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With the different vaccines there are different schedules. In general, you give a primary series of either two or three doses of H. flu type B vaccine and then you give a booster dose at 12-15 months. Now the thing that makes this a little more complicated is that one of these vaccines, the Merck product, you only give two doses for the primary series and you don’t need to give the third dose at six months of age. So these vaccines are interchangeable, however if you do interchange these vaccines you should err on the side of getting more vaccine doses rather than less. For example, if you give the first dose of PedvaxHIB at two months of age and then you switch over to HibTITER for the second dose, then you need to also give the third dose of HibTITER and then another dose at 12-15 months of age. Otherwise these vaccines are interchangeable.
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In terms of catch-up immunization with HIB vaccines, it’s important to know that the older one is, the less doses one needs of HIB vaccine. So that after 15 months of age you only need to give one dose at time zero and you don’t need to give a whole primary series, just the one dose.
Then you need to be aware of combination vaccines. HIB may occur not just alone as a single antigen, but may occur in combination with whole cell DTP vaccine, and this may result in a decreased number of immunizations at 2,4,6 and 12-18 months of age. However, remember, DTP vaccine, whole cell DTP vaccine, is not routinely recommended anymore. What’s preferred is the acellular pertussis component vaccine.
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Well, let’s move on and talk about the DTaP-HIB combination vaccine. Great idea, and unfortunately this is only approved for use at the fourth dose of a vaccine series only; 12-18 months of age. Do not give this vaccine at 2, 4 and 6 months of age. Do not give the combination vaccine. That’s wrong, it’s contraindicated, it’s not approved for use. There is a decreased immune response to the vaccine components when it is given at 2, 4, 6 months of age. And then there is the HIB and hepatitis B vaccine combination, and this can be useful to decrease the number of injections at 2 months, 4 months and 12 months of age. But in terms of knowing all the different vaccines and combinations that exist, it’s important to know that you do have choices and it’s important to know when these choices may be possible and when they shouldn’t be given.

Now I am going to move on and talk about hepatitis B vaccine and the strategy behind recommending universal immunization against hepatitis B. The rationale behind that is that hepatitis B does occur in this country. What we are most familiar with, though, is acute hepatitis B infection. Symptomatic infection which may result in death due to fulminant hepatitis; about 400 per year as shown on this slide from the CDC. Now what may also occur is asymptomatic infection with hepatitis B and whether it’s asymptomatic or symptomatic, chronic carrier carriage may occur following infection with hepatitis B. And this is where the main problem exists in terms of public health importance. Is that chronic carriers can get chronic disease, either death due to cirrhosis or death due to liver cancer, and if you add these up you can see that the chronic disease, death due to chronic liver disease, due to chronic carriers is ten times more important as a public health issue compared to death from acute symptomatic hepatitis B. That’s why it’s important to prevent chronic carriage. Where that enters into pediatrics is shown on this graph by the CDC, which is the inverse correlation between age and risk of having chronic carriage; that is, the younger the age, those who acquire hepatitis B at birth have a 90% risk of becoming chronic carriers and those who get hepatitis B at a year of age, 50% risk, and older children and adults only 5-10% risk of becoming a chronic carrier. Viagra Jelly online without prescription. So really, preventing hepatitis B at the youngest age can really have a major impact on preventing chronic carriage of hepatitis B and that’s where the main number of deaths occur. A lot of times it is said that, “Well, the kids that I’m treating, my population, aren’t at risk. They don’t have the classic risk factors for hepatitis B” and this slide from the CDC shows intensely investigated cases of acute hepatitis B. The usual risk factors that we are familiar with; IV drug use, high risk heterosexual or homosexual activity or needle stick. But you can see that 35-40% of cases of acute hepatitis B don’t have these classic risk factors and so everybody is at risk for hepatitis B whether they have the classic risk factor or not. Children especially are at risk of becoming chronic carriers. So because of this we do recommend universal immunization with hepatitis B vaccine.

