Croup and Bronchiolitis

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Transcript Croup and Bronchiolitis

Immunizations 3
Karen D. Sawitz, MD
St. Barnabas Hospital
Department of Pediatrics
Rotavirus Vaccines
Influenza Vaccines
Meningococcal Disease Vaccines
Human Papillomavirus Vaccines
RSV Prophylaxis (Palivizumab)
Catch-Up Schedules
Rotavirus: about the disease
• Causes severe diarrhea, often with vomiting and
• Mostly affects babies and young children
• Almost all US kids infected by 5 years
• 1 in 50 get severe dehydration
• 1 in 150 were hospitalized and 1 in 11 visited ER
or doctor’s office
• Easily spread, remains on surfaces
• Vaccine reduced ER/hospital stays by 85%
Rotavirus: vaccine history
• RotaShield: tetravalent reassortant
rhesus-human vaccine licensed August
1998 and withdrawn October 1999
• Risk of intussusception found to be
increased by 1-2 additional cases per
10,000 infants vaccinated.
Rotavirus: current vaccines
• Two currently available oral vaccines
• RotaTeq (Merck) licensed 2006
– pentavalent vaccine (RV5)
– 3 doses at 2, 4, and 6 months
• Rotarix (GSK) licensed 2008
– monovalent vaccine (RV1)
– 2 doses at 2 and 4 months
• If any RotaTeq need 3 doses
Rotavirus: about the vaccine
• First dose may be given as early as 6
weeks and must be by 14 weeks 6 days
• Last dose must be given by 8 months
• Porcine circovirus components found in
both vaccines are safe
Rotavirus vaccine
• Contraindications
– Previous anaphylaxis to this vaccine or a component
(if latex allergic use RV5)
– History of intussusception
– Diagnosis of SCID
• Precautions
– Moderate or severe acute illness
– Altered immunocompetence (other than SCID)
– Chronic GI disease
– Spina bifida or bladder extrophy
Influenza: about the disease
• Spread by coughing, sneezing or nasal secretions
• Causes fever/chills, myalgias, cough, fatigue, headache,
sore throat and can lead to pneumonia and make
existing conditions worse
• More severe in young children, elderly, pregnant women,
heart/lung disease, immune compromise
• Highest infection rates in children, more morbidity in
• 36,000 deaths and 148,000 hospitalizations yearly
• Types A, B, and C
• Influenza A subtypes (16 HA and 7 NA) shift & drift
Influenza and Children
• Children commonly need medical care because of influenza,
especially before they turn 5 years old.
• Each year an average of 20,000 children under the age of 5 are
hospitalized because of influenza complications.
• Flu seasons vary in severity, however some children will die from flu
each year. From 2003-2004 to 2010-2011, pediatric deaths reported
to CDC ranged from 46 to 153 per year. During the 2009 H1N1
pandemic, 345 deaths in children were reported to CDC from April
26, 2009 to May 22, 2010.
• Severe influenza complications are most common in children
younger than 2 years old.
• Children with chronic health problems like asthma and diabetes are
at especially high risk of developing serious flu complications.
Influenza: about the vaccines
• In use since1945
• Contain 3 virus strains expected in coming season;
updated each year
• Since 2001 trivalent inactivated virus (TIV) vaccines
available in split virus form only, for IM injection
– Dosing 0.5 cc for 3 and up, 0.25 cc for 6 mos-under 3
• Intranasal live attenuated temperature-sensitive virus
vaccine (LAIV) licensed in 2003 for age 5 and up; then
lowered to age 2 and up. Not indicated in 2-4 year olds
who wheeze or those with chronic illness.
