TAB D B A PEDIATRICIAN=S APPROACH TO IMMUNIZATION

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  • 1. TAB D - IMMUNIZATION PEDIATRIC QUESTIONS AND ANSWERS 1. A 2-month-old white male is seen for a well child examination. The infant was delivered vaginally at 32 weeks gestation because of premature rupture of the membranes; he spent 3 weeks in a Neonatal Intensive Care Unit (NICU). He had several seizures during that time, but no cause was determined. He has been seizure-free since hospital dismissal. The developmental assessment and neurologic examination are normal. With respect to administration of pertussis vaccine, the physician should select which one of the following options? A) Administering the standard dose of DTaP vaccine according to the usual schedule. B) Administering the standard dose of DTaP vaccine according to the usual schedule, dividing each dose into several smaller aliquots. C) Substituting DT for DTaP vaccine and proceeding with the usual schedule. D) Delaying administration of DT or DTaP until a progressive neurologic disorder is excluded. E) Avoiding pertussis vaccination at any time in the future. ANSWER: D Clearly, the infant described is at increased risk for convulsion following the administration of pertussis vaccine. The practice of splitting doses of DTaP does not reduce the incidence of untoward events and the administration of split doses is ineffective in providing immunity. Convulsive activity, with or without fever, within 72 hours of receiving pertussis vaccine is an absolute contraindication to subsequent administration of pertussis vaccine. The history of a seizure disorder unrelated to pertussis vaccine is, however, not an absolute contraindication to future use of pertussis vaccine. In such instances, pertussis vaccine may be deferred until the seizure disorder is considered stable and a progressive neurologic disorder is excluded. DTaP (acellular pertussis) is the current vaccine of choice. Ref: 1) Cherry JD, Brunell PA, Golden G, et al: Report of the Task Force on Pertussis and Pertussis Immunization-1988. Pediatrics 1988;81(6):939-984. 2) Pertussis vaccination: Use of acellular pertussis vaccines among infants and young children: Recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR 1997; 46 (RR-7); 1-25. 2. A 9-month-old white male is in your office for a well baby check. His mother mentions that they will be traveling to an area where measles is endemic and wonders if he should be vaccinated. You tell her: A) not to worry, as he should still have enough maternal antibody. B) that allowing the child to contract natural measles is the preferred method of immunization at this age. C) that you recommend monovalent measles vaccine now. D) that you recommend she not take him, as there is no way to protect him at this age. E) that even though not routinely given until 1 year of age, you recommend that, given the circumstances, the MMR vaccine be given now. ANSWER: C The incidence of measles has been greatly reduced since the introduction of an effective vaccine in 1963. However, epidemics continue to occur, and in some areas of this country, as well as many areas abroad, measles is endemic. The Centers for Disease Control recently changed its recommendations concerning the vaccination schedule in preschool children residing in or visiting areas with endemic measles. Specifically, it is recommended that single measles vaccine be given between 9 and 12 months, and MMR thereafter. Infants vaccinated with the monovalent measles vaccine before the first birthday should also receive an MMR at about 15 months. Ref: Measles prevention: Supplementary statement. MMWR 1989;38:11-14. Immunization – page 1 of 17
  • 2. 3. You are seeing a 4-month-old white male for his well child visit. Both his father and his teenage brother have idiopathic epilepsy, which began during early childhood. Six hours after the infant’s 2 month DTP he developed a fever of 39.5 C (103.1p F) rectally. His parents are concerned about the safety of further DTP immunization. Which one of the following is the best approach to DTP immunization at this visit? A) Administer routine DTP immunization B) Administer DTaP (acellular pertussis) C) Administer one half the usual dose of DTP D) Administer DT (no pertussis component) E) Delay further DTP until he is 6 months old ANSWER: B False assumptions regarding contraindications often result in the needless deferment of indicated immunizations. The list of contraindications and precautions for DTP immunization does not include a previous febrile reaction unless the fever was greater than 105 degrees Fahrenheit, nor does it include a family history of seizures. DTaP includes acellular pertussis and has minimal side effects when compared with DTP; sequelae of DTaP administration only very rarely includes seizures or significant febrile reactions and DTaP is the current immunization of choice. Ref: Ad Hoc Working Group for the Development of Standards for Pediatric Immunization Practices: Standards for pediatric immunization practices. JAMA 1993;269(14):1817-1822. 4. A 2-year-old Hispanic female visiting from Mexico presents with a 1week history of repeated episodes of severe coughing. Her mother reports that a runny nose and “cold” preceded the onset of the cough. The mother notes that the family with whom they are staying has a dog who recently contracted “kennel cough”. The child is currently afebrile and appears mildly ill; her lungs are clear. When coughing, she is clearly uncomfortable and vomits a small amount of mucus. Your management would include which one of the following? A) Hospitalization for ribavirin (Virazole) aerosol therapy B) Reassurance that the cough will abate over the next week C) Oral erythromycin therapy for 2 weeks D) Having the dog treated by a veterinarian to avoid spread of this infection to other persons in the home E) Administration of immune serum globulin intramuscularly ANSWER: C This child’s presentation is highly suspicious for pertussis, given the severe coughing paroxysms and possibility of inadequate immunization. Two weeks of oral erythromycin is recommended for mildly to moderately ill children, principally to halt the spread of the illness. Ribavirin, was previously commonly used, but now is rarely, if ever, recommended for respiratory syncytial virus (RSV) infection, generally seen in much younger children and with more respiratory distress. The cough of pertussis often lasts several weeks. Although “kennel cough” is produced by a canine Bordetella species, B. pertussis is seen only in humans. Immune globulin is not recommended. Ref: Hoekelman RA (ed): Primary Pediatric Care, ed 2. Mosby-Year Book Inc. 1992, pp 1445-1447. 