
infection.
Serious side effects: anaphylaxis
Nursing considerations - Varicella
 Any child with a rash as described above should be
put in isolation IMMEDIETLRY
 If a case of varicella is diagnosed, ALL contacts at
school, work, daycare, clinic, playgroup must be
notified and assessed for infection.
 Prior to immunization a carefully assessment of
medical history must be obtained with emphasis on
possible immunosuppression
 Urine HcG of all women that can potentially be
pregnant prior to immunization.
 Assess for allergy to neomycin or gelatin
Pneumococcal Disease
Caused by streptococcus pneumoniae, a gram + bacteria.
The organism is found in the pharynx of healthy people.
Outbreaks occur in the winter and spring under crowded
conditions
Most common in the 6 month- 2 year age group.
S & S of disease are related to the focal area of infection.
Can cause: OM, sinusitis, URI, pneumonia, meningitis,
Laryngotracheobronchitis and bacteremia.
Pneumococcal disease
In OM and URI:
In bacteremia:
fever, pain, decreased appetite
unexplained fever (FUO) with no
source of infection
In pneumonia:
fever, chills, chest pain,
dyspnea, productive cough.
In meningitis:
inconsolable crying, irritability,
lethargy, refusal to eat,
vomiting, diarrhea,
myalgia, photophobia and
seizures
With rapid diagnosis and treatment, prognosis and recovery
is good, but highly dependant on the condition the
organism causes and the resistance of the organism to
antibiotics
Treatment of invasive pneumococcal
disease
PCN for PCN sensitive strains BUT up to
48% of infections are PCN resistant.
Macrolide antibiotics (erythromycin,
azithromycin and clairthromycin) are
used in some PCN resistant cases,
some are also treated with third
generation cephalosporin's
(Cefotaxime or Ceftriaxone)
Pneumococcal disease
Mode of transmission: Respiratory
secretions and droplets, URI’s help the
spread.
Incubation: 1-3 days
Period of communicability: unknown,
probably less than 24 hours after abx’s
are started.
Pneumococcal Vaccine
PCV-7, Prevnar
Age:
2, 4, 6, 12-15 months
Route:
IM
Dose:
0.5ml
Common side effects: soreness, redness,
swelling at injection site. Mild-moderate
fever, irritability, restless sleep, decreased
appetite.
Serious side effects: anaphylaxis
Contraindications: Hypersensitivity to
diphtheria toxoid