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The 5 th Annual Metropolitan New York/New Jersey Pediatric Board Review Course

The 5 th Annual Metropolitan New York/New Jersey Pediatric Board Review Course. General Pediatrics Andrew D. Racine, M.D., Ph.D. May 16, 2010. Outline. Update on immunizations Breastfeeding Nutrition Injury Prevention Development Anticipatory Guidance. Update on Immunizations.

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The 5 th Annual Metropolitan New York/New Jersey Pediatric Board Review Course

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  1. The 5th Annual Metropolitan New York/New Jersey Pediatric Board Review Course General Pediatrics Andrew D. Racine, M.D., Ph.D. May 16, 2010

  2. Outline • Update on immunizations • Breastfeeding • Nutrition • Injury Prevention • Development • Anticipatory Guidance

  3. Update on Immunizations

  4. Case #1 Question 1 A 12 year old girl presents to your office for a regular checkup for school entry. She is a recent immigrant from Mexico. Her mother states that she does not have an immunization record. She denies any significant past medical history. There is no history of allergies. Physical exam reveals no abnormalities. Which immunizations would you give at this time?

  5. A. Td, IPV, MMR, Varicella, Hep B, MCV4 B. Td, IPV, MMR, Varicella, Hep B, MPSV4, Influenza C. Td, IPV, MMR, Varicella, Hep B, Hep A, HPV D. Tdap, IPV, MMR, Varicella, Hep B, MPSV4 E. Tdap, IPV, MMR, Varicella, Hep B, MCV4, Hep A, HPV, Influenza

  6. MMWR January 8, 2010/ Vol. 58/ No. 51 and 52

  7. MMWR January 8, 2010/ Vol. 58/ No. 51 and 52

  8. Based on the catch up schedule and the requirements for a patient this age the patient should receive: A. Td, IPV, MMR, Varicella, Hep B, MCV4 B. Td, IPV, MMR, Varicella, Hep B, MPSV4, Influenza C. Td, IPV, MMR, Varicella, Hep B, Hep A, HPV D. Tdap, IPV, MMR, Varicella, Hep B, MPSV4 E. Tdap, IPV, MMR, Varicella, Hep B, MCV4, HEP A, HPV, Influenza

  9. Pertussis Pertussis remains endemic despite universal immunization with DTaP. Since the introduction of Tdap in 2005, however, the epidemiology of this disease has changed.

  10. Pertussis Since 2005 when Tdap was introduced the incidence of pertussis has declined significantly. In 2007 10,454 cases of pertussis were reported in the U.S., down from 25,827 cases in 2004.

  11. Pertussis There used to be 2 peaks of incidence. One in children under the age of 6 months who were not vaccinated or incompletely vaccinated and the other in adolescents whose immunity had waned. 2004 2007

  12. Pertussis Vaccine (Tdap) Two tetanus toxoid, reduced diphtheria toxoid and acellularpertussis vaccines were approved by the FDA in 2005 and are now recommended for: Adolescents aged 11-12 years who completed their primary series of DTP/DTaP and have not received a Td booster dose Adolescents 13-18 years who missed the 11-12 year Td/Tdap booster and completed their primary series Adolescents who have not received DTP/DTaP/Td/Tdap vaccination (or have no documentation) For wound management in adolescents who have not received Tdap before

  13. Licensed Tdap Vaccines • BOOSTRIXGlaxoSmithklineBiologicals 10-64 years of age, same t, d, p antigens as INFANRIX but in smaller concentrations • ADACELsanofipasteur 11-64 years of age, same t, d, p antigens as DAPTACEL but in smaller concentrations

  14. Side Effects of Tdap Vaccination Local Reactions • Pain • Erythema • Swelling Systemic Reactions • Headache • Fatigue • Fever • GI events Immediate Reactions including dizziness, syncope and vasovagal reactions were reported with ADACEL

  15. Case #1 Question 2 Before you give the Tdap vaccine to the patient you ask your attending what is a true contraindication for the vaccine. Your attending responds that:

  16. A. Temperature greater than 105 F within 48 hours of a previous DTP/DTaP B. Collapse or shock like state within 48 hours of a previous DTP/DTaP C. History of encephalopathy within 7 days of previous DTP/DTaP D. Latex Allergy E. Pregnancy

  17. Contraindications of Tdap • Anaphylaxis to any components of the vaccine • History of encephalopathy (coma or prolonged seizure) within 7 days of administration of a pertussis vaccine that cannot be attributed to a different cause

  18. Precautions of Tdap • History of an Arthus-type reaction following a previous dose of tetanus- or diphtheria-containing vaccine • Progressive neurological disorder, uncontrolled epilepsy, or progressive encephalopathy • History of Guillain-Barre syndrome (GBS) within 6 weeks after a previous dose of tetanus toxoid-containing vaccine • Moderate or severe acute illness