2) Peter G (ed): 1994 Red Book: Report of the Committee on Infectious Diseases. American Academy of Pediatrics, 1994, p 356. 5. The United States Public Health Service Advisory Council on Immunization Practices (ACIP) has recommended several alternatives for polio vaccination, including the intramuscular enhanced-potency inactivated polio virus vaccine (eIPV). Which one of the following is a specific expected benefit of this vaccine? A) Provision of enhanced immunity in a larger percentage of the population B) Reduction of the world wide spread of wild polio virus types C) Reduction of the number of necessary doses of polio vaccine from four to two D) Reduction of vaccine-induced polio in immunodeficient recipients or their contacts ANSWER: D The relatively new recommendation for alternative methods of vaccination against polio virus is for the purpose of eliminating the few (approximately 8/year in the U.S.) cases of vaccine-induced polio. It is particularly indicated for primary immunization of patients with congenital or acquired immune deficiency states or altered immune status, as well as for members of their household or close contacts. Routine use of inactivated polio preparation is now standard practice in America. Ref: Institute for Clinical Systems Integration: Pediatric immunization. Postgrad Med 1996:100(5):213-225. 2) Vaccine side Immunization – page 2 of 17
  • 3. effects, adverse reactions, contraindications, and precautions: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1996:45(RR-12):8-9. 6. The influenza vaccine is contraindicated in patients who have hypersensitivity to: A) citrus. B) eggs. C) penicillin. D) quinolones. E) sulfa. ANSWER: B Up to 5% of individuals will experience low-grade fever and mild systemic symptoms 8 to 24 hours after vaccination with influenza vaccine, and up to 1/3 will have mild redness or tenderness at the vaccination site. Since the vaccine is produced in eggs, individuals with true hypersensitivity to egg products (i.e., who can not eat eggs without an anaphylactic reaction) either should be desensitized or should not receive the vaccine. Ref: Fauci AS, Braunwald E, Isselbacher KJ, et al (eds): Harrison’s Principles of Internal Medicine, ed 14. McGraw-Hill, 1998, p 1116. 7. Which one of the following is the preferred site for intramuscular injection of medication or vaccines in infants? A) Upper arm B) Upper abdomen C) Buttock D) Anteromedial thigh E) Anterolateral thigh ANSWER: E The abdomen is not a preferred site for routine immunizations. Abdominal injections typically are limited to subcutaneous insulin administration in older children and adolescents. Serious complications of intramuscular injection include infections and neurovascular or muscular injuries. Severe nerve injuries are the result of direct intrafascicular injection. Two sites where such injuries can occur in young infants are the upper arm and the buttock (dorsogluteal muscle). Injection into the sciatic nerve can lead to foot drop, or even paralysis of the lower extremity. Infants and children are at special risk for this complication due to their limited muscle mass. The radial nerve has a superficial location throughout the middle third of the upper arm. Thus, the buttock and upper arm (deltoid muscle) should be avoided as injection sites for infants. The preferred site is the anterolateral thigh. Ref: Peter G (ed): 1997 Red Book: Report of the Committee on Infectious Diseases, ed 24. American Academy of Pediatrics, 1997, p 14. 2)Losek JD, Gyuro J: Pediatric intramuscular injections: Do you know the procedure and complications? Pediatr Emerg Care 1992; 8 (2): 79-81. 3) McMillan JA, DeAngelis CD, Feigin RD, et al (eds): Oski’s Pediatrics: Principles and Practice, ed 3. Lippincott Williams & Wilkins, 1999, pp 479-481. 8. Which one of the following is a contraindication to pertussis vaccination? A) Soreness, redness, or swelling in the immediate vicinity of the vaccination site after a previous DTaP/DTP immunization. B) Temperature greater than 104.9° temporally associated with the previous DTaP/DTP immunization. C) A diarrheal illness in an otherwise well child. D) Current antimicrobial therapy. E) A family history of sudden infant death syndrome (SIDS). ANSWER: B Some health-care providers inappropriately consider certain conditions or circumstances to be contraindications to vaccination. Of the options listed, only high fever (>40.5°C) after a previous DTaP/DTP is a contraindication to routine vaccination. Absolute contraindications for giving pertussis vaccine include: anaphylactic reaction, encephalopathy within 24 hours, fever > 104.9°F, convulsions within 3 days, shock within 48 hours, persistent crying >3 days. Ref: Peter G (ed): 1997 Red Book: Report of the Committee on Infectious Diseases, ed 24. American Academy of Pediatrics, 1997, pp 404-405. Immunization – page 3 of 17
  • 4. 9. Which one of the following immunizations is contraindicated in pregnancy? A) Varicella-zoster immune globulin (VZIG) B) Diphtheria-tetanus toxoid C) Influenza vaccine D) Hepatitis B vaccine E) Rubella vaccine ANSWER: E Susceptible women with acute exposure to varicella should receive varicella-zoster immune globulin (VZIG). As a general rule, only live viral or bacterial vaccines are contraindicated in pregnancy. The most commonly used live virus vaccines in the United States are measles, mumps, and rubella (MMR). Ideally, all women of childbearing age should be immune to measles, mumps, rubella, as well as diphtheria, tetanus, pertussis, and poliomyelitis. Women who are susceptible may receive toxoids or inactivated vaccines, if clinically indicated, during pregnancy. Live virus vaccinations should be deferred until after delivery. Certain obstetric patients merit special consideration for vaccination during pregnancy. Patients with risk factors for hepatitis B should be vaccinated with the recombinant vaccine. Patients with acute exposure to hepatitis B should also receive Hepatitis B Immune Globulin (HBIG). Pregnant women who have cardiopulmonary disease (e.g., CHF or asthma), diabetes, hemoglobinopathy, or chronic renal disease are candidates for the influenza vaccine. Some authorities actually recommend influenza vaccines be given to all pregnant women (unless they have a true allergy to eggs). Ref: Cunninham FG, MacDonald PC, Gant NF, et al: Williams Obstetrics, ed 20. Appleton & Lange, 1997, p 243. 2) Peter G (ed): 1997 Red Book: Report of the Committee on Infectious Diseases, ed 24. American Academy of Pediatrics, 1997, p 461. 3) Holzman GB (ed): Precis, Obstetrics: An Update in Obstetrics and Gynecology. American College of Obstetricians and Gynecologists, 1998, pp 79-82. Immunization – page 4 of 17
