Pediatric ImmunizationsUpdate and Controversies

Diane Dooley MD

March 27, 2009

ImmunizationsThe most effective component of well child care

1796 – Edward Jenner develops cowpox vaccine

1873 – 175,000 Americans died of infectious diseases. The majority of these were children dying of whooping cough, measles, scarlatina, diphtheria, etc

1880 – Pasteur, Koch and others demonstrated that diphtheria and cholera were infectious diseases transmitted by microbes.

1977 – Last known case of smallpox occurs in Somalia

Immunizations 2009

Recent Hib Deaths Measles cases Pertussis New Immunization

registry

Vaccine Schedule

Rotavirus Vaccine

Most common cause of severe diarrhea in infants and children

1/14 of children in US seen in ER or admitted by age 5

Live, oral 2 or 3 dose series

85-98% protection vs severe disease

Toddler Gap

Immunization rates drop in the second year of life, especially DTaPMMR rates 90%DTaP rates 71%

Health disparity for African Americans

Toddler gap

Issues contributing to toddler gap:Health care coverage gapsSimultaneous administration of

multiple shots – MMR,VZV,HIB,

PNV, DTaPParental/family issuesSystems issues

Coordinating Immunizations with a well child exam

Well child schedule: Less then 1 week, 1 mo, 2mo, 4mo, 6mo 9mo, 12mo, 15mo, 18mo Annually from 2-18 years

Goals re: well child care Regular visits for developmental screening,

anticipatory guidance Timely administration of vaccines Continuity relationship with provider

Always reappoint to the next well child visit with PCP!

Vaccine Schedule

Teen Vaccinations

Meningitis vaccine (MCV4)

• 11-12 years

• College freshman

HPV

• Females aged 9-26 years

Tdap

• 11-12 year olds who have completed their DTaP series but have not received Td.

• 13-18 year olds if they have completed their DTaP series and either missed their Td at 11-12 or it has been 5 years since they received their Td

Special Considerations

Preterm infants HBsAg + mothers Immunocompromised Egg allergy Reactions to a previous

vaccine Progressive neurologic

disorder/seizures Minor illness with or without fever does not contraindicate

immunization

Reasons Why Kids Miss ShotsHealth System Issues

Cost of vaccines HPV, Rotavirus,

MMR-V, MCV4 Vaccine shortages Inappropriate

deferral of shots Health coverage

Reasons Why Kids Miss ShotsParental Issues

Fear of autism Fear of injections,

early exposure Lack of trust Disbelief about

infections Belief in herd

immunity

www.vaccinateyourbaby.org, www.cispimmunize.org

Pediatrics: The Problem with Dr. Bob’s Alternative Vaccine Schedule January 2009

Dealing with Parental Refusals

70% of pediatricians report recent parental refusal of vaccines

Clarify concerns Religious or philosophical grounds Concerns re: injections, combined

vaccines Risk/Benefit ratio

Dealing with Parental Refusals

EducateRisk/BenefitHerd immunityClinical management of acute illnessesSchool entry lawsWebsites

Negotiate Continuing Care ?Medical Neglect