GNRS 5303 University of Texas Medical Branch in Galveston Marissa Hampton RN BSN SNNP and Gabriela Olivas RN BSN SNNP Goals Objective To describe each disease process for immunization ID: 774736
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Slide1
Texas immunizationsAdvanced newborn health assessmentGNRS 5303University of Texas Medical Branch in Galveston
Marissa Hampton RN, BSN, SNNP
and
Gabriela
Olivas
RN, BSN, SNNP
Slide2Goals
Objective
To describe each disease process for immunization
To discuss
the origin
and history of vaccination, particularly in Texas
To detail
each part of
immunization and its purpose
To provide evidence
based
practices of immunization
To identify
any long term outcome
or
management issues if
vaccination is not provided
Slide3Definitions
Immunization: The method in which a person becomes protected from a disease process.Vaccination: Injection of a killed or weakened infectious organism in order to prevent the disease.Vaccine: A product that produces immunity against the disease.
(Centers for Diseases Control and Prevention, 2012a)
Slide4How do immunizations work?
When bacteria/virus enter the body, they multiple and attack healthy cells.The immune system fights invaders and makes memory cells to recognize them so the body can fight if ever attacked again.Vaccines develop immunity by imitating infection. This imitation does not cause illness, but instead helps the individual to build an immunity. If exposed again, the body will use memory cells to fight the infection.
(Centers for disease control and prevention, 2012b)
Slide5Recommended immunizations by the Center for Disease Control and Prevention
Slide6Immunizations as recommended from the state of Texas
Slide7Vaccine administration
Slide8Hepatitis B
Viral disease that is spread via puncture wounds through the skin or through blood and body fluid secretionsSigns and symptoms: Vary with ageMost newly infected patients and infants are asymptomatic Fever, fatigue, loss of appetite, nausea, vomitting, abdominal pain, dark urine, joint pain, jaundiceHigh risk individuals:Include sex with an infected partner , injection drug use or needle sticks, an infant born to an infected mother or contact with blood or open sores of infected personAcute Hepatitis B: at time of initial infection Chronic Hepatitis B: Progressive worsening of liver disease; Chronic patients may continue to have signs and symptoms, further complications and cause infection in others.Persons with chronic HBV infection might be asymptomatic, have no evidence of liver disease, or have a spectrum of disease ranging from chronic hepatitis to cirrhosis or hepatocellular carcinoma (a type of liver cancer).
(Texas Department State of Health Services, 2013a)
Slide9Hepatitis B
History United StatesBefore 1982: 200,000 to 300,000 people infected including 20,000 children90 % chance transmission from + mother to infant without prophylaxis25 % infected at childhood will die from cirrhosisNo method for pre exposure prophylaxis1984: Advisory committee on immunization practices (ACIP) recommends testing for high risk individuals1988: ACIP recommends screening pregnant women for Hepatitis B1991: ACIP recommends comprehensive strategy: prenatal screening, prophylaxis treatment of infants from + mothers, universal childhood vaccintationTexas1991: Texas implemented recommendations from CDC into state lawVaccination is required prior to day care and school admission in Texas
(Morbidity and Mortality Weekly Report, 2002)
(
Wasley
,
Kruszon
-Moran,
Kuhnert
,
Simard
,
Finelli
,
McQuillan
,& Bell, 2012)
(Texas
Department
State
of
Health Services, 2013a)
Slide10Hepatitis B Vaccine
Heptavax-B, Recombivax HB, Engerix-B Indication and Use: Immunization against infection caused by all known subtypes of hepatitis B virus in individualsActions: Promotes immunity by inducing the production of specific antibodies to the virusDosage: IM recommended schedule 0.5 ml/dose in 3 total doses. Infants born to hepatitis B surface antigen(HBsAg)-positive mothers: First does within the first 12 hours of life even if premature and regardless of birth weight (hepatitis immune globulin should also be administered at the same tie/different site); second dose at 1-2 months of age; third dose at 6 months. Check anti-HBs and HBsAg at 9-15 months of age. IF anti-HBs and HBsAg are negative, reimmunize with 3 doses 2 months apart and reassess.Infants born to HBsAg-negative mothers: First dose prior to discharge; however, the first dose may be given at 1-2 months of age. Another dose given 1-2 months later, and a final dose at 6 months of age. A total of 4 doses of vaccine may be given if a “birth dose” is administered and a combination vaccine is used to complete the series. Infants born to mothers whose HBsAg status is unknown at birth: first dose within 12 hours of birth even if premature, regardless of birth weight; second dose following 1-2 months later, and a final dose at 6 months of age. If the mother’s blood HBsAg test is positive, the infant should receive hepatitis immune globulin as soon as possible (no later than 1 week
(Cunningham,
Eyal
&
Gomella
, 2013)
Slide11Effects of Hepatitis B Vaccine
United States1990-2004: Hepatitis B rates have declined by 94% in children due to screening, universal vaccination and prophylaxis, if needed.Texas1991- 2012: Steady decline of Hepatitis B rates in TexasIn 2012 , 170 reportable cases of acute Hepatitis B, lowest rates in history.Overall decline was greatest among children and adolescents under 18 years.