  • 5. 10. A 15-month-old boy is brought to the family physician’s office by his mother for a check-up. She usually brings him to the physician’s office only when he is ill and not for regular visits as recommended. There is no record of any vaccinations since his two-month visit. The mother reports that the boy’s four-year-old sister came home yesterday with a temperature of 103°F (39.3° C) after visiting her father. Her fever is lower today, but is still around 101° F (38.3° C). The boy’s body temperature is normal, and he appears completely healthy. Which of the following statements is true regarding this child? A) His entire immunization series should be restarted because it has been more than a year since the last vaccination. B) Doses of the same vaccine may be given at intervals of as little as one month when “catching up” on missed vaccines. C) The presence of fever in a household contact is a contraindication to administration of any immunizations at this visit. D) All of the missed vaccines should be administered at this office visit. ANSWER: B A vaccine series never needs to be restarted. If a child misses one or more vaccinations, the series may be continued at the point where it was interrupted. When “catching up” on missed vaccines, doses of the same vaccine series may be given at intervals of as little as one month. The presence of febrile illness in a household contact does not constitute a contraindication to vaccination of this child. 11. Which of the following vaccines is recommended by the Advisory Committee on Immunization Practices (ACIP) for immunization of infants against diphtheria, tetanus, and pertussis? A) Diphtheria, tetanus, and whole-cell pertussis (DTP) vaccine (Tri-Immunol®). B) Diphtheria, tetanus, and acellular pertussis (DTaP) vaccine (Acel-Imune®, Tripedia®). C) Diphtheria and tetanus toxoids (DT). D) Diphtheria and tetanus toxoids, adsorbed (adult type) (Td). ANSWER: B The Advisory Committee on Immunization Practices (ACIP) recommends that diphtheria, tetanus, and acellular pertussis (DTaP) vaccine (Acel-Imune®, Tripedia®) be used preferentially over diphtheria, tetanus, and whole-cell pertussis (DTP) vaccine (Tri- Immunol®) in this patient population because of its lower incidence of adverse reactions. Diphtheria and tetanus toxoids (DT) and diphtheria and tetanus toxoids, adsorbed (adult type) (Td), do not provide immunization against pertussis. Td is used as the adult booster dose after the primary immunization series has been completed and in children over six years of age. 12. Which of the following statements is true regarding vaccination against polio virus in the United States? A) The current recommended vaccination series consists of only the enhanced potency inactivated poliovirus vaccine (eIPV) (IPOL®, Poliovax®). B) The current recommended vaccination series consists of two does of eIPV followed by two doses of OPV. C) The incidence of vaccine-associated paralytic poliomyelitis (VAPP) has increased since the introduction of IPV. D) Immunocompromised household contacts of children who continue to receive an all-dose series of OPV are at no increased risk for VAPP. ANSWER: A Live oral poliovirus vaccine (OPV) was once used for all four polio vaccinations in the standard series administered to children in the United States because of the vigorous mucosal immunity it provides. For all patients, especially for those who are immunocompromised and those with immunocompromised household contacts, eIPV is the only vaccine recommended for use. Thus, since January 2000, the latest ACIP recommendation is that the United States adopt an eIPV-only polio vaccination schedule. Ref: Pediatrics, Dec 1999: AAP update policy. Immunization – page 5 of 17
  • 6. 13. An outbreak of measles occurs in a community. An eight-month-old girl is brought in by her mother for a routine check-up. Which of the following statements is true regarding this patient? A) She should receive measles-mumps-rubella (MMR) vaccine (M-M-R-II®) at this visit, with the second dose administered at four to six years of age; no further dosing is needed. B) She should receive MMR vaccine at this visit, with the second dose administered at 12 to 15 months of age; no further dosing is needed. C) She should not receive MMR vaccine until she is 12 to 15 months of age; she will then need a second dose at four to six years of age. D) She should receive MMR vaccine at this visit; she will then need a second dose at 12 to 15 months of age and an additional dose at four to six years of age. ANSWER: D Two doses of measles-mumps-rubella vaccine (MMR II®) are recommended, with the first given between 12 and 15 months of age and the second between four and six years of age. In the event of an epidemic, the initial dose may be given to patients under 12 months of age, but is not considered a “true” first dose and should be followed by the complete, standard vaccination series. 14. A 19-month-old boy presents for a routine health maintenance visit. To date, he has received only one dose of Haemophilus influenzae type b (Hib) vaccine. Which of the following statements is true regarding this patient? A) One more dose of Hib vaccine is required and may be given at this visit. B) He should continue with the regular Hib series and receive three additional doses of vaccine given at one-month intervals. C) No further Hib vaccination is necessary because children are not at substantial risk from H. influenzae infection after 15 months of age. D) He should receive a double dose of Hib vaccine at this visit; no further vaccinations are necessary. ANSWER: A Immunization schedules vary for the different Haemophilus influenzae type b (Hib) vaccine formulations. Typically, Hib vaccinations are given at two, four, and six months of age, and between 12 and 15 months of age. A child presenting between the ages of 15 months and 5 years should receive only one dose of vaccine, regardless of the number of doses received before 15 months of age. 15. All of the following infants should receive varicella-zoster immune globulin after exposure to chickenpox except: A) An immunocompromised infant with no history of varicella. B) A healthy four-month-old infant whose older sibling has chickenpox. C) A neonate whose mother developed varicella three days before delivery. D) A premature neonate. ANSWER: B Varicella-zoster immune globulin (VZIG) is not routinely recommended for all infants exposed to chickenpox. An infant who has been exposed to chickenpox should be given VZIG in the following circumstances: (1) the infant is immunocompromised and has no history of varicella, (2) the infant’s mother had onset of varicella during the period between five days before and two days after delivery, or (3) the neonate was born prematurely. Immunization – page 6 of 17
