Infectious disease and immunization chap 23

specific viral disease hepatitis A virus

Epidemiology HAV is an RNA-containing virus belonging to the Picornaviridae family; it causes a primary infection in the liver. highly contagious infection and commonly spreads through person-to-person contact and fecal-oral contamination of food and water; rarely is it transmitted by contaminated blood transfusion. most of the acute and benign viral hepatitis in the U.S. and worldwide. There is no seasonal or geographic variance. Transmission in households and daycare centers; risk factors, personal contact with an infected individual, international travel, recognized food-borne outbreak, men who have sex with men, and illicit drug use. In children less than 6 years old, 30% symptomatic, <10% having jaundice. This high anicteric incidence allows considerable spread of disease to adult caretakers in childcare settings. Infants are protected by maternal antibodies during the first few months of life. Older children and adults tend to have more symptomatic disease. rates decrease dramatically in the 5-14 year age ranges after the advent of the HAV vaccine program for children that targeted high-risk communities in the U.S. Incubation Period 15 to 50 days (average 25 to 30 days). contagion is as long as the patient sheds virus and usually lasts 1 to 3 weeks. The patient is most contagious from up to 2 weeks before the onset of illness until 1 week after the onset of jaundice. Clinical Findings two phases may be seen: 1. Preicteric phase: acute febrile illness. Malaise, nausea, anorexia, vomiting, digestive complaints, and occasional abdominal complaints occur. This phase goes unnoticed in many children. There can be dull right upper quadrant pain during exercise. 2. Jaundiced phase: Jaundice appears shortly after the onset of symptoms (70% incidence in older children and adults) and can last from a few days to almost a month; subtle in children. Urine darkens, and stools become clay colored. Often these are the only apparent signs of the illness. Diarrhea in infants, constipation in older children and adults. Patients feel sick. Infants have poor weight gain during the icteric phase. Fulminant disease is rare. Complete recovery can be expected within 1 month with occasional relapses lasting up to 6 months. Diagnostic Studies Serologic testing is widely available. IgM-specific antibodies indicate recent infection. These are replaced by IgG-specific antibodies 2 to 4 months later and serve as indicators of past infection. Changes in liver enzymes indicate the degree of injury. There is elevation of serum transaminases (serum glutamic-oxaloacetic transaminase [SGOT], AST, serum glutamate pyruvate transaminase [SGPT], ALT). Prothrombin time can be elevated. Differential Diagnosis Any cause of jaundice. • Infancy: Physiologic jaundice, hemolytic disease, galactosemia, hypothyroidism, biliary metabolic disorders, biliary atresia, alpha 1-antitrypsin deficiency, and choledochal cysts. Hypervitaminosis A causes a yellow pigmentation (carotenemia) of the skin often mistaken for jaundice in children. Infections, such as toxoplasmosis, rubella, CMV, and herpes (TORCH) also cause hepatitis. • Older infants, children, and adolescents: Hemolytic- uremic syndrome, Reye syndrome, malaria, leptospirosis, brucellosis, chronic hemolytic diseases with gallstone development, Wilson disease, cystic fibrosis (CF), Banti syndrome, collagen-vascular disease (e.g., SLE), infectious mononucleosis syndrome (IMS), CMV, coxsackievirus, toxoplasmosis, Weil disease, yellow fever, acute cholangitis, amebiasis, and hepatitis B, C, and D. Drugs and poisons such as pyrazinamide, isoniazid, valproic acid, acetaminophen overdose, zoxazolamine, gold, cinchophen, phenothiazines, and methyltestosterone also cause hepatitis. Management Therapy is supportive. Good hand hygiene after diaper changes is a crucial preventive measure, especially for daycare personnel. The use of gamma globulin or HAV vaccine within 2 weeks of exposure. Those with acute infections who work as food handlers or in schools/childcare settings should be excluded for 1 week after onset of symptoms. Complications Although patients can become very ill, most cases of HAV resolve completely. Fulminant hepatitis with liver failure is rare. Prevention HA vaccine for those 12 months and older and improved sanitation.

