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Topic 1 - Childhood Immunizations (1)

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Childhood
Immunizations
Topic 1
Immunizations = Vaccinations

Vaccination is the administration of a small amount of antigen, which is
capable of stimulating an immune response but does not typically produce the
disease.

Traditional: inactivated (killed) microorganism

Attenuated: live, weakened (attenuated) microorganism

Toxoids: inactivated toxins stimulate formation of antitoxins that produce active
immunity (tetanus toxoid)

Conjugated vaccines (newer): require a protein or toxoid to link with diseasecausing microorganism (H. influenza type B)

Recombinant subunit vaccines: insertion of genetic material (DNA) of pathogen into
another cell where the antigen is produced in massive quantities (HepB)
Immunization Requirements


Infancy

Primary schedule begins at birth

Diphtheria, Tetanus, and acellular Pertussis (DTaP); Poliovirus; Measles, Mumps,
and Rubella (MMR); Haemophilus influenza type b (Hib); Hepatitis A virus (HAV);
Hepatitis B virus (HBV); Pneumococcal Conjugate Vaccine (PCV); Influenza;
Meningococcal; and, Varicella-zoster virus (VZV; Chickenpox).
Early Childhood

Primary schedule is completed; with the exception of boosters
Immunization Requirements
Schedules


Nurses - Need to know where to obtain recommendations:

Advisory Committee on Immunizations Practices (ACIP) of the Centers for Disease
Control and Prevention (CDC)

Committee on Infectious Diseases of the American Academy of Pediatrics (AAP)
Schedules for Vaccinations and Catch-up Vaccination Schedules:


https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-childcombined-schedule.pdf
Healthy People 2020 target goal of 90% was met for children aged 19 to 35
months who received the recommended doses of DTaP, polio, MMR, Hib, HepB,
PCV, and varicella vaccines
Immunization Requirements
Hepatitis A Virus (HepA)


Significant child health problem

Fecal-oral route

Person-to-person contact

Ingested contaminated food or water
Two doses: 1 year old and 6 months after first dose
Immunization Requirements
Hepatitis B Virus (HBV)

Significance: HBV during childhood and adolescence can lead to fatality from
cirrhosis of liver cancer in adulthood

Newborn – administer before discharge

Three additional doses: 1, 2, and 6 months of age

Safe to administer at a separate site with DTaP, MMR, and Hib vaccines
Immunization Requirements
Diphtheria, Tetanus, and Pertussis (DTaP)

Diphtheria vaccine - does not produce absolute immunity; need booster every
10 years

Tetanus vaccine – provides antitoxin levels for about 10 years; need booster
every 10 years

Pertussis vaccine - increased cases of pertussis in children, adolescents and
adults


CDC recommends administration of Tdap booster regardless of time interval from
last tetanus
Four doses: 2, 4, and 6 months of age, and fourth dose on or after four years
old – DTaP is recommended
Immunization Requirements
Inactivated Poliovirus (IPV)

Significance: Exclusive use of IPV due to rare risk of vaccine-associated polio
paralysis (VAPP) from oral polio vaccine (OPV)

Four doses: 2 months, 4 months, 6 to 18 months, and 4 to 6 years of age

PEDIARIX – combination vaccine containing DTaP, Hep B, and IPV
Immunization Requirements
Measles, Mumps, and Rubella (MMR)

Significance: due to recurrence of measles in older children and young adults,
susceptible individuals should be immunized if 2 doses not administered
previously

Two doses: 12 to 15 months of age and 4 to 6 years of age (school entry)

Measles, mumps, rubella, and varicella (MMRV) – attenuated live virus vaccine
Measles (Rubeola)
Rubella (German Measles)
Immunization Requirements
Pneumococcal Conjugate Vaccine (PCV 13)


Significance: Streptococcal pneumococci (bacterial infection) younger than 2
years who attend day care and are immuno-compromised

Septicemia

Meningitis

Otitis media

Sinusitis

Pneumonia
Four doses: 2, 4, and 6 months, and 12 to 15 months of age
Immunization Requirements
Haemophilus influenzae Type B (Hib)