  • 7. 16. A seven-month-old boy who attends a day-care center is brought in by his parents for a well-child visit. The parents have read about a vaccine against rotavirus infection and want their infant immunized. Which of the following statements is true regarding this vaccine? A) The standard series consists of three injections given at intervals of at least six weeks. B) The vaccine may not be administered concurrently with any other routine immunizations. C) This vaccine series should not be initiated. D) Breast-feeding is a contraindication to vaccination. E) The child should not attend day care for one week after immunization because of the high rate of viral shedding associated with vaccination. ANSWER: C In July 1999, the Centers for Disease Control and Prevention, American Academy of Family Physicians, and American Academy of Pediatrics recommended that administration of the rotavirus vaccine (RotaShield), a tetravalent vaccine, be suspended because of studies reporting an increased rate of intussusception in infants receiving the vaccine. 17. With the exception of hepatitis B immunization administration when mothers are hepatitis B surface antigen negative, the immunization schedule in preterm infants should be A) altered so that DTaP immunization is preceded by a 0.1-ml test dose. B) altered so that inactivated polio vaccine is given for the first two doses. C) delayed until catch-up growth (growth acceleration) has begun. D) based on chronologic (postnatal) age. E) based on corrected (postconceptual) age. ANSWER: D Although preterm infants have a variety of reasons for relative immunodeficiency, they generally have a normal response to immunization. It has been demonstrated that if the timing of immunization is based on postnatal rather than postconceptual age, preterm infants have a competent immunologic response. Therefore, the American Academy of Pediatrics has recommended that preterm infants be immunized using the same standard schedule used for term infants. The only exception to this is preterm infants weighing less than 2 kg who are born to HBsAg-negative women. Seroconversion rates in very low birth weight infants may be lower than at an older age for hepatitis B vaccination; thus, it is recommended that very low birthweight preterm infants should not be vaccinated until just before hospital discharge providing the infant weighs 2 kg or more, or until 2 months of postnatal age when other immunizations are given. Ref: Peter G (ed): 1997 Red Book: Report of the Committee on Infectious Diseases. American Academy of Pediatrics, 1997, pp 254-255. 18. A 2-month-old white male is seen for a well child examination. The infant was delivered vaginally at 32 weeks gestation because of premature rupture of the membranes; he spent 3 weeks in a Neonatal Intensive Care Unit (NICU). He had several seizures during that time, but no cause was determined. He has been seizure-free since his release from the hospital. The developmental assessment and neurologic examination are normal. With respect to administration of pertussis vaccine, the physician should elect which one of the following options? A) Administering the standard dose of DTaP vaccine according to the usual schedule B) Administering the standard dose of DTaP vaccine according to the usual schedule, dividing each dose into several smaller aliquots C) Substituting DT for DTaP vaccine and proceeding with the usual schedule D) Delaying administration of DTaP or DT until a progressive neurologic disorder is excluded E) Avoiding pertussis vaccination at any time in the future ANSWER: D Clearly, the young infant described is at increased risk for convulsion following the administration of pertussis vaccine. The practice of splitting doses of DTP has not been proven to reduce the incidence of untoward events and its effectiveness in providing immunity is unknown. Convulsive activity, with or without fever, within 72 hours of receiving pertussis vaccine is an absolute contraindication to subsequent administration of pertussis vaccine. The history of a seizure disorder unrelated to perussis vaccine is, however, not an absolute contraindication to further use of pertussis vaccine. In such instances, pertussis vaccine may be deferred until the seizure disorder is considered stable and a progressive neurologic disorder is excluded. In the United States, children in the first year of life with neurologic disorders that necessitate temporary deferral of pertussis immunization often do not receive either DT or DTP because the risk of acquiring diphtheria or tetanus in children less than 1 year of age is remote. At the first birthday, or as early in the second year of life as feasible, the decision to give either DTaP or DT should be made. Immunization – page 7 of 17
  • 8. Ref: Pertussis vaccination: Use of acellular pertussis vaccines among infants and young children: Recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR 1997; 46 (RR-7); 1-25. 19. None of the following pediatric patients has a history of varicella infection. In which one of the patients presenting for well child care should varicella vaccine be postponed? A) A 13-year-old whose mother never had chickenpox or the vaccine B) A 6-year-old who just immigrated from Brazil C) A 5-year-old who received high-dose systemic corticosteroids for asthma 2 weeks ago D) A 2-year-old with a documented anaphylactic reaction to eggs E) A 14-month-old who will be given MMR vaccine on this visit ANSWER: C Varicella vaccine is recommended for everyone over a year old who is in good health and has no history of clinical varicella, including adults, who should receive two doses one month apart It can be administered at the same time as MMR, using separate syringes and injection sites. It is especially indicated in immigrants from tropical countries, where the disease is less common and the patient is thus more likely immunosusceptible. As the varicella vaccine virus is attenuated, transmission of the vaccine virus from healthy vacinees to others is theoretically possible but has not been documented. Ideally, unvaccinated susceptible adults could be vaccinated at the same time. The vaccine should not be given to patients who have received high doses of systemic steroids in the previous month, because of possible safety and immunogenicity issues. Chicken embryos are not a part of the manufacturing process, nor are eggs, so allergy to eggs is not a contraindication. 20. You are seeing a 4-month-old white male for his well-child visit. Both his father and his teenage brother have idiopathic epilepsy, which began during early childhood. Six hours after the infant’s 2-month DTaP he developed a fever of 39.5°C (103.1°F) rectally. His parents are concerned about the safety of further DTP immunization. Which one of the following is the best approach to DTaP immunization at this visit? A) Administer the routine DTaP immunizaiton B) Administer DTaP (acellular pertussis) C) Administer one-half the usual dose of DTaP D) Administer dT (no pertussis component) E) Delay further DTaP until he is 6 months old ANSWER: A False assumptions regarding contraindications often result in the needless deferment of indicated immunizations. The list of contraindications and precautions for DTaP immunization does not include a previous febrile reaction unless the fever was greater than 105°F, nor does it include a family history of seizures. Ref: Ad Hoc Working Group for the Development of Standards for Pediatric Immunization Practices: Standards for pediatric immunization practices. JAMA 1993; 269 (14): 1817-1822. Immunization – page 8 of 17