specific viral disease hepatitis B virus

Epidemiology HBV is a DNA-containing hepadnavirus. It is highly contagious and causes severe liver disease. method of transmission is percutaneous or mucous membrane exposure to contaminated blood, wound exudates, semen, vaginal secretions, or saliva (lesser so); it is not spread by the fecal-oral route. can survive in a dried state for more than 1 week, but is highly susceptible to common household disinfectants. Prolonged percutaneous contact with contaminated fomites can be a source of infection. The major reservoirs for HBV are healthy chronic carriers and patients with acute disease. Unimmunized children who have immigrated to the U.S. from China, Southeast Asia, Africa, and other high endemic areas pose the highest infection risk. high immunization coverage in children within the U.S.- transmission is rare. Highest rates of infection- men from 24 to 44 years old. Perinatal transmission is highly efficient during the birthing process (in utero transmission is rare) from female carriers (HBsAg positive or HBeAg positive, or both) to their newborn children, 70% to 90% if both maternal antigen markers are positive, 5% to 25% if the mother is HbsAg positive but HBeAg negative. Whether chronic infection develops depends on the age one is infected and the rate of loss of HBeAg. More than 90% of untreated newborns develop chronic infection after exposure. From 25% to 50% of children, who acquire the infection between 1 and 5 years old, develop chronic HBV infection. Individuals who abuse IV drugs or who engage in sexual activity with multiple partners or have male-to-male sex have the greatest risk. Health care workers who are exposed to blood, blood products, or blood-contaminated body fluids (working with the developmentally disabled), also chronic renal dialysis patients. Tattooing or body piercing with contaminated instruments is another route of infection. Breastfeeding is not contraindicated. Adolescents who missed the birth dose of HBV should be screened, especially if their parents were born in regions of high-HBV endemicity. Incubation Period 45 to 160 days (average of 120 days). Clinical Findings asymptomatic seroconversion to fulminating disease and death. gradual onset. Most children asymptomatic. Some have minimal nonspecific constitutional complaints such as fever, nausea, and minimal hepatomegaly. Arthralgia and skin problems, such as urticaria or other rashes, can be the first apparent signs. Papular acrodermatitis has been described in infants. Acute HBV infection is somewhat similar to the icteric phase of HAV, but it is usually more severe. Skin, mucous membranes, and sclerae are icteric. The liver is enlarged and tender. Diagnostic Studies Serologic tests include HBsAg, hepatitis B core antigen (HBcAg), HBeAg, and antibodies to these antigens; the results can be useful in determining the stage of infection. Positive HBsAg and HBcAg assay results indicate active infection. Changes in liver enzymes indicate the degree of injury. There is elevation of serum transaminases (SGOT, AST, SGPT, ALT). Prothrombin time can be elevated, especially in fulminating disease. Hybridization assays, nucleic acid amplification testing, and gene amplification techniques (e.g., PCR) are also available. differential Diagnosis Any cause of jaundice is included; refer to the section on differential diagnosis of HAV. Management A specialist in hepatitis B in children should be consulted. Therapy is supportive. The use of active and passive vaccination has been discussed. Interferon-alfa and lamivudine are FDA-approved drugs for children. chronic infection should receive yearly liver ultrasound and testing of liver function and alpha- fetoprotein concentration, and vaccinate for HAV. Liver biopsies may be done to accurately monitor the effects of liver involvement. HBIG and corticosteroids are not useful. Complications 15% to 25% of those chronically infected will develop hepatic and extrahepatic complications (liver failure, cirrhosis, hepatocellular carcinoma). Prevention The initial infection can be prevented with HB vaccination.

parainfluenza virus

Epidemiology Parainfluenza virus, a paramyxovirus, is similar to the influenza and mumps viruses and is an important cause of croup, bronchitis, bronchiolitis, and pneumonia. There are four antigenic types. Most children have been exposed to types 1, 2, and 3 by the time they are 3 years old. Type 3 is endemic, associated more with illnesses in those less than 6 months old, results in shorter immunity (a particular problem for immunocompromised patients), and outbreaks tend to peak in the spring. Types 1 and 2 usually strike children 2 to 6 years old, and outbreaks are seen more in summer and fall and in odd-numbered years; reinfections occur at any age. Type 1 is most frequently associated with croup. Type 4 infections are less well pathologically and clinically understood but are not believed to cause severe illness (Wright, 2007). This virus is spread by direct person-to-person contact through infected nasopharyngeal secretions or from fomite contamination; it replicates only in respiratory epithelium of the upper large airways and eustachian tube environs. Infection occurs throughout the year depending on the type. By the time most children are 5 years old, they have been exposed to all of the types (Pickering et al, 2009). Incubation Period The incubation period is 2 to 6 days. Depending on the serotype, healthy children can shed virus for 4 to 7 days before symptom onset and up to 7 to 21 days after resolution of symptoms. Clinical Findings Eighty percent of parainfluenza infections affect the upper airways. This virus accounts for 50% of hospital admissions for croup and 15% of admissions for bronchiolitis and pneumonia (Wright, 2007). Sore throat is a common complaint in older children. Fever is found in only 20% of cases and is inversely proportional to the age of the child. Discrete maculopapular rashes of short duration can be found if the patient is carefully examined. Diagnostic Studies Routine testing is not needed. The virus can be isolated from nasopharyngeal secretions; results are usually available within 4 to 7 days (or earlier) depending on the testing technique available. Confirmation is by rapid antigen detection. Sensitivities vary when rapid antigen identification is done by immunofluorescent assays, enzyme immunoassays, and fluoroimmunoassays. Multiplex RT-PCR may also be available. Differential Diagnosis The differential diagnosis includes other viral URIs, allergic croup, bacterial URIs, laryngotracheitis, and other acute upper airway obstructive diseases (e.g., acute angioneurotic edema, epiglottitis, and foreign body aspiration). Management The treatment is supportive. Antiviral therapy is not available (Pickering et al, 2009). Oxygen saturation and hypercapnia monitoring in more severely affected children are appropriate. Antibiotics are reasonable in cases of severe infection when secondary bacterial invasion is suspected (e.g., otitis media, pneumonia). See Chapter 31 for more specific treatment recommendations based on the diagnosis. No vaccine is available. Good hand hygiene is important. Complications Complications are infrequent. Secondary bacterial infections, including otitis media, bronchitis, tracheitis, and pneumonia may occur, especially in those who are immunocompromised.