(Texas Department State of Health Services, 2013a)
Slide12Long term outcome or management if untreated
TreatmentNo specific therapy for acute HBV infection. Treatment is supportive. Interferon is the most effective treatment for chronic HBV infection and is successful in 25% to 50% of cases. Hepatitis B complications Fulminant hepatitis, hospitalization, cirrhosis, hepatocellular carcinoma, death
(Centers for Disease control and prevention, 2012c)
Female patient from Cambodia with a
heptoma
due to chronic Hepatitis B infection.
(CDC, 1995)
Slide13Rotovirus
Leading cause of gastroenteritis in infants and children under age 5Prior to vaccination 4 out 5 children will be infected by age 5Transmitted Fecal- Oral RouteSigns and SymptomsFever, vomiting, diarrhea, abdominal pain, loss of appetite, dehydration.Dehydration may be severe; may cause electrolyte imbalance, shock and death
(Morbidity and Mortality Weekly Report, 2009)
Slide14Rotovirus
State of Texas does not currently recommend immunization against rotovirusRotaTeq® [RV5]3 dose series licensed in 2006Given at 2, 4, 6 monthsRecommended by ACIP for all infantsRotarix® [RV1]2 dose series licensed in 2008Given at 2, 4 monthsRecommended by ACIP to replace previous vaccine
(Morbidity and Mortality Weekly Report, 2009)
Slide15DTap
DiphtheriaInfection caused by Corynebacterium diphtheriae bacteriaSpread by respiratory droplets or contaminated objectsBacteria invades the respiratory system and produces toxinsCause weakness, sore throat, fever, swollen glands in the neck, pseudomembrane- build up of dead tissue that causes difficulty breathing Toxins damages the heart, kidneys and nervesTetanusInfection caused by bacteria Clostridium tetani.Enters the body through broken skin, from contaminated objects. Causes headache, jaw cramping, sudden, involuntary muscle tightening – often in the stomach (muscle spasms), painful muscle stiffness, difficulty swallowing, seizures, fever, sweating, high blood pressure and fast heart ratePertussisInfectious disease caused by the bacterium Bordetella pertussis.Early symptoms: runny nose, low-grade fever, mild, occasional cough , apnea,With progression, traditional symptoms appear: Many, rapid coughs followed by a high-pitched "whoop“, vomiting, exhaustion after coughing fits. Coughing fits can go on for up to 10 weeks or more.
(Center for Diseases Control and Prevention, 2011)
(Center for Diseases Control and Prevention, 2013)
(Center for Diseases Control and Prevention, 2012d)
Slide16DTaP
History
Diphtheria
Early 1900s: First prophylaxis
was
attempted
1921: toxoid
was
developed but not used until 1930
1940: Vaccine was
incorporated with tetanus toxoid and
pertussis.
Tetanus
1914- 1919: World War I- passive immunity used for treatment and prophylaxis
1920: Inactivating tetanus toxin process
1924: Development of tetanus
toxid
; widely used in World War II
1940’s: Tetanus
toxid
introduced into routine childhood immunizations
Tetanus became nationally
notifiable
; 500-600 cases annually
Pertussis
1906: First isolated organism
1940: Development of pertussis vaccine
200,000 cases reported annually
Texas
1971: Texas legislation passed to vaccinate children against diphtheria and
tetnus
passes (Gee & Sowell, 1975)
Slide17DTaP vaccine
4 combination vaccines: DTaP, Tdap, DT, and Td. DTaP and DT are given to children younger than 7 years of ageTdap and Td are given to older children and adults.DTaPChildren should get 5 doses of DTaP, one dose at each of the following ages: 2, 4, 6, and 15-18 months and 4-6 years. Vaccines approved for ages 6 weeks and older: Infanrix, Tripedia and DaptacelDTVaccine does not contain pertussisUsed in children who can not tolerate pertussis vaccine
(Center for Diseases Control and Prevention, 2007)
Slide18Effects of DTaP Vaccine
DipthteriaUnited StatesRapid decline in rates since vaccination Began in 19401970-1979: 196 reportable cases1980-2004: 57 reportable casesTexasAccording to Texas Health services website, therehave been no reportable cases in years, but is still considered a reportable rare disease
Child
with diphtheria presented with a characteristic swollen neck, sometimes referred to as “bull neck
”. (CDC, 1995)
Slide19Effects of DTaP
TetanusUnited StatesSteady decrease since vaccine introduced into routine childhood vaccination in 19402001-2008: 233 cases of reported tetanus, averaging 29 cases annually.Neonatal tetanus is rare, two cases reported since 1989. TexasRare. Most reported cases are unvaccinated individuals or those who have not received booster shot in the following 10 years.Since 2008 only 5 reported cases, one of which was fatal.