  • 9. 21. The measles (rubeola) vaccine recommended for use in the United States A) is a killed virus vaccine. B) is optimally given at 18 months of age. C) may be used in infants 6 to 12 months of age who have been recently exposed to measles. D) is contraindicated if the patient has been exposed to measles. E) may cause subacute sclerosing panencephalitis (SSPE). ANSWER: C The measles (rubeola) vaccine recommended for use in this country is a live attenuated vaccine and is recommended for routine use at 12-15 months of age. But, whenever there is likely exposure to natural measles, infants as young as 6 months should be vaccinated and then revaccinated at 12-15 months to ensure protection. Exposure to measles is not a contraindication to vaccination, and if the vaccination is given within 72 hours of exposure, it may provide protection. Studies indicate that measles vaccine, by protecting against measles, significantly reduces an individual’s chances of developing subacute sclerosing panencephalitis (SSPE), a “slow virus” infection of the central nervous system associated with a measles-like virus. Ref: Behrman RE, Kliegman RM, Jenson HB (eds): Nelson Textbook of Pediatrics, ed 16. WB Saunders Co, 2000, pp 948-949. CASE PRESENTATION: Questions 22-27 True/False A 14-month-old boy presents to a family practice clinic as a new patient. His mother explains that the family has just recently moved to the area from Germany, where her husband has been stationed with the U.S. Air Force. The boy is current with most of his vaccination series, but needs to receive his first dose of varicella vaccine (Varivax) at this visit. The following topics are appropriate to include in a discussion between the physician and the child’s mother regarding this vaccine: 22. The likelihood of seroconversion after vaccination of a child this age is greater than 95 percent. A) True B) False 23. The vaccine has been shown to reduce the incidence of episodes of herpes zoster. A) True B) False 24. The most common side effect of vaccination is transient arthralgia. A) True B) False 25. The risk of developing generalized varicella after vaccination is less than 1 percent. A) True B) False Immunization – page 9 of 17
  • 10. 26. Recipients of the vaccine who develop generalized varicella are more infectious than non-immunized patients who develop the infection. A) True B) False 27. Children with an immunocompromised household contact may be vaccinated. A) True B) False ANSWERS: A, A, B, B, B, A The varicella vaccine (Varivax) is a live, attenuated vaccine. It is given to children between one and 12 years of age and results in a 97 percent seroconversion rate. In older children and adults, the seroconversion rate is about 80 percent after one dose and 98 percent or greater after two doses, thus two doses are given at one month intervals to adolescents and young adults. As it is attenuated, the vaccine has also been demonstrated to reduce the incidence of episodes of herpes zoster in healthy recipients. The most common side effects of vaccination are fever, which is seen in ~15 percent of vaccine recipients, and generalized varicella, which is seen in ~5 percent of recipients. Vaccinated persons who subsequently develop generalized varicella may infect other susceptible individuals. Children vaccinated with the attenuated virus are less infectious than non-vaccinated individuals because if they do acquire varicella they tend to have fewer skin lesions than those infected by the wild virus. Thus, it is actually safer for the immunocompromised patient to be exposed to an immunized patient rather than one who could acquired and transmit the wild virus to contacts. Children should be vaccinated against varicella even in the presence of an immunocompromised household contact. TRUE/FALSE: (Questions 28-30) 28. Premature infants should be vaccinated according to their chronologic age and without modification of the standard vaccine dose. A) True B) False ANSWER: A Premature infants should be vaccinated according to their chronologic age and without modification of the standard vaccine dose. The use of live vaccines should be avoided if premature infants are to be vaccinated while still in a Neonatal Intensive Care Unit (e.g., inactivated polio virus vaccine is always used instead of live polio virus vaccine.) 29. Pertussis vaccination is contraindicated in an infant with a history of uncomplicated febrile seizures. A) True B) False ANSWER: B Administration of the pertussis component of DTP or DTaP vaccine should be postponed in children with evolving neurologic conditions. However, it is acceptable for use in children with a non-progressive brain injury or in those with a history of simple febrile seizures. DTaP is more appropriate in children with a history of febrile seizures because it produces less fever as a side effect. Immunization – page 10 of 17
