I’m not going to talk much about whole cell DTP vaccine because it’s the old vaccine. Now what’s recommended and is preferred is to use the acellular vaccine because there are less reactions to it. The whole cell vaccine contains endotoxin and does have more reaction. Given in the same series as the acellular vaccine, has the same contraindications and precautions and similar efficacy. But it does have a lot of reactions, as shown in this table. This is a study by Cody and colleagues showing really the high rates of reaction to whole cell DTP vaccine; up to 50% local reactions, half the patients with fever and then systemic reactions, such as drowsiness, irritability, persistent crying. Again, a lot of these reactions due to endotoxin. Give the acellular pertussis component vaccine, you get less reaction and that’s why it’s preferred. But because it’s so reactagenic, in the past it’s been blamed for a lot of other things. Just to clear up some misconceptions; pertussis-containing vaccines do not cause sudden infant death syndrome. Pertussis-containing vaccines do not cause brain damage. There is no causal link between any pertussis component vaccine and brain damage. In the past some practitioners have given half doses of DTP vaccine in an attempt to prevent reaction. Half doses have not been well studied. The immunogenicity and efficacy of that is not well known and therefore you should not give half doses of vaccine. Give the regular dose.
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Now polio vaccine; this is also one of these areas that is really in a state of flux, and a good portion of the polio discussion in the syllabus is about OPV, oral polio vaccine, live vaccine. And there are some changes in that regard that are coming up and therefore for Board review purposes, you have to realize it takes a while for these Board tests to catch up with what’s going on. So if you know the latest information, that’s fine. And if you know the old information, that’s fine too. You are not going to be dinked on that if it’s a transitional period and that’s where we are right now, in a transitional period. What you need to know is that the oral, live vaccine is a very good vaccine but it has a rare side effect. And that’s that the oral vaccine may mutate into a virulent form and cause vaccine-associated paralytic polio. This occurs rarely so the benefits of this vaccine outweigh the risks. However, in this day and age when we’ve done such an excellent job in eliminating polio from this country, the risks of vaccine are no longer acceptable. That’s why now we don’t recommend the oral vaccine and as of January 1st 2000, recommend that all four doses of polio vaccinations should be with the killed vaccine, the inactivated polio vaccine administered subcutaneously. The killed vaccine has no risk of reversion to the wild type, virulent strain. No risk of causing paralytic polio. The current schedule, however, – and in the syllabus and on this slide – until Y2K, is to give the first doses of IPV at two months and at four months of age. The second doses, personal choice; either OPV or IPV and I’m not going to go into the logistics of 6-18 months, 12-18 months and 4-6 years. Really what’s going to happen after January 1st is you should just give two months, four months, 6-18 months is the third dose of IPV and 4-6 years for the fourth dose of IPV. And then somebody will be up to date. Until then, the second two doses may be oral polio vaccine.
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Precautions and contraindications are specific really for the oral polio component, which again is sort of out of date. But IPV should be used only for immunocompromised subjects or household contacts. The oral vaccine may multiply and can be transmitted person to person, and so should not be given if there is anybody immunocompromised, such as with HIV infection, in the household. In pregnancy there is a theoretical risk and so one should avoid vaccination if possible.
B12 deficiency; extremely unusual unless you have someone who has a congenital defect in absorption of B12. There’s a syndrome called Imerslund syndrome which is a congenital failure to be able to absorb vitamin B12 in the terminal ileum because they lack the binding sites in the terminal ileum for the B12. They typically present at about one year of age with these characteristics, as well as they get posterior column diseases and mental changes because of the B12 deficiency. When else can you see it? If an infant has the ileum resected and the physician is not aware of it, or it has not been tested for, they can become B12 deficient. Remember, you are born with B12 stores for up to a year at birth. Obviously after later on in childhood if the ileum is resected, most people have 3-5 years worth of stores of vitamin B12 present in the body.
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Ascorbic acid deficiency, or scurvy. Again, these are the characteristics of it; poor wound healing, which is very similar to what you see in essential fatty acid deficiency. Be aware that bleeding problems, which also can be seen in essential fatty acid deficiency, are characteristic of it. Easy fracture of bones. Bleeding gingiva with loose teeth perhaps in the older child. So many of these conditions have overlaps between them and sometimes you are asked to show the similarities or the differences between them.