(Center for Diseases Control and Prevention, 2013)(Texas Department of State Health Services, 2013)
Body rigidity from neonatal tetanus
(CDC, 1995)
Slide20Effects of DTaP vaccine
PertussisUnited States1940: Following introduction of vaccine, rates gradually declined1980–1990: An average of 2,900 cases per year were reported2001-2003: Average annual cases began to rise once again TexasPertussis rates in Texas historically climbs every 3 to 5 years then sharply declines.Documented outbreaks occurred in 2005 and 2008. 2012: There were 2,218 reported cases, doubling the 2011 count of 961. 2013: Outbreak of Pertussis continues with 2,652 pertussis cases reported in Texas.2000-2012, a total of 43 deaths were attributed to pertussis in Texas, with most deaths under the age of 1.
(Texas Department of State Health Services, 2013b)(Centers for Diseases Control and Prevention, 2012d)
Pertussis rates: United States 1940-2009
(CDC, 2012 d)
Slide21Long term outcome and management if untreated
DipthteriaTreatment: Diphtheria antitoxin to neutralize toxins produced by bacteria. Antibiotics are used, patients are kept in isolation for 48 hours after antibiotic treatment begins. Complications: Blocked airway, myocarditis, polyneuropathy, Paralysis, Pneumonia or respiratory failure.TetanusTreatment: Tetanus is a medical emergency requiring hospitalization, immediate treatment with human tetanus immune globulin (TIG) , a tetanus toxoid booster, wound care and antibiotics. Complications: Uncontrolled/involuntary muscular contraction of the vocal cords, fracture, nosocomial infections, pulmonary embolism, aspiration pneumonia, difficulty breathing, death
(Center for Diseases Control and Prevention, 2011)
(Center for Diseases Control and Prevention, 2013)
Slide22Long term outcome and management if untreated
Pertussis
Complications
:
Serious
and potentially life-threatening complications
in
unvaccinated infants:
Apnea, pneumonia, seizures, encephalopathy and death
More than half of infants who acquire pertussis and are
younger than 12 months of
age must
be
hospitalized.
Hospitalization
is
common
in infants younger than 6 months of age.
Other complications:
Anorexia
, dehydration, difficulty sleeping, epistaxis, hernias, otitis media, and urinary
incontinence
More
severe complications
include
pneumothorax, rectal prolapse, and subdural hematomas.
Slide23Haemophilus influenzae type B(Hib)
6 types of Haemophilus influenzae bacteriaHaemophilus influenzae bacterium may cause severe infection; occurs mostly in infants and children younger than five.Haemophilus influenzae type b (Hib) bacteria causes:Pneumonia, bacteremia, meningitis, epiglottitis, septic arthritis, cellulitis, otitis media, purulent pericarditis, endocarditis and osteomyelitis. Transmission occurs through direct contact with respiratory droplets. Neonates can acquire infection by aspiration of amniotic fluid or contact with genital tract secretions containing the bacteria.
(Center for Diseases Control and Prevention, 2012e)
Infant with severe
vasculitis
with disseminated intravascular coagulation (DIC) with gangrene of the hand secondary to
Hib
septicemia (American Academy of Pediatrics,
n.d
).
Slide24Hib
History United StatesBefore vaccination era, Hib was the leading cause of bacterial meningitis in children younger than 51930: 1 in 200 children developed HibTwo thirds in children younger than 18 months.Peak age of occurrence among children 6- 11 months1980’s: Estimated 20,000 cases of Hib occurred in the US1985: A pure polysaccharide vaccine (HbPV) was licensed in the U.S.Not effective in children younger than 18 months of age.1987: First conjugate vaccine licensed in U.S.Texas1988: Follows ACIP recommendations to vaccinate
Centers for Diseases Control and Prevention, 2013)
Slide25Hib Vaccine
Hib vaccine Infant primary series is given in 3 doses at 2, 4, 6 months or 2 doses at 2, 4 monthsBooster dose is needed at 12 to 15 months.2 monovalent conjugate Hib vaccinesPRP-OMP (PedvaxHIB) vaccine is 2 doses PRP-T (ActHIB) is 3 doses2 combination conjugate Hib vaccinesDTaP-IPV/Hib: PentacelHepatitis B-Hib: Comvax
(Centers for Diseases Control and Prevention, 2013)
Slide26Effects of Hib vaccine
United StatesLate 1980’s: Rates of Hib infection decreased by 99 percent as compared to pre-vaccine era.1991: Hib infections became nationally reportable.1996-2000: 341 confirmed cases of Hib reportedApproximately 22 percent within children less than 5 years old.TexasRare in TexasAverage of 8 cases reported annually
(Center for Disease Control and Prevention, 2012)
(Texas Department of State Health Services, 2013)
Slide27Long term outcome and management if untreated
Invasive HibHospitalizationAntimicrobial therapy Third-generation cephalosporin (cefotaxime or ceftriaxone)Chloramphenicol in combination with ampicillin Treatment is 10 days.
(Center for Disease Control and Prevention, 2012)
Slide28Pneumococcal Disease
Streptococcus pneumoniae causes an acute bacterial infection.Transmission of S. pneumoniae occurs as the result of direct person-to-person contact via respiratory droplets and by autoinoculation in persons carrying the bacteria in their upper respiratory tract. The major clinical syndromes of pneumococcal disease are pneumonia, bacteremia, and meningitis.The immunologic mechanism that allows disease to occur in a carrier is not clearly understood. Disease most often occurs when a predisposing condition exists, particularly pulmonary disease.