  • 11. 30. A nine-month-old non-immunized child develops invasive disease secondary to infection with Haemophilus influenzae type b. The child recovers fully. Vaccination with H. influenzae type b vaccine is not necessary to prevent future infection because the child can be expected to have developed sufficient antibodies from the infection. A) True B) False ANSWER: B Administration of Haemophilus influenzae type b vaccine is most important for children less than 15 months of age. Vaccination is also important for children less than two years of age who develop invasive illness secondary to H. influenzae infection because these children do not subsequently develop adequate immunity to the bacteria. DIRECTIONS: Below is a multiple true-false problem which consists of a stem and four or five lettered options. For each of these lettered options, indicate “T” if the option is true or “F” if the option is false. 32. A 15-month-old child is brought to the office because of a runny nose and temperature of 38.0 C (100.4 F). The child has received no immunizations. Which immunizations could/should be given at this time? A) Diphtheria/tetanus/acellular pertussis vaccine (DTaP). B) Inactivated polio vaccine (IPV). C) Haemophilus influenzae type b vaccine (Hib C). D) Measles/mumps/rubella vaccine (MMR). E) Varicella vaccine (Varivax). ANSWERS: A) True; B) True; C) True; D) True; E) True Mild acute illness with or without low-grade fever is not a contraindication to giving vaccinations. If follow-up is not assured, HBV, DTaP, IPV, Hib C, MMR, and varicella vaccine may be given concurrently. Ref: Kimmel SR, Madlon-Kay DJ, Burns IT, et al: Breaking the barriers of childhood immunization. Am Fam Physician 1996;53(5):1649-1652. 33. The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) has recommended the use of inactivated poliovirus vaccine for routine childhood immunization. Which one of the following is the expected benefit of this change? A) Provision of enhanced immunity in a larger percentage of the population B) Reduction of the worldwide spread of wild poliovirus types C) Reduction of the number of required doses of polio vaccine from four to two D) Reduction of vaccine-induced polio in immunodeficient recipients or their contacts ANSWER: D The new recommendation for alternative methods of vaccination against poliovirus is for the purpose of eliminating the few (8/year in the U .S.) cases of vaccine-induced polio. Ref: Sutter RW, Prevots DR, Cochi SL: Poliovirus vaccines: Progress toward global poliomyelitis eradication and changing routine immunization recommendations in the United States. Pediatr Clin North Am 2000; 47(2): 287-308. (ABFP, 2000). Immunization – page 11 of 17
  • 12. 34. True statements regarding preventable childhood illnesses include which of the following? A) Children who have not received hepatitis B vaccine should be immunized at 11-12 years of age B) Everyone born after 1956 should receive the MMR one time only C) In a person requiring measles immunization, MMR should be given instead of measles vaccine alone D) Administration of live attenuated oral polio vaccine can result in paralytic illness ANSWERS: A) T; B) F; C) T; D) T If three doses of hepatitis B were, not administered during infancy, children should receive the vaccine before the ages of 11-12. It is now strongly recommended (and required in public schools and many colleges) that everyone born since 1956 receive a two-dose measles immunization. Because the same epidemiologic characteristics pertain to mumps and rubella as well, MMR rather than the monovalent measles vaccine is the vaccine of choice. There is no evidence to suggest adverse consequences from giving MMR to a person who is already immune to one or more of its components as a result of earlier immunization or natural disease. Although uncommon, paralytic illness can occur after the administration of the live attenuated oral polio vaccine. For adults requiring primary immunization, the enhanced-potency inactivated polio vaccine (eIPV) eliminates the risk of vaccine-associated paralytic illness. A one-time booster of either eIPV or OPV is indicated for previously immunized travelers to areas where poliomyelitis remains a threat. Ref: Pickering LK (ed): 2000 Red Book: Report of the Committee on Infectious Diseases, ed 25. American Academy of Pediatrics, 2000, pp 292-296, 389-396, 465-470. (ABFP, 2000, 171). 35. Which one of the following is true concerning varicella zoster virus (VZV) infection and varicella vaccine? A) Immunity rarely results from subclinical infection. B) Immigrants from tropical countries are less susceptible to VZV infection than U.S. residents of similar age C) Vaccinated children who subsequently develop mild disease cannot transmit the infection D) The incidence of zoster after vaccination with varicella vaccine is no higher than after natural varicella infection ANSWER: D Varicella zoster virus (VZV) is the cause of varicella (chickenpox) , a primary infection, and zoster (shingles), a secondary infection which is the result of reactivation of latent VZV. In persons over 18 years of age with no known history of varicella, over 70% have been infected, resulting in positive serology. Live attenuated varicella vaccine was licensed by the Food and Drug Administration in March 1995. Vaccines may produce a varicella syndrome that is milder than that in unvaccinated children. Vaccinated children with mild disease may be potentially infectious to susceptible individuals. The incidence of zoster after vaccination is no higher than that occurring after natural varicella. Ref: American Academy of Pediatrics, Committee on Infectious Diseases: Recommendations for the use of live attenuated varicella vaccine. Pediatrics 1995; 95(5): 791-796. 2) Pickering LK (ed): 2000 Red Book: Report of the Committee on Infectious Diseases, ed 25. American Academy of Pediatrics, 2000, pp 631-632. (ABFP, 2001, 10). 36. Following recent exposure to the varicella virus, varicella-zoster immune globulin (VZIG) should be administered to: A) all individuals over age 20. B) women of childbearing age. C) children between 1 week and 1 year of age. D) children with leukemia. ANSWER: D Immunization – page 12 of 17
  • 13. The most reliable hormonal change in early menopause is an increase in circulating follicle-stimulating hormone (FSH). Levels of estrogen and estrone may be maintained in the low-normal range, even after ovarian failure, due to the peripheral conversion of androgens. Progesterone and testosterone levels fall with the menopause, but not before FSH levels rise. Luteinizing hormone (LH) is elevated with menopause, but may also be elevated in mid-cycle or in casts of chronic anovulation, making this test less specific than FSH for confirming menopause. Ref: Berek JS, Adashi EV, Hillard PA (eds): Novak's Gynecology, ed 12. Williams & Wilkins, 1996, pp 983-991. (ABFP, 2001, 110). 37. Which one of the following is true regarding diphtheria, tetanus, acellular pertussis (DTaP) immunization? A) Live virus vaccines must not be given simultaneously with DTaP B) If the fourth dose is given after the fourth birthday, the preschool dose is not indicated C) DTaP is recommended for persons over 7 years of age every 10 years D) The minimum interval between DTaP doses is 12 weeks ANSWER: B If the recommended dose of DTaP is missed at 18 months, the booster dose at school entrance is adequate protection for school-age children. Td (adult type) is recommended for those over 7 years of age. The usual minimal interval between doses for children following the recommended schedule is 8 weeks. Live virus vaccines such as MMR may be administered concurrently. Ref: Pickering LK (ed): 2000 Red Book: Report of the Committee on Infectious Diseases, ed 25. American Academy of Pediatrics, 2000, pp 441-442. (ABFP, 2001, 127). 