Many immunoglobulins used in prevention are now synthesized. Which ones come from pooled serum immunoglobulin, instead?

(2)

• Hep A

• Measles

(give in first 6 days post-exposure)

Is there a monoclonal antibody that’s helpful with RSV infection?

Yes – palivizumab

(only used for sickest infants & those with congenital heart disease)

Are there any indications for giving palivizumab (RSV IG) prophylactically?

Yes – infants with

1. Chronic lung disease

2. Prematurity <28 weeks gestation

3. Birth between 29–32 weeks gestation & less than 6 months old at start of RSV season

If RSV IG is started prophylactically, how long should it be continued?

Until infant is 12 months old and RSV season is completed

(If they turn 12 months during the season, you don’t stop it until the season is over)

How common is it for patients to have bad reactions to IVIG?

Not common

If a patient anaphylaxes to IVIG, what underlying immune problem do they probably have?

IgA deficiency

What IVIG complication is common in very small patients, especially?

Fluid overload

Most of the time, preemies get their immunization at the regular chronological age. When should immunizations be deferred? (2 reasons)

1. Medically unstable

2. Inadequate muscle mass to receive immunization (less than 1,500 g)

Is it alright to give a reduced or a divided dose of pertussis vaccine?

No

Why is acellular pertussis a better vaccine than whole cell?

Fewer side effects, but close to the same efficacy

Why do we try to avoid giving more tetanus shots than necessary?

Increased (local) hypersensitivity reactions

At what age are children considered to be at high risk for pneumococcus?

Age 2–5 years

If a child missed his pneumococcal vaccination series, and doesn’t present until age 3 years, what should you do about the immunization?

Start it late

(still in the high-risk age group, until age 5 years)

If a child aged 2–5 years presents who has not received pneumococcal vaccination, or didn’t complete the series of early immunizations, how many pneumococcal vaccine doses should you give?

Just 1

(patients with high-risk conditions, such as sickle cell, may be given one or two doses)

Which pediatric patients are considered “high risk” for pneumococcus, based on other medical conditions?

(4 groups)

Immunocompromised –

• Sickle cell or other patients with subnormal splenic function

• HIV infected

• Other – diabetes, chemo, transplant, etc.

Chronic lung or heart disease

CSF leaks

Cochlear implants

How many types of pneumococcus does the basic childhood immunization cover?

(the conjugate vaccine)

Thirteen

(the first vaccine version covered 7 types – it has been replaced)

What is the basic childhood immunization called?

PCV13 –

Brand name Prevnar^®

(PCV stands for pneumococcal conjugate vaccine)

How many types of pneumococcal diseases does the polysaccharide vaccine address?

23

(known as PPSV23)

(PPSV stands for pneumococcal polysaccharide vaccine)

Which children get the vaccine for the 23 types of pneumococcus?

>2 years old & high risk

Is there a reason that the polysaccharide vaccine for pneumococcus can’t be used for children less than 2 years old?

Yes –

doesn’t stimulate an immune response

Which kids qualify for an extra dose of pneumococcal vaccine in the “low-risk” ages from 6 to 18 years?

Kids with high-risk medical conditions who have not previously received the PCV13 vaccine – even if they did previously receive PCV7 or PPSV23

What is the protocol for immunizing children with the polysaccharide pneumococcal vaccine?

First immunization after 2nd birthday –

One more 5 years later for children with splenic dysfunction & immunocompromise

The “regular” pneumococcal vaccine, PCV13, cannot be combined with which other vaccines?

PPSV23 (wait at least 8 weeks after the last PCV13 is given to give PPSV23, if indicated)

&

Meningococcal vaccine

(aka MCV4)

For an asplenic child, which takes priority, immunizing for pneumococcus or immunizing for meningococcus?

Pneumococcus –

It is the more likely problem

At what age can meningococcal vaccine be given?

9 months for Menactra™

[aka MCV4–D]

&

2 years for Menveo™

[aka MCV4–CRM]

(Recent change: The FDA has approved Menveo for children as young as 2 months in August 2013, if indicated for travel, etc. This will likely take a year or two to be reflected in board exam questions.)