– Volume lowered from 2 cc to 1 cc, no longer frozen
Influenza: about the vaccine
• As of 2010 everyone 6 months and up is
recommended to get flu vaccine
• Should be given as early as possible, usually
available by late September
• Children 9 and up require one dose annually
• This season, children <9 years who have not
have had 2 doses of seasonal flu vaccine since
July 1, 2010 should get 2 doses, 4 weeks apart
Influenza: 2012-2013 vaccines
• In February WHO recommended that the Northern
Hemisphere's 2012-2013 seasonal influenza vaccine
contain the following three vaccine viruses:
• an A/California/7/2009 (H1N1)-like virus
• an A/Victoria/361/2011 (H3N2)-like virus
• a B/Wisconsin/1/2010-like virus
• While the H1N1 virus is the same, the H3N2 and B
vaccine viruses are different from those that were
selected for the Northern Hemisphere for the 2011-2012
influenza vaccine.
• These strains approved by FDA in August for US
manufacture by 6 companies
Influenza vaccines
• Contraindications
– Previous anaphylaxis to the vaccine or component
– For LAIV: age under 2, pregnancy, chronic disease
including asthma, immunosuppression, long-term aspirin
therapy in children under 18y, wheezing in past 12 months
in children 2-4y
• Precautions
– Moderate or severe acute illness
– GBS within 6 weeks after previous flu vaccine
– Increased risk of febrile seizure with TIV with concurrent
PCV13 esp 12-23 mos (deferral NOT recommended)
– For LAIV: receipt of anti-flu antivirals 48h before
vaccination (avoid for 14d after vaccination)
Meningococcal Disease
• A serious bacterial illness causing meningitis
and blood infections
• 1,000-1,200 cases annually in US
• 10-15% mortality
• 11-19% survive with limb and/or hearing loss,
seizures, strokes, neurological damage or
mental retardation
• Peaks in infancy, age 16-21. Immune
compromise and communal living such as
military recruits and college freshmen in dorms
have increased risk.
Meningococcal vaccines
• Polysaccharide vaccine (MPSV4/Menomune)
licensed in 1970s
• Conjugate vaccine (MCV4) first released in 2005
now preferred for longer immunity.
– Menactra (Sanofi) licensed for 9m – 55y
– Menveo (Novartis) licensed for 2y-55y
• Both protect against serotypes A,C,Y and W-135
which account for 2/3 of cases in US. Serotype
B is not covered.
MCV Recommendations
• Routinely given at 11-12 year visit (2005).
• Booster now recommended (2010) at age
16 for this group, at age 16-18 if got first
dose at 13-15. No booster if first dose at
• For others at increased risk: travelers to
meningitis belt in Africa and other areas,
functional asplenics, complement
deficiency, exposed during outbreak.
MCV4 in Young Children
• Give Menactra to 9-23 month olds with
persistent complement deficiency, travel to
endemic areas, or present during covered
outbreak; 2 doses 3 months apart
• Give Menactra or Menveo to 24 month
olds and up with complement deficiency or
anatomic or functional asplenia; 2 doses 3
months apart.
• Separate Menactra from final PCV13 by 4
Meningococcal vaccines
• Contraindication
– Previous anaphylaxis to this vaccine or any of
its components
• Precaution
– Moderate or severe acute illness
• Use MPSV4 only if there if permanent
contraindication or precaution to MCV4
MCV4 and Guillain-Barre
• Shortly after introduction in 2005 there were concerns
over a small number of cases of GBS in adolescents
who had received Menactra in the previous 6 weeks.
• The vaccine was kept on the market but wording was
included in the VIS advising caution in anyone with a
history of GBS
• ACIP voted to remove the wording in 2010 after 2 large
studies showed that none of the 2.4 million adolescents
vaccinated with MCV4 developed GBS within 6 weeks of
receiving the vaccine.