(Center for Disease control and Prevention, 2009)
Slide29Pneumococcal
History1911: First developments in creating a pneumococcal vaccine1940: Penicillin development; Vaccine developments stopped1960’s: Increased mortality despite antibiotic therapyEfforts made toward development of vaccine1977: First Pneumococcal vaccine licensed1998: 24 cases per year of Pneumococcal Disease, highest rates in children under 2 years of age2000: First conjugate pneumococcal vaccine licensedTexas2005: Texas mandates pneumococcal requirement for children 5 years and younger
(Center for Disease Control and Prevention, 2012)
Slide30Pneumococcal 13-velent conjugate vaccine (Prevnar)
Prevnar
Protects
against:
Streptococcus
pneumoniae
Indication and use
: for active immunization of infants/toddlers against Streptococcus
pneumoniae
invasive disease caused by the 13 capsular serotypes in the vaccine for all children 2-23 months of age. It is also recommended for certain children 24-59 months of age.
Dosage
: IM. O.5ml/dose as a single dose IM at 2, 4, 6, and 12-15 months of age. Shake well before administration.
Adverse effects
: decreased appetite, drowsiness, irritability, fever and injection site local tenderness, redness and edema. Not a treatment of active infection. Use of this vaccine does not replace the use of the 23-valent pneumococcal polysaccharide vaccine in children> 24 month old with sickle cell disease, chronic illness,
asplenia
, HIV, or those who are
immunocompromised
.
(
Cunningham,
Eyal
&
Gomella
, 2013, pg.991)
Slide31Effects of Pneumococcal Vaccine
United States
1998-1999: In children 5 and younger, reported 99 cases per 100,000 of pneumococcal disease
2008: Reported 21 cases per 100,000 in same age group
Texas
No information found on reportable cases for pneumococcal related disease
Slide32Long term outcome or management if untreated
What does
S
.Pneumoniae
cause if patient infected?
Causes
invasive
infections
Bacteremia
, meningitis, pneumonia, otitis media and sinusitis
Leading cause of bacterial meningitis among children <5 years of age
Disease
complications:
Bacteremia
,
meningitis, death
Treatment:
Resistance
to penicillin and other antibiotics is common
.
In
some areas of the United States, up to 40% of invasive pneumococcal isolates are resistant to penicillin.
Treatment
will usually include a broad-spectrum cephalosporin, and often
vancomycin
, until results of antibiotic sensitivity testing are available.
(Centers for Diseases Control and Prevention,2012
)
Slide33Poliomyelitis
Enterovirus
Enters through the mouth
Implants and replicates in the gastrointestinal tract
Migrates to the nervous system to destroy motor neurons
Excreted in feces
(Center for Disease Control and Prevention, 2012)
Slide34Poliomyletitis
History United States
First outbreaks recorded in 1843
Epidemic outbreaks for the next century
1952: Outbreaks peaked
in the
U.S.
More
than 21,000 paralytic
cases reported
1955: Introduction of inactivated polio vaccine (IPV)
Following introduction of vaccine rates declined dramatically
1961: Introduction of oral polio vaccine (OPV)
1979: Last reported case of
polio
Texas
1949: Large wide spread outbreak in San Angelo
1950: Second large wide spread outbreak in Houston
1955: Texas begins use of polio vaccine (Lee, 2005)
(Center for Disease Control and Prevention, 2012)
(Lee, 2005)
Slide35Poliomyelitis vaccine
Two
types of polio
vaccines:
oral
and
inactive
Inactivated Polio
Vaccine (IPV)
Highly
effective in producing immunity to poliovirus
90
%
immune
after 2
doses
99
% immune after 3
doses
Duration
of immunity not known with
certainty
Only effective treatment recommended against polio
Vaccinations due at 2, 4 months, between 6-18 months and at age 4.
May be given as a combination vaccine
Oral Polio
Vaccine(OPV)
Highly
effective in producing immunity to poliovirus
.
Approximately
50% immune after 1 dose
.
More
than 95% immune after 3 doses
.
Immunity
probably
lifelong
Shed in stool for up to 6 weeks following
vaccination
OPV not used due to increased risk for vaccine associated paralytic polio
.
(Center for Diseases Control and Prevention. 2012)
Slide36Effects of Poliomyelitis vaccine
United States1955: Dramatic decrease in rates after IPV introduced1960: 2,525 reported cases of paralytic polio1961: Introduction of OPV introduction1965: 61 reported cases of paralytic polio1979: Last reported case of polio, found in Midwestern statesTexasReportable in Texas, but has not occurred in years1970: Last reported cases of polio affected 22 children, all under age of 4.