What is the main shortcoming of the meningococcal vaccine?

30 % of the US cases are type B – the vaccine doesn’t cover it

When should the meningococcal vaccine be routinely given?

Age 11 (roughly) &

again at age 16–18

Which kids are at highest risk to develop meningococcus?

1. No spleen

2. Complement deficiency (C3 or terminal complement)

3. Dorm–style living (including military recruits)

4. Travel in endemic area

Generally, oral polio vaccine should not be used. What are the rare circumstances in which you might choose it?

(2)

1. Outbreaks – useful for mass immunization

2. Incompletely immunized child traveling to an epidemic area

What are the two big problems with oral polio vaccination?

1. GI shedding can produce disease in non–immune household contacts

2. Occasionally causes paralytic polio

What does the influenza vaccine protect you from?

Most popular A and B strains for each year

(reformulated each year!)

How many immunizations are normally required for influenza immunity?

One each year

(assuming the vaccine covers the influenza circulating)

In children less than 9 years old, the influenza vaccine is not as effective as it is in older individuals. How should these young children be vaccinated?

Two doses 1 month apart – just the first year they receive it

Does influenza vaccination have any significant complications?

No

When should you give influenza vaccine?

October–November

(ideally)

(okay to give until the END of flu season, however, if not given earlier)

Which kids are at high risk for bad influenza for pulmonary reasons?

Asthma & chronic pulmonary problems

Patients taking long-term aspirin therapy should have influenza vaccine. Why?

Greater risk for complications (e.g., Reye’s syndrome)

Do metabolic disorders qualify you as high risk for influenza?

Yup

Which patients are eligible to receive

Hep A vaccine?

> 1 year old

Which patients should definitely receive

Hep A vaccination?

(4)

1. Chronic liver disease (prevent another insult to the liver)

2. Receiving clotting factor concentrates (for clotting factor disorder)

3. Living in an endemic state (11 western US states have endemic rates)

4. Travel to endemic area

What is the link between adoption & hepatitis A?

Children arriving from countries where Hep A is common frequently bring it to their new home – best to immunize close contacts of newly arrived children

Bites from which types of animals mean that you definitely need to consider rabies prophylaxis?

Bats and carnivorous mammals

Which mammal groups do NOT transmit rabies?

(2)

Rodents & lagomorphs

(lagomorphs are rabbits & hares)

Can you catch rabies when the nice doggie licks you?

Yes – if there is an area of broken skin (abrasions that you might not notice do count !)

If the patient develops rabies, how can this be treated?

It can’t –

That’s why we are so careful with prophylaxis

(Coma protocols show some promise, but virtually all patients die if not immunized)

If you’ve been in an enclosed space with a bat or animal that might have rabies, are you at risk if the animal never touched you?

Yes – mucous membrane and conjunctival exposure can produce rabies, and breathing droplet of infected urine also seems to cause disease

(& sometimes a scratch isn’t so

obvious …)

If you think you might have been exposed to rabies, what should you do before you go to the ER?

Very thorough soap & water wash (reduces infection rate dramatically)

Injuries in what location tend to produce clinical rabies the fastest?

Head & neck

(short distance to reach to the CNS)

A squirrel has bitten your patient. Is rabies prophylaxis an issue?

No – that’s a rodent

If rabies prophylaxis is needed, what should you give?

Both immunoglobulin & vaccine

• Ig as much as possible around the site of the injury

• Vaccine elsewhere (usually deltoid)

Why must you avoid giving vaccines & immunoglobulin in the same area of the body, at the same time?

They are likely to bind each other, making both useless to the patient

When traveling, patients are at highest risk for rabies exposure from which animals?

DOGS & bats

Rabies is VERY prevalent in dogs in many parts of the world & travelers are at high risk!

If your patient’s possible rabies exposure occurred more than a week before they present to you, should you still consider rabies prophylaxis?