Finally, the last part of MMR vaccine; the R is for rubella vaccine and rubella vaccine is also a live virus vaccine. The strategy to prevent intrauterine infection in this country, to prevent congenital rubella syndrome, is to vaccinate everybody routinely. To do that you give the rubella vaccine, the live virus vaccine. The main reactions to be concerned about are an attenuated form of rubella. A mild rash, a low-grade fever, and in children sometimes you get some occipital or posterior auricular lymphadenopathy and arthralgia. In young women the rubella vaccine may be slightly more reactagenic, resulting in not only transient arthralgias but sometimes transient arthritis as well.
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Precautions and contraindications are similar; pregnancy, immunocompromised – it might multiply more than you would want it to in that situation – and immune globulin will interfere with vaccine take. Excellent seroconversion is obtained with rubella vaccine. Again, a graph from the CDC shows a marked reduction in the cases of rubella in this country. It’s been quite successful.
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So now we are going to move on from MMR vaccine and move on to H. flu type B vaccine. I haven’t talked much about the science behind a lot of these vaccines and that’s because that’s not important for test-taking purposes. However, with H. flu type B vaccine, that’s different. So I am going to spend a little bit talking about the science behind it. The important thing with H. flu type B in terms of immunity is immunity to the polysaccharides. However if you take the plain polysaccharide and you use that as a vaccine, it’s very weak. You get a very weak antibody response in infants and really don’t get a very good antibody response until 18-24 months of age. If you take this polysaccharide and you bind it to a protein, then it becomes a T-cell dependent immunogen. Canadian viagra for sale. It has enhanced immunogenicity, especially in infants, you get a better immune response and you get a booster response if you give repeated doses of vaccine or if you get exposure to H. flu type B. Because of this has been remarkably successful, as you’ll see. This is being applied to other vaccines and development of other vaccines, such as improved vaccine against pneumococcus, improved vaccine against meningococcus. And because of that, because you will see it in the future, this is the kind of thing, that basic science sort of thing, that actually may be tested because I think it is important to understand that this technology is improving vaccines.
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So there are several different vaccines in general. It’s not important to know the main differences between them, but there are different manufacturers of the vaccine. The polysaccharide is linked to different protein carriers. Most of these have been used before so there is a lot of clinical experience with them, and that’s why they have been chosen. But all of them are very safe vaccines, very minor reactions, local reactions. Rarely you get a low-grade fever after vaccination with the routinely used HIB vaccines. Again, these have been remarkably successful. The conjugate vaccines were introduced in 1988 and then in 1990 they were recommended for infants. You can see invasive H. flu type B disease in this country more than a 95% reduction. This has been quite a success story.

Now, biotin deficiency is one of the rarer types. Again, there is the overlap between this and the other vitamin B2, B6 deficiencies. Just be aware that they share some similar features.
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What about toxicity states? Can you get vitamin poisoning? Would you be able to recognize vitamin poisoning if you saw it? There are only three water soluble vitamins which cause toxicity when given in excess; niacin, vitamin B6 and vitamin C. Know that. How would you know niacin toxicity? These are its characteristics. It became apparent, one of the ways that they treat some adults who have problems with cholesterol and they try to increase, those who are able, their HDL production is by giving those individuals large amounts of niacin. One of the characteristics that these people talk to you about is the skin flushing. They get very very red and they get tingling. It’s not a very pleasant experience, and sometimes they stop the niacin because the toxic effects are really too much for them to tolerate.
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Vitamin B6 toxicity. These are basically all neurological manifestations that are seen with it. Again, it would be an unusual phenomenon to see but it does occur. Probably vitamin C toxicity would be the commonest vitamin toxicity we might see, of the water soluble vitamins, in children because a lot of parents believe that vitamin C taken in high doses will prevent viral infections, will stimulate the immunity. Maybe it does, I don’t know, but there are considerable side effects from it; nausea, diarrhea, cramps, kidney stones. What kind of dosage will produce this? If you give vitamin C at a dosage that is greater than 10 times what the RDA’s are, this is when you start to see this phenomenon begin to become manifest.
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There are four fat soluble vitamins, A,D,E and K. What are the signs of deficiency? The characteristics that you see with vitamin A deficiency, clinical presentation, night blindness. And the other thing is xerophthalmia where they get problems like scaly-ness of the eyelids is one of the characteristics of it because it affects the skin and affects the cornea of the patient. So the cornea tends to become irregular. They also have a general problem with their skin as a result of it. Photophobia, conjunctivitis, so-called Bitot’s spots, keratomalacia, again because in vitamin A deficiency you have failure to regenerate the epithelium of the eye as well as the conjunctiva. They also get hyperkeratosis in the sun, on the skin. Poor growth, impaired resistance to infection. Vitamin D deficiency, the clinical presentation is most likely going to be rickets and it is very common – and I’ve seen this so repeatedly – that they will show you an x-ray and have you try to make a diagnosis of rickets. Here you see some of the classical features. You see splaying of the ends of the long bones in this patient. That’s the other thing that you see, this is before and this is after. This is the normal, this is the abnormal. And they will ask you, “What is this characteristic of?” and they will show you some vitamins, but they usually show this. Again, this is a patient who turned out to have vitamin C deficiency and one of the things that this patient has is very osteopenic bone. But they are probably not going to ask you that.