specific viral diseases poliomyelitis virus

Epidemiology enterovirus with three serotypes (types 1, 2, and 3). asymptomatic illness to severe CNS involvement. Humans are the only documented source of infection. Transmission is through fecal-oral and respiratory routes. Almost all cases in North America occur in individuals most likely exposed to children who had received oral poliovirus vaccine in another country. Poliomyelitis should be considered in any unimmunized or underimmunized child who has a nonspecific febrile illness, aseptic meningitis, or paralytic symptoms. Asymptomatic disease occurs in 95% of those infected; symptomatic but nonparalytic illness occurs in approximately 5%. diagnostic: viral culture from stool and throat (two samples taken 24 to 48 hours apart) as soon as polio is suspected and at least within 14 days of onset of symptoms. The wild-type virus needs to be differentiated from the vaccine-acquired type. The CSF may be normal or show changes based on the degree of CNS involvement. Antibody titers vary from the acute phase and those taken 3 to 6 weeks later. Differential Diagnosis, management and prevention: Polio is rare. Differential diagnoses include other conditions causing flaccid muscular weakness and/or paralysis: GBS, peripheral neuritis, transverse myelitis, encephalitis, VAPP, rabies, tetanus, botulism, demyelinating encephalomyelitis, tick-bite paralysis, WNV, spinal cord tumors, familial periodic paralysis, myasthenia gravis, and hysterical paralysis. Conditions that cause decreased limb movement or pseudo-weakness- unrecognized trauma of the sciatic nerve, toxic synovitis, acute osteomyelitis, acute rheumatic fever, scurvy, and congenital syphilitic osteomyelitis. Management: supportive and directed at minimizing skeletal deformity in the paralytic form of the disease. Both nonparalytic and mild paralytic cases can be managed on an outpatient basis, otherwise hospitalized. During the early stages of the disease, individuals should be advised against increasing their physical activity, exercising, or becoming fatigued because these factors may increase the risk of paralytic disease. Prevention measures include active and passive vaccination.