38. A 2-year-old white male who has not received any immunizations is diagnosed with pertussis. His babysitter should: A) receive a DTP booster. B) allow him to return to day care within 48 hours of treatment initiation. C) receive erythromycin prophylaxis. D) be reassured that she will not develop pertussis, because she has been immunized. ANSWER: C Household and other close contacts of children with pertussis, whether children or adults, should be prophylactically treated with oral erythromycin for 14 days at a dosage of 40-50 mg/kg/day (maximum 2 g/day) in four divided doses. Pertussis boosters are given only to children under 7 years of age. Children with pertussis may be allowed to return to day care after 5 days of erythromycin therapy, assuming their general condition permits unrestricted activity. Completely immunized individuals can still develop pertussis, but the disease is typically milder. Ref: Pickering LK (ed): 2000 Red Book: Report of the Committee on Infectious Diseases, ed 25. American Academy of Pediatrics, 2000, pp 438-439. (ABFP, 2001, 162). 39. An 8-year-old African-American male has a presumptive diagnosis of meningococcal meningitis, based on clinical findings and the presence of gram-negative diplococci in the cerebrospinal fluid. Cultures are pending. Which one of the following would be the most appropriate intervention for other members of his household? A) Isolation until the incubation period is past B) Immediate administration of meningococcal vaccine C) Immediate administration of oral rifampin (Rifadin) D) No intervention unless symptoms develop ANSWER: C Chemoprophylaxis with rifampin or ceftriaxone is indicated for close contacts (including household and child care contacts) of all persons with invasive meningococcal disease. This includes contact with the index case during the 7 days prior to the onset of symptoms. Ideally, this prophylaxis should be started within 24 hours of case identification. It is probably not very useful if more than 2 weeks have elapsed since the contact. Although vaccination is indicated during an outbreak of the serogroups contained in the vaccine, it does not prevent early-onset disease. Ref: American Academy of Pediatrics Committee on Infectious Diseases, Canadian Pediatric Society Infectious Diseases and Immunization Committee: Meningococcal disease prevention and control strategies for practice-based physicians. Pediatrics 1996; 97(3): 404-411. (ABFP, 2001, 164). Immunization – page 13 of 17
  • 14. 40. An 18-year-old patient presents with his father for a pre-college physical examination. The student plans to attend college in a nearby state and will live in a university-owned residence hall. A review of his record shows that he received all of the currently recommended immunizations on time throughout childhood. The benefits of vaccination against which one of the following organisms should be discussed during his visit? A) Measles B) Tetanus C) Pertussis D) Meningococcus E) HIV ANSWER: D College freshmen, especially those who live in dormitories, are at a modestly increased risk for meningococcal disease compared with other persons of the same age, and vaccination with the currently available quadrivalent meningococcal polysaccharide vaccine will decrease their risk. The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommends that incoming and current college freshmen, and their parents, be informed about meningococcal disease and the benefits of vaccination. This is particularly true for those who live in dormitories and residence halls. In this case, the patient has received vaccinations against measles, tetanus, and pertussis at the recommended times, and booster vaccinations are not indicated now. Regretfully, there is no HIV vaccine currently utilized outside of research settings. Ref: Meningococcal disease and college students: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMR 2000; 49(RR-7): 13-20. (ABFM 2002) 41. You diagnose varicella in the two preschool children of a 28-year-old patient. She has no history of having had the disease, and serology done in your office confirms her lack of immunity. A pregnancy test is also negative and you tell her to return for a varicella vaccination, which she does the following week. She returns after 5 weeks because a home pregnancy test is now positive, and a pregnancy test in her physician’s office is also positive. She is concerned about the effect of varicella vaccine on the fetus. Which one of the following would be the most accurate advice? A) There is little likelihood of a problem. B) She should receive varicella zoster immune globulin (VZIG) to protect the fetus. C) She has a high likelihood of having a spontaneous abortion. D) Women receiving varicella vaccine during the first trimester are likely to have children with congenital varicella. E) Her risk of problems would be much higher in the second or third trimester. ANSWER: A In a study of varicella vaccine exposure during pregnancy, rates of congenital varicella syndrome and congenital abnormalities were calculated for seronegative women receiving vaccine during pregnancy. No cases of congenital varicella syndrome and no specific pattern of congenital abnormalities were identified among women receiving the vaccine. Ref: Shields KE, Galil K, Seward J, et al: Varicella vaccine exposure during pregnancy: Data from the first 5 years of the pregnancy registry. Obstet Gynecol 2001;98(1):14-19. (ABFM 2002) 42. In a infant, pneumococcal 7-valent conjugate vaccine (Prevnar) is preferred rather than polyvalent pneumococcal vaccine (Pneumovax) because of which one of the following advantages? A) It is available in an oral form. B) It is less expensive. C) It requires only one dose. D) It can be combined with MMR in a single injection. E) It is more immunogenic. ANSWER: E Pneumococcal 7-valent vaccine (Prevnar) produces a satisfactory immune response in a infant, while polyvalent vaccine does not induce a good antibody response in children under the age of 2. Neither vaccine is available orally. The advantages of protecting infants against invasive pneumococcal disaease are cost-effective though many states and insurance companies do not yet cover the cost of Prevnar. The 7-valent vaccine requires multiple doses. Neither vaccine can be combined with MMR in a single injection. Immunization – page 14 of 17