Poliomyelitis - United States, 1940-1995
(Center for Diseases Control and Prevention, 2012)
(Texas Department of Heath Services, 2013)
Slide37Longterm outcome or management if untreated
Disease is rareResponse to polio infection is variableUp to 95 % of cases maybe asymptomaticParalytic polioSymptoms last 1-7 daysFever, loss of superficial reflexes, initially increased deep tendon reflexes, severe muscle aches and spasms in the limbs or back.Paralysis is commonly asymmetrical, strength returns3 types depending on level of involvement: Spinal, Bulbo, BulbospinalMaybe fatal in 2-3 percent of infant casesNon paralytic polioSymptoms will last 2 to 10 daysstiffness of the neck, back, legs, usually following several days after “minor illness”
Infant with affected lower limb from Poliomyelitis infection
(Center for Diseases Control and Prevention, 2012)
(Center for Diseases Control and Prevention, 1995b)
Slide38Influenza
Single stranded RNA virus
Acquired via droplets, invades respiratory system and replicates
Incubation period is 1- 4 days
Symptoms
“Classic”
symptoms abrupt
onset of fever, myalgia, sore throat, nonproductive cough
, headache and fever.
3 strains:
Type A- moderate to sever illness, all ages
Type B- mild illness, primarily children
Type C- rare
(Center for Disease Control and Prevention, 2013)
Slide39Influenza
History United States
Children
0–4 years of age,
hospital rates vary
from
100 to 500
per 100,000 healthy
children
Hospitalization
rates for children 24 months of age and younger are comparable to rates for persons 65 and older.
1940: Trivalent
inactivated influenza vaccine (
TIV) is available
C
ontains
three inactivated viruses: type A (H1N1), type A (H3N2), and type
B
2003: First live attenuated influenza vaccine
Texas
2005: House Bill passed requiring current vaccinations for child care settings (HB 1316, 2005).
Texas follows current recommendations for annual flu vaccine
(Center for Disease Control and Prevention, 2012)
Slide40Influenza vaccine
Vaccine protects against influenza
Spread by air, direct
contact
2
initial
doses
First
dose at 6
months
Second
dose at 28 days after first
dose
Once a year immunizations thereafter
Contraindications:
Infants with
moderate-to-severe illness with or without a fever
People
with a history
of
Guillain-Barr
é
Syndrome
that
occurred after receiving influenza
vaccine
Special Considerations regarding egg
allergy
People
who have ever had a severe allergic reaction to eggs may be advised not to get vaccinated.
People
who have had a mild reaction to egg—that is, one which only involved hives—may receive a flu shot with additional precautions.
(Centers for Disease Control and Prevention,
2013)
Slide41Effects of Influenza vaccine
United States
Reporting season for influenza: October to May
Vaccine
effectiveness depends on the strains and patient health status
With similar strains, vaccines are up to 90% effective in protecting
individuals
Texas
Influenza peaks
in
January/February
Individual
cases of influenza are not
tracked
Slide42Long term outcome and management if untreated
Most people who get influenza will recover in a few days to less than two weeks.
Symptoms
: fever, muscle pain, sore throat, cough , extreme fatigue
Complications
:
Bronchitis, sinus, ear infections, pneumonia which can be fatal
Treatment:
Antiviral
medications with activity against influenza
viruses, antiviral prescription drugs can be used for prevention
Influenza vaccine
Two
FDA-approved influenza antiviral
medications:
Oseltamivir
(Tamiflu®) and
Z
anamivir
(Relenza®).
Oseltamivir
and
Zanamivir
are chemically related antiviral medications that have activity against both influenza A and B viruses.
Antiviral resistance to
oseltamivir
and
zanamivir
among circulating influenza viruses is currently low.
(
Center for Disease Control and Prevention, 2012)
Slide43MMR
MeaslesMeasles (Rubeola) virus grows in the cells of the throat and lungs.Spread through droplet and direct contactHighly contagiousSigns and Symptoms: Mild to moderate fever, cough, runny nose, red eyes, and sore throat.Kopliks spots: Tiny white spots appear inside the mouth 2 to 3 days after infection.Complications: Diarrhea, pneumonia, otitis media with hearing loss, death. Leading cause of blindness in African childrenRelated to vitamin A deficiency in malnourished children.
(Center for Disease
Contol and Prevention , 2009)
(CDC,
n.d
)
Slide44MMR
Mumps
Acquired by respiratory droplets and direct contact.
Replicates in the
nasopharynx
and regional lymph nodes.
After
12 to 25 days a
viremia
occurs, which lasts from 3 to 5 days. During the
viremia
, the virus spreads to multiple tissues
, including
the meninges, and glands such as the salivary, pancreas, testes, and ovaries
.
Inflammation
in infected tissues leads to characteristic symptoms of
parotitis
and aseptic meningitis.
Most mumps transmission likely occurs before the salivary glands begin to swell and within the 5 days after the swelling begins. Therefore, CDC recommends isolating mumps patients for 5 days after their glands begin to swell.
Up
to half of people who get mumps have very mild or no symptoms, and therefore do not know they were infected with mumps.
Disease symptoms: swollen salivary glands, fever, headache, tiredness, muscle pain
Currently
, there is no specific treatment for mumps. Supportive care should be given as needed.
Slide45MMR
Rubella
, also known as German Measles, or 3 day measles
Rubella is a viral illness caused by a
togavirus
of the genus
Rubivirus
and is characterized by a mild,
maculopapular
rash.