We are going to move on to MMR vaccine. The first part of the M is measles vaccine. And measles vaccine is a live virus vaccine and you may get this live, attenuated, weakened form of the measles virus. It may multiply within the host and actually produce an attenuated case of measles, which you can see a week to 12 days after immunization, with a low grade fever and a mild rash. Seroconversion depends upon the age at which MMR vaccine is given. If you give it at a year of age you have excellent immunogenicity. Giving MMR vaccine at six months of age, you can see the seroconversion is only 50%. That’s because many children at six months of age will still have their passively acquired maternal measles antibody, if the mother is immune to measles and therefore this will interfere with vaccine take. It will inactivate the live vaccine so it won’t multiply and you won’t get a good immune response.
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For measles vaccine, the precautions and contraindications are shown on this slide. Pregnancy; it’s a live vaccine, so theoretical concerns. Gelatin or a mycin allergy, this will be an anaphylactic allergy. That’s in the vaccine. Thrombocytopenia; measles-containing vaccine may cause a lowering of the platelet count, so in a patient with thrombocytopenia you could think about whether it’s worthwhile to vaccinate them against measles or not. Recent immune globulin will interfere with vaccine take. In general, immunocompromised subjects should not get MMR vaccine or measles-containing vaccine. And that’s because it may multiply more than you would want it to. However, HIV infected subjects may be give measles-containing vaccine, unless they are severely immunocompromised. Egg allergy; this is relatively new, over the past few years. Egg allergy in the past had been considered a contraindication of vaccination. No longer, as there is such a small amount of egg protein in the vaccine. Then the issue of the PPD. PPD may be performed on the day of vaccination or one month later. If you do it in between those times, the PPD may not be reliable.
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The recommendations for measles vaccine; two doses after the first birthday separated by at least a month, so the general routine is to give the first dose at 12-15 months of age, the second dose, 4-6 years of age. And in an outbreak situation you can give an additional dose at six months of age but this doesn’t count for those two doses after a year of age because, again, the vaccine take is unreliable. This graph from the CDC just shows how successful we’ve been with vaccinating against measles. A marked decline and then here we had a little bit of outbreak of measles and this is where the second dose recommendation came in. It has really been very successful at controlling measles in this country.
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Now we are going to move on to the second M in MMR, mumps vaccine. This is a slide from the CDC showing a child with parotid gland swelling due to mumps. Mumps does cause salivary gland swelling and also may cause complications – mostly in older individuals – may cause pancreatitis, meningitis, hearing loss as well as orchitis. Mumps vaccine is also a live virus vaccine. Reactions to mumps vaccine are rare. The precautions and complications are similar to what you’ve already heard for measles vaccine; pregnancy, immunocompromised, recent immune globulin will interfere with vaccine take, and the seroconversion is excellent with mumps vaccine. This graph from the CDC also illustrates a marked decline in mumps in this country with routine vaccine. So this has been quite successful.

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.