erythema infectiosum

Erythema infectiosum, or fifth disease, is caused by parvovirus B19. The virus is a member of the Parvoviridae family and a single-stranded DNA virus that replicates in erythrocyte precursors. It is called fifth disease because it was the fifth eruptive rash described. These rashes include scarlet fever, measles, rubella, erythema subitum (roseola infantum; sixth disease), and erythema infectiosum. Humans are the only reservoir. Erythema infectiosum is spread via vertical transmission from mother to fetus, by respiratory tract secretions, and percutaneous exposure to blood or blood products. Distribution is worldwide. It is a disease of childhood, highest in 5- to 15-year-olds, but infants and adults are not immune. Secondary spread to household contacts is up to 50% (Pickering et al, 2009). The disease occurs most commonly in late winter and early spring. Incubation Period The incubation period is approximately 4 to 21 days; the rash and symptoms occur between 2 and 3 weeks after exposure. The period of communicability lasts until the https://read.amazon.com/ 1/1 rash appears. Chronic infection can occur in those immunocompromised or with most types of hemolytic anemias. Clinical Findings The following two phases are seen in erythema infectiosum: 1. Prodrome: Consists of mild fever (15% to 30% of cases), myalgias, headache, malaise, URI symptoms 2. Rash: Appears 7 to 10 days after the prodromal stage and occurs in three stages: It first appears on the face as an intense red eruption on the cheeks (slapped cheek) with circumoral pallor that lasts 1 to 4 days. Next a lacy maculopapular eruption appears on the trunk, then moves peripherally to the arms, thighs, and buttocks. Palms and soles are generally spared. This phase can last a month. Finally, the rash subsides. Older children may have pruritus. There may be periodic recurrences precipitated by trauma, heat, exercise, stress, sunlight, or cold (see Color Plate). Children experience arthralgia less than 10% of the time; knees are more commonly involved. Adult females are more likely to complain of polyarthropathy (Pickering et al, 2009). Arthralgia most commonly resolves in 2 to 4 weeks. Those with hemolytic anemias or who are immunocompromised may have fever, pallor, tachycardia, and symptoms of heart failure. Diagnostic Studies Laboratory testing is not generally indicated because the diagnosis can be made clinically. Serum B19-specific IgM confirms the presence of infection and persists for 6 to 8 weeks. Anti-B19 IgG confirms past infection. For immunocompromised individuals, viral DNA testing methods are required. There are PCR or nucleic acid hybridization tests for B19. The virus is difficult to grow in culture. in culture. Differential Diagnosis This is not a difficult disease to diagnose. The differential diagnoses include rubella, enterovirus disease, lupus, atypical measles, and drug rashes. Management There is no specific antiviral treatment. Those with hemolytic anemia or who are immunocompromised should be considered for hospitalization. IGIV offers some help for those with immunocompromised conditions. Complications These are few and typically not significant. All previously healthy patients usually recover without sequelae. The most frequently reported complications include arthritis (hands, wrists, knees, ankles occurring 2 to 3 weeks after onset of initial symptoms); chronic infection in those immunodeficient; aplastic crisis (more common in those with chronic hemolytic anemias, including sickle cell anemia, thalassemia, hereditary spherocytosis, or other types of chronic hemolysis); fetal hydrops and death or intrauterine growth retardation if exposed in utero (no reports of congenital anomalies) (Koch, 2007); thrombocytopenic purpura or neutropenia; myocarditis (rare); papular-purpuric "gloves and socks" syndrome (fever, pruritus, purpura, painful edema, and redness in a glove-and-sock distribution pattern) followed by petechiae and oral lesions. Prevention Because there is widespread unapparent infection in children and adults avoidance of known exposure can reduce but not eliminate the risk of infection. An exposed pregnant woman should consult with her health care provider. Children in the rash stage may attend school.

serologic testing

For some infections, diagnosis by culture is difficult or impractical. tests that rely on the generation of an antibody response may be useful. detect the presence of antibodies to specific infectious organisms, though cross- reactivity may cause false-positive and false-negative test results. Specific organisms that often rely on serologic diagnosis include HIV, West Nile virus, Bartonella henselae, and Mycoplasma pneumoniae.