Respiratory transmission of rubella virus, replication of the virus is thought to occur in the
nasopharynx
and regional lymph nodes. A
viremia
occurs 5 to 7 days after exposure with spread of the virus throughout the body.
Transplacental
infection of the fetus occurs during
viremia
. Fetal damage occurs through destruction of cells.
Incubation
period of rubella is 14 days, with a range of 12 to 23 days.
Symptoms
are often mild, and up to 50% of infections may be subclinical or
inapparent
.
Mild
fever of 102 F, headache, stuffy or runny nose, inflamed red eyes, enlarged, tender lymph nodes at the base of the skull, the back of the neck and behind the ears, fine, pink rash that begins on the face and quickly spreads to the trunk and then the arms and legs, before disappearing in the same sequence, and aching joints, especially in young women
(
Center for Disease Control and Prevention, 2012)
Slide46MMR
History: United States
Measles
1954: Measles virus isolated from human tissue
1963: First live attenuated vaccine licensed
Prevaccine
era
500,000 reported cases annually, 500 of which were fatal
Epidemic cycles noted every 2 to 3 years
Texas
1958: 85,862 reportable cases of
measles
1971:
Texas legislation passed to vaccinate children against
measles
passes (Gee & Sowell, 1975)
(CDC, 2012)
Slide47MMR
History United StatesMumpsPrevaccine Era: Mumps was cause of frequent outbreaks in militaryMost common cause of aseptic meningitits and sensorineural deafness in childhood1934: mumps discovered1945: Virus isolated 1948: Short lasting vaccine developedUsed until 1970’s1964: 212,000 reported cases of mumps1967:Development of live attenuated mumps vaccine1968: Nationally reportable disease
(Centers for Disease Control and Prevention, 2012)
Slide48MMR
History: United StatesRubella1940: Widespread Rubella infection1941: 78 cases of congenital cateracts from infants born to mothers with rubella infection early in pregnancy1962: Rubella isolated1964-1965: 12.5 million reported cases 20,000 newborns with congenital rubella syndrome causing deafness, blindness and mental retardation2,100 neonatal deaths1969: First rubella vaccine licensedTexas1971: Texas legislation passed to vaccinate children against diphtheria and tetanus passes (Gee & Sowell, 1975)Pictured at top right: Infant with blueberry spots from Congenital Rubella Syndrome (CDC, 1978)
(CDC, 2012)
Slide49MMR vaccine
Vaccine protects against measles, mumps, rubella; live virus vaccine
2 Doses:
First
dose given 12-15
months,
Second
dose given between 4-6 years old
Dose is 0.5 ml subcutaneously
Measles and Mumps vaccine is prepared in chick embryo fibroblast tissue culture.
MMR
and MMRV are supplied as a
lyophylized
(freeze-dried) powder and are reconstituted with sterile, preservative-free water. The vaccines contain a small amount of human albumin, neomycin, sorbitol, and gelatin.
MMR adverse effects:
Fever
, rash and joint symptoms (Joint pain attributed to measles and rubella vaccine)
Contraindications
:
Women
known to be pregnant or attempting to become pregnant should not receive rubella vaccine. Although there is no evidence that rubella vaccine virus causes fetal damage, pregnancy should be avoided for 4 weeks (28 days) after rubella or MMR vaccination. Persons with immunodeficiency or immunosuppression, resulting from leukemia, lymphoma, generalized malignancy, immune deficiency disease, or immunosuppressive therapy should not be vaccinated.
(CDC, 2009)
Slide50Effects of MMR vaccine
United states
Measels
Post vaccine era
Decrease in measles by 98 percent
No further 2-3 cyclic events
1978: Measles Elimination program
Goal: To eradicate indigenous
measels
by Oct. 1, 1982
1983:
Resurrgance
of
Measle
outbreak among children less than five
55,626 reported cases, 123 deaths
1991: Intensive efforts made to vaccinate preschool aged children
Vaccination levels increased from 70% in 1990 to 91% in 1997
Since 1993: Fewer than 500 cases reported annually
2008: Total of 140 reported cases
91% of cases were reported in unvaccinated individuals
Texas
Due to vaccination, reportable cases have decreased by
99.9% in Texas. Nearly all cases
Reportable cases since 2000: all reported cases have occurred due to unvaccinated individuals
from
foreign countries
where measles
are
prevelant
2011:6 reportable cases
2012:0 Reported cases
2013: 21 reported cases of measles, in North Texas, from an unvaccinated traveler who was returning home.
Slide51Effects of MMR vaccine
History: United StatesMumpsRapid decline after mumps vaccination implements1983-1985: 3000 reported cases annuallyCyclic resurgence of mumps outbreak in 2006 and 2009TexasAverages 20 cases of mumps a year
(Center for Disease control and Prevention, 2012)
(Texas Department of State Health Services, 2013)
Slide52Effects of MMR vaccine
United StatesRubellaRapid decline in rates following vaccine licensure1983 less than 1,000 cases annually1990-1991: Outbreak of congenital rubella syndrome with 25 and 33 cases respectively.TexasNo reported cases since 2004No reported congenital cases since 1998.
