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.