live vaccine MMR

MMR is a trivalent vaccine; this combination is also offered as a quadrivalent vaccine with varicella (MMRV). difficult, to obtain measles, mumps, and rubella vaccines individually. health care personnel should demonstrate evidence of immunity to each of these diseases. Proof of immunity- received the vaccines (measles: two doses; mumps: two doses; rubella: one dose), or laboratory confirmation/evidence of disease, or born prior to 1957. Measles A live further-attenuated vaccine using a chick embryo cell culture is licensed for use in the U.S. The seroconversion rate is greater than 99% for those receiving two appropriately spaced doses. Children who do not receive the second dose at kindergarten should be revaccinated at the earliest possible time. Persons vaccinated with killed vaccine, live vaccine and IgG, and those vaccinated before 12 months old should be revaccinated twice more. In children receiving synagis, MMR vaccine can be given on schedule. The measles component is responsible for almost all the adverse reactions to the MMR vaccine. Transient rashes and fever of 103° F (39.4° C) approximately 5 to 12 days after vaccination. fever usually have no other symptoms, resolves within 1 to 2 (up to 5) days. Febrile convulsion is an infrequent occurrence, risk increases 8 to 14 days after primary vaccination with MMR (1 per 3000 to 4000 children). Allergic reactions to trace amounts of neomycin, gelatin, and thrombocytopenia have been reported, very rare occurrences. combination MMRV vaccine is given for the primary dose, the risk for febrile seizures increases twofold (one additional seizure in 2300 to 2600 children over MMR alone when varicella is given at the same time in a different site) in children between 12 and 23 months. discuss this increase in risk with parents and offer either the MMR and varicella separately as the primary dose for this age group or the combination (MMRV). The MMRV second dose between 4 and 6 years is not associated with increased risk. The contraindications to measles vaccine should be reviewed to those also needing a TST; who are pregnant or planning to become pregnant within the next 28 days; who have had an anaphylactic reaction to gelatin, egg, neomycin, or prior MMR vaccine; or who have a febrile illness. recommendations for giving MMR to those with compromised immune systems and for those who have received immunoglobulins and blood products available from manufacturer package inserts or from the CDC. Encephalopathy and encephalitis are rare complications lower rate than after the natural disease. Measles Exposure or Epidemics exposure to measles infection- provide some protection if given within 72 hours. IG can be used within 6 days of exposure, prevents or modifies the infection in susceptible people (children and adolescents with HIV infection and children born to HIV-infected women whose own HIV infection status is unknown). During measles outbreaks, begin as early as 6 months of age. Two more doses of the vaccine are then given at the routine recommended ages. Mumps The live-attenuated mumps vaccine is given in combination with MMR or MMRV. It is estimated to achieve an 88% to 95% seroconversion rate after the two appropriately spaced doses. The length of protection may be shorter than once anticipated. Fever, parotitis, and orchitis have been rarely reported as side effects; causality has not been established for febrile seizures, rash, pruritus, nerve deafness, encephalopathy, encephalitis, purpura, or paralysis. much lower rate than they do after the natural disease. Contraindications and the use of IG are the same as for measles. Rubella The live-attenuated rubella vaccine is given in combination with measles and rubella (MMR) or with added varicella (MMRV). The seroconversion rate is greater than 95%. Mild reactions to the vaccine include fever, lymphadenopathy, rash, joint pain and arthralgia (usually seen more in unvaccinated postpubertal females; onset 7 to 21 days after vaccine), small peripheral joint pain, and paresthesias. Contraindications are the same as for the measles vaccine. If inadvertently given to a pregnant woman, it does not serve as an indication for termination of the pregnancy but should be informed that the fetus is at a maximum theoretic risk of 1.3% to exhibit signs of infection rather than congenital defects. CDC for information regarding special vaccination precautions for children who are immunocompromised. Females less than 13 years of age without documentation of rubella immunity (documented second dose of MMR or laboratory confirmation) should be the focus for vaccination. Postpubertal females should be evaluated for rubella susceptibility and given the vaccine if indicated; routine prenatal screening is warranted. Measles, Mumps, Rubella, and Varicella Combination MMR and varicella vaccine is as effective as when MMR and varicella vaccines are given separately, avoids potentially missing the administration of one, fewer vaccinations, excellent immunogenicity. same as measles for side effects regarding the increased risk of febrile seizures with the MMRV versus when MMR and varicella are given at the same time in different injection sites. first dose at 12mths catch up: ensure all school-aged and adolescent had 2 doses, minimum interval 4wks btw two doses. MMRV proquad SC, 0.5ml, combination with varicella, storage? s/e: anaphyl, hypersens, erythema multiform, henoch-schonlein purpura, acute hemorrhagic edema of infancy, SJS, atypical measles, HZ, varicella, thrombocytopenia, febrile seizures, stroke, encephalopathy, encephalitis. GBS, transverse myelitis, aplastic anemia, pneumonitis, varicella transmission 6wks post, viral transmission, site reaction, fever, irritability, rash measles like, rash varicella like. contraindicated: hypersens to drug, class, component, to gelatin, anaphylactic to neomycin, immunocomp, TB active untx, preg of planned preg within 4wk, caution hypersens eggs, in HIV asymptom, in cerebral injury, seizue/fam hx, thrombocytopenia, acute illness. MMRII same as above as well as s/e: arthralgia, arthritis, urticaria, pruritis, dizziness, malaise, H.A, pancreatitis. When multiple vaccines are given on the same extremity, the sites of injection should be at least 1 inch apart; the anterolateral aspect of the thigh is the preferred site for this.

roseola infantum (exanthema subitem)