Human Papillomavirus Infection
• Includes about 40 primarily sexually transmitted viruses
• Genital HPV affects
– 25% of females 15-19 years of age
– 45% of females 20-24 years of age
– 70-80% of women and men over age 50
• Most infections asymptomatic and cleared; some can
persist and cause warts or cancers
• Types 6 and 8 cause 90% of genital warts
• “High-risk” types such as 16 and 18 cause 70% of
cervical cancers in US. Also 85% of anal and 20% of oral
HPV: about the vaccines
• Two currently available injectable vaccines
• Gardasil (Merck) licensed 2006 for prevention of warts
and cervical cancer in females
– quadrivalent vaccine (types 6, 11, 16, 18)
– licensed for prevention of warts in males in 2009
– licensed for anal cancers in both sexes in 2010
• Cervarix (GSK) licensed 2009
– bivalent vaccine (types 16 and 18)
– For prevention of cervical cancer in females
• Males added to ACIP recommendations in 2011
HPV Vaccine Dosing and Considerations
• 3-dose series given IM at 0, 2, and 6
• Recommended routinely to males and
females at 11-12 year visit
• May be given to anyone 9-26 years of age
• No serious adverse reactions other than
increased risk of fainting; patients should
remain seated for few minutes
HPV Vaccines
• Contraindications
– Previous anaphylaxis to this vaccine or any of
its components
• Precautions
– Moderate or severe acute illness
– Pregnancy
• Most common lower respiratory tract infection in infants
• Most common etiology is RSV, most cases between December and
March (75% of cases under 2)
• More common in crowded living conditions and smoke exposure
• Breastfeeding appears to confer a protective advantage
• Most severe symptoms in those under 2
• >50% affected by age 1, 80-90% by age 2, 40% have LRTI
• No permanent RSV immunity, reinfections common
• 1-2% require hospitalization
• 90,000 hospitalizations annually (80% under 1 year)
• Deaths 4500 (1985)  510 (1997)  390 (1999)
• Cost of hospitalization infants under 1 year: $700 mil/yr
• More likely to have respiratory problems when older
RSV Disease
• Rhinitis, tachypnea, wheezing, cough,
• Accessory muscle use and nasal flaring
• Apnea, grunting, cyanosis
• Poor feeding, difficulty sleeping, fussiness
• Tachycardia and dehydration may occur
• Natural course 7-10 days, peak on day 4
Bronchiolitis – Risk Factors for
Severe Disease
• Age under 6-12 weeks
• History of prematurity esp < 28 weeks GA
• Underlying cardiopulmonary disease
– Chronic lung disease (BPD, CF)
– Complex congenital heart disease
– Congenital airway abnormalities
• Immunodeficiency
• Severe neuromuscular disease
RSV Bronchiolitis - Prevention
• Palivizumab (Synagis®) prophylaxis for
selected infants under 24 months
– 15 mg/kg IM monthly November-March
• Hand washing
• Avoiding passive smoke exposure
• Promotion of breastfeeding
Synagis (palivizumab)
• Humanized monoclonal RSV antibody licensed 1998 (MedImmune)
• Given IM (vs over 4-6 hours IV for RSV-IG) so doesn’t require
hospital setting
• 50-100 times more potent than polyclonal RSV IG so the volume is
smaller (15 mg/kg).
• Does not interfere with MMR or varicella vaccines which had to be
deferred for 9 months after RSV-IG.
• Hospitalizations down 55% overall (39-82%), 78% in premies
without CLD, 39% with CLD. Also reduced LOS, admissions to ICU,
days of supplemental O2, and days of moderate to severe illness.
But not mortality or recurrent wheezing.
• No overall savings in health care dollars due to high cost.
Criteria for Prophylaxis
• ≤ 28 weeks gestation and < 12 months of age at the start of RSV season
• 29-32 weeks gestation and < 6 months of age at the start of RSV season
• 32-35 weeks gestation and < 3 months of age at the start of RSV season, if
there is a risk factor (child care attendance or sibling younger than 5 years
Chronic lung disease of prematurity
• Chronic lung disease still requiring oxygen/medication, for the first and
second RSV seasons
• Chronic lung disease that required oxygen/medication within the 6 months
preceding RSV season, for the first RSV season
Congenital heart disease
• Cyanotic heart disease, for the first 24 months of life
• Moderate to severe pulmonary hypertension, for the first 24 months of life
• Congestive heart failure requiring medication, for the first 24 months of life
• Children who have undergone open heart surgery during RSV season, for
one additional dose after cardiopulmonary bypass (only if they still meet one
of the other criteria)
Source: AAP Red Book 2009
Source: AAP Red Book 2009
Catch-Up Schedules