Niacin deficiency is probably the easiest; dermatitis, diarrhea and dementia. And the dermatitis is typically in areas where there has been exposure to the sun. So I used to have a picture of a child with pellagra and it’s disappeared, but it basically showed a youngster who had what looked like a necklace in the neck area and also on the wrist. This patient had sort of a reddish-magenta kind of eruption and that was due to niacin deficiency.
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Folate deficiency. These patients get a macrocytic anemia. They are very much like patients with B12 deficiency. So they get big red blood cells, but different than patients with B12 deficiency syndrome, they get leukopenic, poor growth and gliacitis. Again, they have overlap with patients who have vitamin B and B2 deficiency, and also pyridoxine deficiency. Diarrhea is another characteristic of folate deficiency. The folate is very important for the integrity of the intestinal mucosa. If you get folate deficient, patients are very likely to have leakage from their mucosa and failure to regenerate normal epithelium. The only formula that is deficient in folate normally is goats milk, but if you feed … most of the preparations that are available for children who are fed goats milk are folate-supplemented because we recognize that deficiency.
Again, tetanus toxoid comes in a variety of vaccine formulations and to prevent tetanus we really must pay attention to wound care. Cleaning the wound, making sure you debride any devitalized tissue and taking out any foreign body.
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Finally, you put the D and T together with a pertussis component and you get DTaP vaccine, the acellular pertussis component, and that includes various components of Bordetella pertussis. Including possibly pertussis toxin, filamentous hemagglutinin, pertactin (pertucin?) fimbriae and a variety of combinations of these which we will get to. The main difference with DTaP vaccine and whole cell DTP vaccine is the decreased endotoxin content in the acellular formulation. This is given in a five day series, two for six months, 12-18 months and finally at 4-6 years of age. You do not give pertussis vaccines, at this point, at seven years of age and older. Only less than seven years of age. The efficacy of the DTaP vaccine is similar to DTP vaccine. About 80-95% and the reaction is lower rate to the common reactions compared to the DTP vaccine. Mostly because of the decreased endotoxin content. The DTaP vaccines are shown in this slide. These are all the FDA-approved vaccines. They are all different. They have different names, different manufacturers and different compositions; a variety of different antigens that are produced in different ways, they are in the vaccine in different quantities. For purposes of taking the test, these are all similar in terms of reactagenicity. There is no meaningful clinical differences between the reactagenicity and there are no meaningful differences between the efficacies of these vaccines and immunogenicities of these vaccines for test taking purposes. There is no difference in efficacy. So you really don’t have to spend too much time on the names and all that. But you do need to know that they are all different and they have different composition. The FDA has approved these for different doses. Really, from a practical standpoint, you can use any of these vaccines at any time. And these vaccines are interchangeable, although it is preferable for at least the first three doses to use the same vaccine, but not required.
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The relative contraindications to pertussis vaccine are shown in this slide and this is different from an absolute contraindication. Pertussis, as you know, can be a very severe disease. So depending on a risk of a subject to pertussis and the complications that they could get from the disease, you need to weigh the risks and benefits. But prior vaccine reaction is a relative contraindication. That’s encephalopathy within seven days, a seizure within three days, persistent crying for three or more hours, collapse state or hypotonic hypo-responsive episode, fever greater than or equal to 40.5 C or an anaphylactic reaction. These are relative contraindications to further vaccination with any pertussis component vaccine. Anybody with a known or suspected progressive neurologic disorder or recent seizures. If you give the vaccine it may result in fever. Fever lowers the seizure threshold, this may induce the seizure and it may confuse the clinical picture. So anybody with those conditions or a known or suspected neurologic condition that predisposes to seizures or neurologic deterioration – the common example of that is tuberous sclerosis, where somebody may have tuberous sclerosis and may not show any signs or symptoms but you know that they are at risk for developing them – giving the vaccine may result in lowering the seizure threshold and then you are not sure. Was it the vaccine? Was it the disease? So you need to think about that.
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