Next we are going to talk about a special category of children and talk about immunization of immunocompromised children. In general, immunocompromising conditions are shown on this slide and those are subjects with malignancies, systemic steroids – 1 to 2 mg/kg per day of prednisone or equivalent, or a total of 20 mg per day – congenital immunodeficiencies, HIV infection or transplant recipients. That’s the population I’m talking about. With immunocompromised children, as a general rule, killed vaccines, inactivated vaccines, should be administered routinely and where you need to think about it is in regards to live vaccine. In general, we’ve talked about how they are generally contraindicated. Definitely should give IPV and not OPV for the subject and household contacts. The exception to live vaccines is MMR, and what’s not in your handout, varicella vaccine. Also varicella vaccine as well as MMR vaccine may be given to HIV infected children unless they are severely immunocompromised. If they are severely immunocompromised they should not receive MMR or varicella vaccine.
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Influenza vaccine may be indicated for immunocompromised children. Candidates for influenza vaccine include those with chronic diseases, immunocompromised individuals, and anyone at risk for Reye’s syndrome which may occur with influenza. And that would be, for example, subjects with JRA on long term aspirin therapy. And close contact of anybody with the above conditions and that’s because you can prevent them from coming in contact with influenza. Then age 6 months or older. Shouldn’t be used less than 6 months of age. The vaccine is inactivated, it’s trivalent, containing two strains of influenza A and one strain of influenza B. It changes yearly. You need to vaccinate yearly. The side effects of vaccination are mostly local reactions and the timing of vaccination should be in the fall of every year right before flu season starts. The schedule is here, included for completeness, but really I think if you know who should get influenza vaccine that’s the most important issue, not the exact schedule. You should know that it’s given greater than 6 months of age and that split virus only should be used less than 12 years of age, because that’s less reactagenic, less than 12 years of age. There is a whole virus and a split virus vaccine and both of those can be given after 12 years of age. There is no difference.
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Pneumococcal vaccine consists of 23 different serotypes of pneumococcus that are included in the vaccine. The usual side effects are local reactions and low-grade fever. This should be administered to children who are at least 2 years of age and older, who have conditions such as HIV infection, asplenia and nephrotic syndromes, CFS leaks, malignancy. These are all subjects who are at increased risk of pneumococcal, invasive pneumococcal disease. And also those with chronic diseases are at risk as well.
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Again, we talked about catch-up immunization of the 11-12 year old age group. When they come into the office, pay attention to see if they’ve gotten hepatitis B vaccine in the past and then they should get three doses if they haven’t. In California, this is the first year that requires hepatitis B vaccine for school entry for junior high school.
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Now we will move on and talk about common varicella vaccine. Varicella vaccine is a live virus vaccine, administered subcutaneously. It may result in some reactions. The most common reaction is a local reaction similar to other vaccines; pain, redness at the injection site, mild and goes away in a few days. But it also may result in very subclinical varicella. You can see a papulovesicular rash. This can be either localized to the injection site, or it can be generalized. In general, this is a very small number of lesions and this is what it looks like. This is localized to the injection site. You can just see this is at the injection site. This is ten days following immunization. A few papules. That one actually looks a little bit like a vesical to me, and that goes away in a few days. That’s the vaccine virus multiplying. The vaccine is immunogenic, greater than 95% immunogenicity and the efficacy – I split this up into two kinds of efficacy. One is absolute efficacy; 85% of subjects have prevention of varicella. The other 15% may have breakthrough disease but the breakthrough disease is also … there is some efficacy in breakthrough disease, in which case it’s milder than routine chicken pox which occurs in unvaccinated individuals. The rash is atypical. You get a reduction in skin lesions. Half the patients don’t even have vesicles and only a minority have fever. Recovery is more rapid in children who have chicken pox who have been previously vaccinated, compared to those who haven’t.
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Contraindications and precautions to varicella vaccine are shown on this slide. Live virus vaccine; again, immunocompromised host – you need to think about that – pregnancy, neomycin anaphylactic or gelatin allergy that is in the vaccine, presence of passive antibody will interfere with vaccine take, and aspirin should be avoided after vaccination because of a theoretical risk of Reye’s syndrome which may occur with aspirin and wild type chicken pox.
The recommendations are for routine vaccination at 12-18 months of age. Catch-up immunization for subjects who are out of that age range who are still susceptible to chicken pox; one dose can be given 1-12 years of age. Older than 12 years of age you need two doses to achieve the same immunogenicity. A lot of issues have come up regarding duration of immunity to varicella vaccine. How long will subjects remain immune after vaccination? That’s not known, but ten year follow-up in this country, twenty year follow-up in Japan, so this vaccine does have a long duration of immunity. Further studies are in progress to determine if booster doses are needed. But it’s very reassuring that there has been no severity in breakthrough varicella over time, which would indicate waning immunity.
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Next we’ll move on and talk about passive antibody and prevention of varicella. We’ll talk briefly about VZIG because really active vaccination with varicella is the way to go, but VZIG(Varicella Zoster Immune Globulin) may be administered as soon as possible, definitely within four days of exposure to varicella to subjects who meet three criteria. The three criteria are: susceptible to chicken pox, significant exposure, and high risk for complications. Susceptible to chicken pox means they have never had chicken pox in the past. Significant exposure, shown on this slide, household contact, face-to-face play, hospital roommate or newborn with maternal varicella five days prior to delivery, up to two days postpartum. Those subjects who are at increased risk for complications include those who are immunocompromised, a newborn with the above situation, and premature infants.
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