Rubella and Congenital Rubella Syndrome in the United States from 1966- 2009
(Center for Diseases Control and Prevention , 2012)
(Texas Department of State Health Service, 2013)
Slide53Long term outcome and management if untreated
Live measles vaccine provides permanent protection and may prevent disease if given within 72 hours of exposure. Immune globulin (IG) may prevent or modify disease and provide temporary protection if given within 6 days of exposure. The dose is 0.25 mL/kg body weight, with a maximum of 15 mL intramuscularly. The recommended dose of IG for
immunocompromised
persons is 0.5mL/kg of body weight (maximum 15 mL) intramuscularly. IG may be especially indicated for susceptible household contacts of measles patients, particularly contacts younger than 1 year of age (for whom the risk of complications is highest).
Most people with mumps recover fully. However, mumps can occasionally cause complications, and some of them can be serious. Complications may occur even if a person does not have swollen salivary glands (
parotitis
) and are more common in people who have reached puberty. These complications include
orchitis
in males who have reached puberty, encephalitis, meningitis,
oophoritis
, mastitis in females who have reached puberty, and temporary or permanent deafness
When rubella infection occurs during pregnancy, especially during the first trimester, serious consequences can result. These include miscarriages, fetal deaths/stillbirths, and a constellation of severe birth defects known as congenital rubella syndrome (CRS). The most common congenital defects are cataracts, heart defects and hearing impairment.
(
CDC, 2009)
(
CDC, 2010)
Slide54Varicella
Acute infectious disease caused by varicella zoster virus (VZV). VZV is a DNA virusMember of the herpes virus groupEnters respiratory tract and then replicates in lymphnodesPrimary infection: chicken poxIncubation is 10- 14 dayssigns and symptoms: head then trunkal lesions, prutiticSecondary infection: shinglesRecurrent diseaseUnilateral pain and paretheisia
(Centers of Diseases Control and Prevention, 2013)
Slide55Varicella
United States
Prevaccine
era: Endemic
Virtually
all persons had acquired by
adulthood
Approximately
4 million cases per year
1981: was
removed from the reportable
list
Highest
age specific incidence was in children 1-4- 40
%
1995:
Varivax
, first live attenuated vaccine
liscensd
in US for infants 12 months and older
2005: Combination MMR and Varicella vaccine
avaliable
Texas
Continues to report disease
Slide56Longterm management and outcome
Risk of Varicella increase with out vaccinationPrimaryChicken pox: Self limiting diseaseSecondaryRecurrent disease
Characterisitic
primary varicella lesions in unvaccinated individual
(CDC, 20
Slide57Varicella Vaccine
Two doses of the vaccine are about 98% effective at preventing chickenpox.
Varicella given at 12-15 months, then second dose is administered from age 4-6
Most people who get chickenpox vaccine will not get chickenpox. But if someone who has been vaccinated does get chickenpox, it is usually very mild. They will have fewer blisters, are less likely to have a fever, and will recover faster.
Slide58Effects of Varicella Vaccine
After one dose of single-antigen varicella
vaccine:
97
% of children 12 months to 12
years developed
detectable antibody titers
.
More
than 90% of vaccine responders maintain antibody for at least 6 years
Slide59Hepatitis A
Hepatitis A, caused by infection with the Hepatitis A virus (HAV), which is
nonenveloped
RNA virus that is classified a
picornavirus
; it has an incubation period of approximately 28 days (range: 15–50 days).
HAV replicates in the liver and is shed in high concentrations in feces from 2 weeks before to 1 week after the onset of clinical illness
Primarily transmitted by the fecal-oral route, by either person-to-person contact or consumption of contaminated food or water.
Disease symptoms: there may be no symptoms, fever, headache, weakness, vomiting, jaundice, joint pain
Disease complication: chronic liver infection, liver failure, liver cancer
(CDC, 2013)
Slide60Hepatitis A
History“Historically children age 2 through 18 years of age have had the highest rates of Hepatitis A” during the mid 1990s (CDC, 2012)1940: Differentiated from Hepatitis B1966: Hepatits A became a nationally reportable case1971: 59,606 reported cases of Hepatitis A; Largest in US history1979: Hepatitis A was isolated1989: Last large nationwide epidemic1995: First licensed vaccine against Hepatitis B1999: ACIP recommends routine vaccination, implemented by states, of children ages 2 and older2006: ACIP revised recomndations and advised children 12 months and older should receive vaccineTexas2005: Requires vaccination for children attending daycare setting (HB 1316, 2005) 2009: All school aged children are required to have 2 doses of Hepatitis A vaccine
(Center for Disease Control and Prevention, 2012)
(Sims, 2009)
Slide61Hepatits A vaccine
Vaccine protects against Hepatitis A
Vaccine given at 12-23 months, and 6 months after first dose
Both doses in children are 0.5 ml IM
Two single-antigen Hepatitis A vaccines, HAVRIX® (manufactured by GlaxoSmithKline) and VAQTA® (manufactured by Merck & Co.,
Inc
), are currently licensed in the United States. A combination vaccine, TWINRIX® (manufactured by GlaxoSmithKline), contains both HAV (in a lower dosage; see table) and Hepatitis B virus antigens.