  19. Not Contraindications • Temperature > 105F within 48 hrs of DTP/DTaP • Collapse or shock-like state within 48 hrs of DTP/DTaP • Persistent crying for 3 hrs or longer within 48 hrs of DTP/DTaP • Convulsions with or without fever within 3 days of DTP/DTaP • History of entire or extensive limb swelling after DTP/DTaP/Td • Stable neurological disorder

  20. Not Contraindications • Brachial neuritis • Latex allergy other than anaphylaxis-BOOSTRIX single dose and ADACEL are latex free • Pregnancy and breastfeeding • Immunosuppression • Intercurrent minor illness • Antibiotic use

  21. The only true contraindication of the alternatives listed would be: Temperature greater than 105 F within 48 hours of a previous DTP/DTaP B. Collapse or shock like state within 48 hours of a previous DTP/DTaP C.History of encephalopathy within 7 days of previous DTP/DTaP D. Latex Allergy E. Pregnancy

  22. Case #1 Question 3 Your attending asks you what are the advantages of the new meningococcal conjugate vaccine vs. the old polysaccharide vaccine. You answer that all of the following are true except:

  23. A. The conjugate vaccine produces an antibody response which lasts longer B. The conjugate vaccine stimulates a booster response C. The conjugate vaccine promotes herd immunity D. The conjugate vaccine has less side effects E. The conjugate vaccine reduces nasopharyngeal carriage

  24. Epidemiology of Meningococcemia • Children < 1 year of age • Adolescents 15-18 years of age • College freshmen living in dormitories • C5-C9 or C3 deficiency • Functional asplenia

  25. Meningococcal Disease American Academy Of Pediatrics. Committee on Infectious Diseases. Prevention and Control of Meningococcal Disease: Recommendations for Use of Meningococcal Vaccines in Pediatric Patients. Pediatrics. 2005:116(2):496-505.

  26. Licensed Meningococcal Vaccines MENOIMUNE Meningococcal polysaccharide vaccine MPSV4 Purified capsular polysaccharides A/C/Y/W-135 Licensed in 1981 MENACTRA Meningococcal conjugate vaccine MCV4 Purified capsular polysaccharides A/C/Y/W-135 conjugated to diphtheria toxoid. Licensed in 2005

  27. Meningococcal Vaccine (MCV4) Introduced into the schedule in 2005, the meningococcal conjugate vaccine is recommended in: • Adolescents 11-12 years • Unvaccinated adolescents at school entry • College freshmen living in dormitories • Certain high risk groups

  28. MPSV4 vs. MCV4 MPSV4 antigens induce a T cell independent antibody response. As a result there is • A short lived response • No anamnestic or booster response with subsequent challenge • No reduction in nasopharyngeal carriage MCV4 antigens are conjugated to diphtheria toxoid so they induce a T cell dependent response resulting in • A long lasting memory • Booster response and • Eradication of nasopharyngeal carriage which contributes to herd immunity.

  29. MCV4 Side effects include: Erythema, swelling and induration Guillain-Barre – 17 reported cases from March 2005 – September 2006. GBS incidence estimated at 0.20 per 100,000 person months after vaccine compared to 0.11 per 100,000 person months among 11-19 year olds generally.

  30. Advantages of MCV include all of the following except: A. The conjugate vaccine produces an antibody response which lasts longer B. The conjugate vaccine stimulates a booster response C. The conjugate vaccine promotes herd immunity D. The conjugate vaccine has less side effects E. The conjugate vaccine reduces nasopharyngeal carriage

  31. Case #1 Question 4 You explain to your attending your intention to administer the Gardasil® vaccine and he responds, “Are you nuts? That vaccine costs a gazillion dollars!! What are you a Merck shareholder or something?” You calmly reply that:

  32. The vaccine only costs $50 per dose The treatment of genital warts and cervical cancer costs more than $8 billion a year in the U.S. Depending upon how long you assume immunity lasts and what percent of girls get the vaccine, immunizing all 12 year old girls will cost only $3,000 to $25,000 per QALY. Vaccinating will save the future costs of having to screen for cervical cancer in these patients

  33. Human Papillomavirus • The most common sexually transmitted infection in the United States (6.2 million new cases annually). • HPVs are non-enveloped double stranded DNA viruses of over 100 types including several (16,18,31,33,35, and others) detected in 99% of cervical cancer cases. • Risk of HPV associated with number of sexual partners, partner sexual behavior, and immune status.

  34. Human Papillomavirus • Most infections are transient, asymptomatic and clear within 1-2 years • Of the 6.2 million new cases per year, about 74% occur in women 15-24 • Acquisition occurs soon after sexual debut • Prevalence of HPV 16 may be as high as 40% • Consistent condom use may help prevent acquisition

  35. Human Papillomavirus Vaccine Licensed in June 2006, the ACIP recommends routine immunization of females from 9 years of age up to 26 years of age with a three-dose series where the second and third doses are administered at 2 months and 6 months after the first dose.