Roseola infantum is also known as exanthem subitum or sixth disease; it is one manifestation of infection caused by HHV-6 (less commonly, HHV-7 that causes infection later in life). Humans are the only natural reservoir. The method of transmission is not completely understood but is probably spread via the oral, nasal, and conjunctival routes of other family members, caregivers, or close contacts. Transmission either prenatally or during or after parturition is suspected. The disease is most commonly acquired by children between 6 and 24 months old (peaks by 15 months), after protective maternal antibodies have waned. It is rare in children younger than 3 months old or older than 3 years, but has been documented in infants as young as 8 weeks old (typified by a febrile illness without localized symptoms). Most children are HHV-6 seropositive by 4 years of age, and about 85% are seropositive for HHV-7 by adulthood (Pickering et al, 2009). This shows that there is asymptomatic illness or roseola without rash; in the U.S. the rash is evidenced in about 25% of cases (in Japan rates reach 75%) (Cohen, 2009). Reactivation of infection can occur in those immunocompromised. Visits to emergency departments are common as a result of the associated fevers, toxicity, and/or seizures associated with this disease in infants. The disease occurs worldwide, year-round, and shows no gender preference. Incubation Period The incubation period has a mean of 9 to 10 days. The period of communicability is probably greatest during the fever phase before the rash erupts. Clinical Findings There is a sudden onset of fever from 101° to more than 103° F (38.3° to more than 39.5° C) for 3 to 7 (commonly 3 to 4) days, but the child does not seem particularly ill. There may be signs of a URI; lymphadenopathy in the cervical and posterior occipital areas; lethargy; infected palpebral conjunctiva; eyelid edema; gastrointestinal complaints; reddened TMs (without bulging or effusion); and, occasionally, a febrile convulsion (10% to 15% of cases) (Pickering et al, 2009). As the fever breaks, a diffuse, nonpruritic, discrete, rose-colored maculopapular rash, 2 to 3 mm in diameter, appears (Fig. 23-1). It fades on pressure and rarely coalesces. The roseola exanthema is similar to the rash of rubella. The rash lasts hours to 2 to 3 days, begins on the trunk, and spreads centrifugally. In the rare case of CNS involvement, the anterior fontanelle may bulge. Diagnostic Studies The WBC count is distinctive, showing a decrease for age initially, dropping further by the third or fourth day, and then returning into the normal range. It tends to follow the fever pattern. Serologic testing involves isolating HHV-6 for peripheral blood mononuclear cells and documenting a significant rise in antibody titer; however, test results can vary widely so diagnosing unequivocal acute infection is problematic. Serial titers 2 to 3 weeks apart are more reliable. Fourfold increases in HHV-6 or HHV-7 IgG antibodies suggest active infection. Virus cultures can be helpful. A rapid HHV-6 culture is available. A reverse transcriptase-polymerase chain reaction (RT-PCR) assay can distinguish between the acute and latent infection. Differential Diagnosis The clinical course usually makes this illness easy to diagnose. Most viral rashes, scarlatina, and drug hypersensitivity are included in the differential diagnoses. A roseola-like illness is also associated with parvovirus B19, echovirus 16, other enteroviruses, measles, and adenoviruses. Until the rash develops, fever without focus and bacterial sepsis are in the differential diagnosis. If a febrile seizure occurs, meningitis is usually added to the differential diagnosis. Management Management is supportive. Complications Rare complications include febrile meningoencephalitis, encephalitis, and Associated diseases include ITP, drug sensitivity syndromes, pityriasis rosea, multiple sclerosis (MS), and hepatitis.