All are inactivated whole virus vaccines.
Adverse effects of vaccination: soreness where the shot was given, headache, loss of appetite, tiredness
Slide62Effects of Hepatits A vaccine
United States1995: Hepatitis A rates begin to decline1998: Lowest rates of Hepatitits A2002: Rates of children with Hepatitis A have reached similar rates of other age groupsTexasRates have declined due to childhood immunizations2012: 134 cases of Hepatitis A reportedLowest rate since reporting began
Hepatitis A- United States 1966-2009
(Center of Disease Control and Prevention, 2012)
(Texas Department of State Health Services, 2013)
Slide63Long term outcome and management if untreated
Clinical illness usually does not last longer than 2 months, although 10%–15% of persons have prolonged or relapsing signs and symptoms for up to 6 months. Virus may be excreted during a relapse.
Antibody produced in response to HAV infection persists for life and confers protection against reinfection
What occurs if you have not received the vaccine and are exposed? Until recently, an injection of immune globulin (IG) was the only recommended way to protect people after they have been exposed to Hepatitis A virus. In June 2007, U.S. guidelines were revised to allow for Hepatitis A vaccine to be used after exposure to prevent infection in healthy persons aged 1–40
years.Persons
who have recently been exposed to HAV and who have not been vaccinated previously should be administered a single dose of single-antigen Hepatitis A vaccine or IG (0.02 mL/kg) as soon as possible,
within 2 weeks after exposure
(CDC, 2013)
Slide64References
Center for Diseases Control and Prevention. (2012a).
Immunizations: The basics.
Retrieved from
http
://www.cdc.gov/vaccines/vac-gen/imz-basics.htm
Center for Diseases Control and Prevention . (2012b).
How vaccines prevent diseases.
Retrieved from
http
://
www.cdc.gov/vaccines/parents/vaccine-decision/prevent-diseases.html
Centers for Disease Control and
Prevention.
(
2012c).
Hepatitis B: epidemiology and
prevention
of vaccine
preventable
disease. Retrieved from
http://
www.cdc.gov/vaccines/pubs/pinkbook/hepb.html#post
Centers for Disease Control and Prevention [CDC]. (2011). Diphtheria vaccination. Retrieved
from
http://www.cdc.gov/vaccines/vpd-vac/diphtheria/default.htm#vacc
Centers for Disease Control and Prevention [CDC]. (2007). Diphtheria, pertussis, tetanus (
DTaP
)
vaccine
information statements. Retrieved from
ht
tp
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Centers for Disease Control and Prevention [CDC]. (
2012d).
Pertussis (whooping cough).
Retrieved
from
http
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Center for Disease Control and Prevention. (2012). Poliomyelitis.
Retrieved from
http
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Centers
for Disease Control and Prevention [CDC]. (2013). Tetanus. Retrieved
from h
ttp
://www.cdc.gov/tetanus/index.html
Centers for Disease Control and Prevention[CDC]. (1995).
[This neonate is displaying a bodily
rigidity
produced by Clostridium
tetani
exotoxin, called “neonatal tetanus”.]
[
photograph]. Retrieved from
http
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Cunningham
, M.D.,
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, F.G., &
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, T.L. (2013). Medications used in the neonatal
intensive
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A.K
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H.Lebowitz
(Eds.),
Neonatology: management,
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(
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Morbility
and Mortality Weekly Report (2002
). Achievements
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Morbidity and Mortality Weekly Report (2009).
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Slide65References
Texas Department State of Health Services. (2013).
Infectious diseases control:
Hep
B
[
Data file
]
.
Retreived
from
http
://www.dshs.state.tx.us/idcu/disease/hepatitis/hepatitis_b/.
Texas Department State of Health Services. (2013).
Infectious diseases control: Tetanus
[
Data file]
.
Retreived
from
http://www.dshs.state.tx.us/idcu/disease/tetanus/
Texas Department State of Health Services. (2013).
Infectious diseases control: Pertussis
[
Data file]
.
Retreived
from
http://www.dshs.state.tx.us/idcu/disease/pertussis/
Texas Department State of Health Services. (2013).
Infectious diseases control:
Haemophilus
influenzae
serotype B
[Data file]
.
Retreived
from
http
://www.dshs.state.tx.us/idcu/disease/haemophilus_influenzae/
Texas Department State of Health Services. (2013).
Infectious diseases control:
Diptheria
[
Data file]
.
R
etreived
from
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Texas Department State of Health Services. (2013).
Infectious diseases control:
Poliomyleitis
[Data
file]
.
R
etreived
from
http://www.dshs.state.tx.us/IDCU/disease/NotifiableRareConditions/
Wasley
, A.,
Kruszon
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, W.,
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, E. P.,
Finelli
, L.,
McQuillan
, G. &
Bell
B. (2010).
The Prevalence
of Hepatitis B Virus Infection in the United States
in
the Era of Vaccination.
The Journal
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Diseases 202(2).
192-201. DOI:
10.1086/653622