  36. HPV Vaccine • Quadravalent HPV vaccine (Gardasil®) targets HPV types 6, 11, 16 and 18 • HPV types 16 and 18 cause approximately 70% of cervical cancers and types 6 and 11 cause approximately 90% of genital warts • Administered in 3 doses with second and third doses given 2 and 6 months after the first dose • Combined protocols indicate an efficacy of 98-100% in the prevention of CIN 2/3, AIS or genital warts caused by HPV 6, 11, 16 and 18.

  37. HPV Costs and Benefits • Management of warts and cervical cancer costs about $4 billion per year in the U.S. • Vaccine for Children’s program (VFC) will cover costs of Gardasil for eligible patients • Several cost/benefit analyses estimate the cost of a QALY to be between $3,000 and $25,000 depending upon underlying assumptions • Factors to consider: duration of vaccine protection, duration of natural immunity, frequency of cancer screening, vaccine coverage

  38. The vaccine only costs $50 per dose The treatment of genital warts and cervical cancer costs more than $8 billion a year in the U.S. Depending upon how long you assume immunity lasts and what percent of girls get the vaccine, immunizing all 12 year old girls will cost only $3,000 to $25,000 per QALY. Vaccinating will save the future costs of having to screen for cervical cancer in these patients

  39. HPV Vaccine • October 2009 a new bivalent human papillomavirus vaccine was approved by the ACIP following the same 3 dose schedule as the quadrivalent vaccine. • In addition “permissive use” of HPV-4 was granted for VFC eligible males aged 9-18.

  40. Case #1 Question 5 You ask your 12 year old patient to return in 4 weeks to continue the catch up schedule of vaccination you started. At that visit you will administer:

  41. A. Td,IPV,MMR,Hep B B. Td,IPV,MMR,Varicella,Hep B C. Tdap,IPV,MMR,Hep B,MCV4 D. Tdap,IPV,MMR,Varicella,Hep B E. Tdap,IPV,MMR,Varicella,Hep B,MCV4

  42. MMWR January 8, 2010/ Vol. 58/ No. 51 and 52

  43. Catch-up Schedule • Tdap is licensed for only one dose. According to the AAP, the patient in this case should receive 3 tetanus/diphtheria toxoid vaccines and only one of them should also contain pertussis, preferably the first dose. • Varicella- Two doses are now recommended. A 2nd dose is given in 4 weeks for those over 13 and in 3 months for those less than 13. • MCV4 only one dose is required.

  44. Return Visit should include: A. Td,IPV,MMR,Hep B B. Td,IPV,MMR,Varicella,Hep B C. Tdap,IPV,MMR,Hep B,MCV4 D. Tdap,IPV,MMR,Varicella,Hep B E. Tdap,IPV,MMR,Varicella,Hep B,MCV4

  45. Rotavirus The leading cause of severe gastroenteritis worldwide – more than 500,000 deaths/year. In the US – a major disease burden with 3.2 million episodes of diarrhea, 60,000 hospitalizations and 20-60 deaths annually. Additional problems include • Patients shed virus before sxs develop and up to 21 days after onset of the disease • Insufficient immunity after one infection • Major cause of day-care center acquired gastroenteritis

  46. Rotavirus vaccines All rotavirus vaccines are oral, live attenuated, containing glycoprotein (VP7) and protease-cleaved proteins (VP4) of Group A rotavirus, the most prevalent type found in humans. ROTASHIELD –licensed in 1998, tetravalent rhesus-human reassortment, withdrawn from the market due to cases of intussusception. ROTATEQ–FDA approved in 2006, pentavalent bovine-human reassortment, no intussusception reported in large trial of 70,000 doses (3 dose regimen). ROTARIX – Live attenuated human monovalent vaccine approved for use in April, 2008 (2 dose regimen).

  47. Rotavirus Vaccine

  48. Rotarix Vaccine March 2010 – FDA recommends suspending use of Rotarix due to discovery of an extraneous porcine circavirus in the vaccine. The virus is not known to cause harm to human beings but the current recommendations are to suspend use of it in favor of Rotateq.

  49. Case #2 In December of last year a mother comes into your office with her 4 month old infant daughter who is due for her health care maintenance visit. She brings along her 3 year old son as well. He has not yet received his flu vaccine for this year but did receive it last year. You advise this mother that:

  50. Influenza Vaccine • Both children should receive seasonal flu vaccines and H1N1 vaccines; • Neither child should receive seasonal flu nor H1N1 vaccines; • The three year old should receive both seasonal flu vaccine and H1N1 vaccine but the four month old should receive neither vaccine; • The 4 month old infant should receive seasonal flu vaccine but not the H1N1 vaccine; • The three year old does not need H1N1 vaccine if he is given the seasonal flu vaccine because of cross-reactivity.

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