prevention and reduction perinatal transmission HIV

The use of combination ARV therapy to reduce perinatal transmission of HIV is the norm in the U.S. The CDC, WHO, and United Nations AIDS agencies are useful resources for current treatment regimens; recommendations may vary by country. Research efforts in underdeveloped countries have focused on different ways to prevent transmission via breastfeeding. Strategies studied have included evaluating the acceptance of formula feeding by HIV- infected women, pasteurizing breast milk, avoiding mixed breastfeeding between women, treating breast conditions (mastitis, etc.), restricting breastfeeding to the first 6 months, and the long-term use of antiretroviral therapy in both the breastfeeding woman and her infant (Read and Committee on Pediatric AIDS, 2007; Yogev and Chadwick, 2007). One study showed that if women were treated with prophylactic medications during the first trimester, and the infant for 6 weeks antepartum with zidovudine, the transmission rate decreased to less than 8%. Another study showed a rate of less than 2% (Yogev and Chadwick, 2007). Various studies have also demonstrated that transmission rates to infants from mothers not given zidovudine during their pregnancy can be lowered when mothers are given zidovudine at the time of labor and their infants within 24 hours of delivery for 6 weeks (Luzuriaga and Sullivan, 2008). As a result of these antiretroviral efforts, in 2010, the CDC reported a 90% decrease in reported prenatally acquired HIV and AIDS in children as compared with 1992 rates (Lampe et al, 2010). A standard antiretroviral regimen is now standard treatment for HIV-infected pregnant women and their infants. Providers need to be vigilant regarding maternal adherence with the recommended postnatal HIV prophylaxis for her infant and herself. Such adherence has been shown to be lower in women with asymptomatic HIV, who have poor social networks, who feel guilt or stigma, or who adhere poorly to their own ARV regimens (Demas et al, 2002; Wrubel et al, 2005). • HIV-infected pregnant women and HIV-infected mothers should be counseled about the following (Pickering et al, 2009): Women and their health care providers need to be aware of the potential risk of transmission of HIV infection to infants in utero and in the postpartum period and through human milk. Documented, routine HIV education, and routine testing with consent of all women seeking prenatal care are strongly recommended so that each woman knows her HIV status and the methods available to prevent the acquisition and transmission of HIV to her newborn and to document whether breastfeeding is appropriate. At the time of delivery, provision of education about HIV and testing with consent of all women whose HIV status is unknown are strongly recommended. Knowledge of the woman's HIV status assists in counseling on breastfeeding and helps each woman understand the benefits to herself and her infant of knowing her serostatus and the behaviors that decrease the likelihood of acquisition and transmission of HIV. In general, women who are known to be HIV seronegative should be encouraged to breastfeed. However, women who are HIV seronegative but at particular high risk of seroconversion (e.g., injection drug users) should be educated about HIV with an individualized recommendation concerning the appropriateness of breastfeeding. In addition, during the perinatal period, information should be provided on the potential risk of transmitting HIV through human milk and about methods to reduce the risk of acquiring HIV infection. • NICUs should develop policies that are consistent with these recommendations for the use of expressed human milk for neonates. Gloves should be worn by health care workers in situations in which exposure to breast milk might be frequent or prolonged, such as in milk banking. Human milk banks should follow the guidelines developed by the FDA, CDC, and AAP. The nonprofit Human Milk Banking Association of North America sets standards of testing for all their members' milk banks. • Adolescents must be counseled about the risk of HIV transmission (e.g., sexual transmission, sharing of needles or syringes) and the use of condoms. Condom use has been reported by 61.1% of adolescents, whereas only 12.7% report ever having had an HIV test (female rates are higher than for males) (Eaton et al, 2010). • School attendance: Factors that must be taken into account include the risk to the immunosuppressed child of "normal germs" from healthy kids and school personnel. The benefit from attendance far outweighs the risks. Because casual transmission is unknown, there is no real risk to other children as long as the infected child can control body secretions. Children who display biting behavior or have oozing wounds should be cared for in a setting that minimizes risk to others. The child's primary care provider is the only person with an absolute need to know the child's primary diagnosis. If the family decides to inform the school, those informed should maintain confidentiality. If the family chooses not to inform the school, parents should get assurance that the school will notify them of any communicable disease outbreaks (e.g., varicella, measles) or physical altercations with others. • Routine screening of school-age children for HIV antibodies is not indicated.

live vaccine varicella

This LAIV from the Oka strain of varicella-zoster virus (VZV) is well-tolerated and immunogenic. seroconversion rates ranging from 70% to 90% after one dose; a second dose raises the rate to greater than 95%. Two vaccines are licensed for use in the U.S: a single-antigen vaccine and quadrivalent vaccine with measles, mumps and rubella (MMRV). s/e: develop localized pain, erythema, and tenderness. mild, generalized maculopapular rash or a varicelliform eruption with a few lesions that are generally nonvesicular after vaccination, occurs within 2 weeks of vaccination, and wild-type varicella-zoster virus has been isolated from these lesions. A short period of fever 5 to 12 days after the vaccine. low risk of secondary transmission, immunocompromised household contacts do not need to be isolated from recently vaccinated individuals- contract varicella infection after being immunized usually have minimal fever, fewer than 50 lesions, and recover more rapidly than if not vaccinated. Postexposure Prophylaxis for Varicella Disease: Postexposure varicella-zoster immune globulin (VariZIG) is available to those for whom exposure poses significant risk. It is available 24 hours per day from FFF Enterprises (1-800-843-7477), and participation requires strict compliance to forms and protocols. As a substitute, IGIV, acyclovir, or varicella vaccine (given within 72 hours [and possibly up to 120 hours] after exposure) can be considered. Other individuals are also considered for prophylaxis if significant exposure to varicella or zoster occurs; guidelines from the CDC. limited data on acyclovir as a postexposure prophylaxis measure for healthy children. The varicella vaccine should be given 5 months after VariZIG, unless varicella disease occurred despite VariZIG administration. Serologic testing to determine vaccine-induced antibody response may be unreliable, not used, more reliable for diagnosing natural infection, but not in those who are immunocompromised. first dose at 12mths catch up: 3mths btw 1,2 dose, ensure anyone age 7-18years without evidence of immunity have 2 doses, 7-12 years interval 3mths btw two doses but acceptable if 4wks after first dose. 13 years or older minimum interval 4 wks. SC, 0.5ml, Varivax-single, available combination with MMR (proquad-MMRV), storage? s/e: anaphylax, angioedema, SJS, erythema multiform, henoch-schonlein purpura, HZ, aplastic anemia, thrombocytopenia, ITP, febrile seizure, encephalitis, stroke, tranverse myelitis, GBS, seizures, aseptic meningitis, pneumonitis, varicella transmission 6wks post, site reaction, fever, rash varicella like, URI sx, irritability, H.A contraindication: hypersens to drug, class, component, to gelatin, anaphylactic to neomycin, immunocomp, preg or planned preg within 4wks, TB active untx, caution HIV asymptomatic, acute illness. MMRV- same as above see MMR combination proquad When multiple vaccines are given on the same extremity, the sites of injection should be at least 1 inch apart; the anterolateral aspect of the thigh is the preferred site for this.