  • 15. Ref: 1) Preventing pneumococcal disease among infants and young children: Recommendations of the Advisory Committeee on Immunization Practices. MMWR 2000;49(RR-9). 2) American Academy of Pediatrics Committee on Infectious Diseases: Technical Report: Prevention of pneumococcal infections, including the use of pneumococcal conjugate and polysaccharide vaccines and antibiotic prophylaxis. Pediatrics 2000;106(2pt 1)367-376. (ABFM 2002) 43. Which one of the following is a contraindication to immunization with MMR? A) A household member of the patient has an immunodeficiency. B) The mother of the patient is pregnant. C) The patient is pregnant. D) The patient had a tuberculosis skin test (PPD) within the previous 2 days. E) The patient is breastfeeding her newborn infant. ANSWER: C The failure to provide immunizations because of perceived contraindications is one of the most common reasons for an inadequately protected population. If the patient is pregnant or immunodeficient, rather than a household contact, then MMR is contraindicated. A PPD may be falsely negative if administered 2-30 days after, not before, MMR administration. Breast feeding is not a contraindication. Ref: 1)Institute for Clinical Systems Integration: Pediatric immunization. Postgrad Med 1996;100(5):213-225. 2) Pickering LK (ed): 2000 Red Book: Report of the committee of Infectious Diseases, ed 25. American Academy of Pediatrics, 2000, pp 34-35, 38-39, 393-395. (ABFM 2002) 44. An 11-year-old white male cut his foot when he stepped on a pecan shell while walking barefoot in his back yard. On examination the laceration is deep, with ragged edges. Your records indicate that the patient has completed a full primary immunization series with tetanus toxoid. His last tetanus toxoid injection was 7 years ago. This patient should be given: A) tetanus toxoid. B) tetanus immune globulin (TIG) and tetanus toxoid. C) TIG and Td. D) combined tetanus and diphtheria toxoid (Td). E) no immunizations at this time. ANSWER: D This patient presents with a contaminated wound and a completed primary immunization series for tetanus. According to Centers for Disease Control guidelines, he should receive tetanus prophylaxis, because it has been more than 5 years since his previous tetanus immunization. Combined tetanus and diphtheria toxoid is preferred, as it also enhances diphtheria protection. Half-doses are not recommended. Ref: Braunwald E, Fauci AS, Kasper DL, et al (eds): Harrison's Principles of Internal Medicine, ed 15. McGraw-Hill, 2001, p 920. 45. In addition to routine immunizations, which one of the following is specifically indicated for adolescent males who have sex with other males? A) Polio vaccine B) Varicella virus vaccine C) Pneumococcal polysaccharide vaccine D) Hepatitis A vaccine E) MMR ANSWER: D Immunization – page 15 of 17
  • 16. Hepatitis A vaccine should be administered to unvaccinated adolescents who plan to travel to or work in an area of high endemicity of hepatitis A virus infection, those who receive clotting factors, those who have chronic liver disease or use alcohol and/or illegal drugs, and males who have sex with males. Routine hepatitis A vaccination of all children has been proposed, and implementation strategies are being studied. Ref: Prevention of hepatitis A through active or passive immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1999; 48(RR-12):1-37. 46. Which one of the following vaccination practices is consistent with current recommendations? A) A fourth dose of DTaP for an 18-month-old girl with symptomatic HIV infection. B) Influenza vaccine for a 10-year-old who has a history of hives after egg ingestion. C) A second dose of MMR vaccine for a 6-year-old girl who had an anaphylactic reaction to gelatin last year. D) Varicella vaccine for a 15-month-old boy who is being treated for lymphoma. E) Rubella vaccine for a susceptible 18-year-old woman who intends to try to become pregnant within the next month. ANSWER: A Patients with altered immunocompetence, such as those with HIV infection, leukemia, or lymphoma, should not be vaccinated with live viral vaccines. Thus, the patient with HIV may be vaccinated with the killed DTaP vaccine, while the patient with lymphoma may not be vaccinated with the varicella vaccine. Persons with a history of anaphylactic or anaphylactic-like allergy to eggs or egg proteins should not be given vaccine prepared using embryonated chicken eggs, such as influenza vaccine. Although no cases of congenital rubella or abnormalities attributable to fetal infection have been observed among infants born to susceptible women who received rubella vaccine during pregnancy, the Advisory Committee on Immunization Practices and the American Academy of Family Physicians recommend that women avoid becoming pregnant during the 4 weeks following immunization. The rubella vaccine is grown in human diploid cell cultures and can be safely administered to persons with a history of severe allergy to egg and egg proteins. The rare serious allergic reactions after MMR are not believed to be caused by egg antigens, but to other components of the vaccine, such as gelatin. MMR and its component vaccines, as well as some other vaccines, contain hydrolyzed gelatin as a stabilizer. Extreme caution should be exercised when administering vaccines that contain gelatin to persons who have a history of an anaphylactic reaction to gelatin or gelatin-containing products. Ref: General recommendations on immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians (AAFP). MMWR 2002; 5 1 (RR-2): 1-36. 47. A medical student who completed a hepatitis B vaccine series a year ago is accidentally stuck by a needle that has just been used on a dialysis patient. The patient is known to be HBsAg-positive. Your first response should be to: A) provide reassurance only. B) test the nurse for hepatitis B antibody. C) repeat the hepatitis B vaccine series. D) administer hepatitis B immune globulin (HBIG) only. E) administer HBIG plus a booster of hepatitis B vaccine. ANSWER: B Immunization – page 16 of 17
  • 17. Postexposure prophylaxis after hepatitis B exposure via the percutaneous route depends upon the source of the exposure and the vaccination status of the exposed person. In the case described, a vaccinated person has been exposed to a known positive individual. The exposed person should be tested for hepatitis B antibodies; if antibody levels are inadequate (<10 IU/L by radioimmunoassay, negative by enzyme immunoassay) HBIG should be administered immediately, as well as a hepatitis B vaccine booster dose. An unvaccinated individual in this same setting should receive HBIG immediately (preferably within 24 hours after exposure) followed by the hepatitis B vaccine series (injection in 1 week or less, followed by a second dose in 1 month and a third dose in 6 months). Ref: Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR 2001; 50(RR-11):22. Immunization – page 17 of 17