Significance: protect against serious infections

Bacterial Meningitis

Epiglottitis

Bacterial pneumonia

Septic arthritis

Sepsis

Four doses: 2, 4, 6, and 12 to 15 months of age

Administered by IM injection using separate syringe and a site separate from
any concurrent vaccinations.
Immunization Requirements
Varicella

Significance: any susceptible child

Two doses: 12 to 15 months and 4 to 6 years of age

Administered subcutaneous injection

ProQuad is licensed combination vaccination MMRV

Must have 2 doses to ensure they will have one-third less breakthrough illness
compared with children who have 1 dose

Children who do contract varicella have less vesicles, lower fever, and faster
recovery.

Antibodies persist for at least 8 years

May be given simultaneously with DTaP, IPV, HepB, or Hib vaccine
Varicella
Immunization Requirements
Influenza

Significance: especially to children with asthma, cardiac disease, HIV,
diabetes, sickle cell disease that place them at risk for influenza-related
complications

Recommended annually (usually in the Fall) starting at 6 months of age

First-time recipients: 2 separate doses 4 weeks apart

Assessment for egg allergies prior to administration

May give at same time as other vaccinations:

Use separate syringe

Use separate injection site
Immunization Requirements
Meningococcal Infections

Significance: highest fatalities occur in adolescents and college freshmen
living in residence halls; morbidities include limb or digit amputation, skin
scarring, hearing loss and neurologic disability

Two doses: first at 11 to 12 years of age with second at 16 to 18 years of age

MCV-4 is single immunization; Menactra is licensed vaccination

May give at same time as other vaccinations:

Use separate syringe

Use separate injection site
Immunization Requirements
Rotavirus

Significance: Acute gastroenteritis; contagious and may be particularly severe in
infants and young children

Due to small increase in cases of intussusception from rotavirus vaccination,
health care providers should weigh the potential risks and benefits of
administering rotavirus vaccine to infants with a previous history of
intussusception.

Both rotavirus vaccines are administered orally, by putting drops in the infant’s
mouth. Each requires multiple doses:

RotaTeq® (RV5) is given in three doses at 2 months, 4 months, and 6 months of age.

Rotarix® (RV1) is given in two doses at 2 months and 4 months of age.
Immunization Requirements
Human Papillomavirus (HPV)

Significance: Sexually transmitted and seen as cervical, vaginal, anal, and
oropharyngeal cancers and genital warts

Beginning at 11 or 12 years old (can start as early as age 9)

Age 9 to 14 years: 2 doses (at least 5 months apart)

Age 15 or older: 3 doses at 0, 1-2 months, and 6 months

Persons who have completed a valid series with any HPV vaccine do not need
any additional doses
Reactions

Safest and most reliable drugs available

Inactive components are incorporated: preservatives, stabilizers, antibiotics
(neomycin in MMR) and purified culture medium proteins (eggs, yeast culture)

Child may react to the preservative

Occur within a few hours to days:

Local tenderness

Erythema

Swelling at the injection site – cold compress; administer acetaminophen

Low grade fever - administer acetaminophen

Behavioral changes: drowsiness, eating less, prolonged or unusual cry

Additional side effects specific to individual vaccines
Reporting and Safety

Health care providers are responsible for reporting cases of vaccine
preventable diseases and adverse reactions following immunization

Vaccine Adverse Events Reporting System (VAERS)


National Childhood Vaccine Injury Act of 1986 initiated the National Vaccine
Injury Compensation Program (NVICP)


https://vaers.hhs.gov/index.html
https://www.hrsa.gov/vaccine-compensation/data/index.html
NVICP requires health care provider to distribute a Vaccine Information
Statement (VIS) before the vaccine is administered

www.cdc.gov/vaccines/hcp/vis
Contraindications and Precautions

Contraindication: a condition in an individual that increases the risk for a serious
adverse reaction or anaphylaxis

General contraindication for all immunizations is a severe febrile illness

Minor illness such as common cold is not a contraindication

Live virus vaccines such as Varicella and MMR should not be administered to child
who is severely immunocompromised

Known allergic response to a previously administered vaccine or a substance in the
vaccine

Precaution: a condition in a recipient that might increase the risk for a serious
adverse reaction or that might compromise the ability of the vaccine to produce
immunity

If the child scheduled for vaccination is not feeling well, the healthcare provider might
decide to reschedule the shot on another day
Administration

Communicating with parents about immunizations

Be flexible, provide options regarding multiple vaccines

Infants – 2, 4, 6 months; allow parents to space office visits to decrease the total
number of injections at one time; some pediatrician offices have “Nurse only”
appointments, provided the child is healthy, for immunization purposes only

Teach parent about administering acetaminophen 45 minutes before the
immunizations

Application of EMLA cream to the injection site before administration
Administration


Fewer local reactions to immunizations when the vaccine is given deep into the
muscle

Minimum of 25 mm (1 inch) needle length for anterolateral thigh with infants

Minimum of 25 to 32 mm (1 to 1 ¼ inches) needle length for toddlers

Minimum of 38 to 51 mm (1 ½ to 2 inches) needle length for older children
When multiple injections to be given, two may be given into the thigh


At least 2.5 cm (1 inch) apart
Sites

Dorsogluteal muscle should be avoided at all times

Anterolateral thigh for infants (not walking)

Deltoid site for children older than 1 year

Ventrogluteal site for any age
Administration

Multiple Injection Technique for Children

https://www.youtube.com/watch?v=WRVCptt-wpg

Positioning Children for Immunizations

https://www.cdc.gov/vaccines/parents/tools/holds-factsheet.html

Respect the parent’s ultimate wishes
Prototype Drug Chart
Varicella Vaccine

Varicella Vaccine is the Prototype Drug that is provided in your Pharmacology
textbook

See the Prototype Drug Chart 31.1 on page 437 in the Pharmacology textbook

Using the pharmacologic data for varicella vaccine, complete the Drug Card
Template seen on the following slide

The Drug Card Template should be familiar to you from Pharmacology class
in Level 1

Completion of this card will be valuable to you because the information regarding
that prototype will be included on Exam 1 and possibly the Comprehensive Final
Exam
Drug Card Template
Classification:
Action:
Therapeutic Effects/Uses:
Side Effects:
Adverse Effects:
Contraindications:
Drug-Lab-Food Interactions:
Nursing Implications:
Nursing Process: Patient-Centered
Collaborative Care – Varicella Vaccine
(Pharmacology textbook pages 439 to 440)

Nursing Interventions:

Patient Teaching:

Strictly adhere to vaccine storage
requirements

Discuss vaccine-preventable
diseases

Upon reconstitution, administer
within time limits stated in
package insert

Answer questions clearly

Advise females to avoid pregnancy
for 1 month

Avoid contact with
immunocompromised persons

Provide VIS before administering
the vaccine

Administer at separate sites

Do not mix vaccines in the same
syringe

Document completely

Observe for adverse reactions


Keep epinephrine available for use
in the case of anaphylactic
reaction
Patient or patient’s family to
maintain vaccine record

Provide return date for next
immunizations

Advise to contact health care
provider if signs of reaction occur

Provide patient with record of
immunizations received
Don’t Wait! Vaccinate!

SHARE reasons why the vaccine is right for the patient.

HIGHLIGHT positive experiences.

ADDRESS the patient’s/ parent’s questions about the vaccine.

REMIND the patient/parent that vaccines protect against disease.

EXPLAIN the costs and consequences of getting the disease.
References

McCuistion, L.E., Vuljoin-DiMaggio,K., Winton, M. B., &Yeager, J. J. (2018).
Pharmacology: A patient-centered nursing process approach (9th ed.).
St. Louis, Missouri: Elsevier.

Perry, S. E., Lowdermilk, D. L., Cashion, K., & Alden, K. R. (2018). Maternal
child nursing care (6th ed.). St. Louis, Missouri: Elsevier.
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