inactivated vaccine influenza

universal vaccination for those more than 6 months of age, including all adults, unless contraindicated. Influenza disease rates are highest among children less than the age of 2 years, in those equal to or older than 65 years, and in those with high-risk medical conditions. Children serve as a major vector for influenza transmission because of their own high rates for contracting the virus; they also shed the virus at higher rates and for longer periods than adults. After even one influenza illness, people remain susceptible to other influenza strains. Two multivalent vaccines are available; each contains three virus strains (influenza A [H3N2 and seasonal H1N1], and B). The trivalent inactivated vaccine (TIV) is available IM for those 6 months or older, whereas the live-attenuated inactivated vaccine (LAIV) is restricted to healthy, nonpregnant individuals 2 years to 49 years. The LAIV is only available as an intranasal prefilled spray for these age groups . The number of dosages depends on the age and vaccine history during any prior influenza season. given yearly. formulated yearly based on epidemiologic forecasts. Usually one or two influenza A virus strains are changed based on the anticipated dominant influenza strain(s) projected to infect the population in the approaching flu season. Major changes in viral antigens generally occur at 10-year intervals- antigenic shift. Minor variations- antigenic drift. changes can prevent the body's immune system from recognizing the altered strain and mounting an immunologic response. common childhood viral agents can cause diseases that look like influenza, the effect of the vaccine is less likely to be evident in children. The efficacy rate ranges from 50% to 95% for TIV in healthy children older than 2 years (higher if the vaccine strain closely matches the circulating wild strain); lower in children less than 24 months. LAIV efficacy rate of between 86% and 96%. LAIV has a greater relative efficacy when compared with TIV in younger children. given as soon as it becomes available before the onset of the yearly influenza season. It can be given any time until the anticipated end of the infective season (including April). Different preparations of the vaccine have different recommendations for administration as to site and concurrent use with live vaccines. can sign up for vaccine updates from the CDC as the influenza season progresses. first dose 6mths for inactivated 18yrs for recombinant 6mths-8yrs, 2 doses separated by 4wks, 9yrs and older 1 dose if not previously vaccinated for influenza. catch up: annual vaccine fluzone quadrivalent IM, 0.25ml, combination flu A/B inactivated, storage? s/e: hypersens, anaphylax, SJS, neurologic disorder, GBS, seizure, vasculitis, thrombocytopenia, site reaction, irritability, myalgia, malaise, drowsy, appetite dcr, H.A, vomit, fever, shivering. contraindications: hypersens to drug, class, component, to thimerosal (multidose vial form), caution GBS within 6wk prior vacc, if immunocomp, if acute, mod-severe illness. When multiple vaccines are given on the same extremity, the sites of injection should be at least 1 inch apart; the anterolateral aspect of the thigh is the preferred site for this.

history

The goal- generation and prioritization of differential diagnoses for that particular individual based on symptomatology and history. Crucial aspects assist in determining the responsible pathogen include: • The history of present illness with a careful analysis of the presenting symptoms. When did the symptoms start? What other symptoms were associated with the illness? Were there periods when the patient seemed improved or even back to normal? Details about the presenting history are critically important and can help narrow the differential diagnosis from a broad list of possibilities. As an example, fever is most commonly associated with infectious illnesses, but also occurs with rheumatologic or oncologic diseases. • A comprehensive past medical history. Careful questioning makes certain diagnoses more or less likely. A history of asthma in a teenager with fever and cough, for example, is suspicious of atypical pneumonia. Determine place of birth. • Current and recent medications. Recent antibiotic use may affect the provider's ability to interpret negative culture results or be important information to know in the case of methicillin-resistant Staphylococcus aureus (MRSA) tissue infection. Include any nonprescription, herbal, or natural health products that may have recently been used. • Immunizations. Adherence to recommended vaccine schedules (including age and spacing of vaccines) is an important consideration if the child's symptoms suggest a disease usually prevented by vaccines. • Family history, particularly regarding infectious illness. Important information includes a history of any relative (first or second degree) with a known immune deficiency, with numerous infections or difficulty recovering from infections, or with a history of recurrent miscarriages. Any of these may raise suspicion for an immune deficiency. A strong history of autoimmune disease in the family may suggest possible rheumatologic diagnoses as opposed to an infectious process. • Social history. Attendance at daycare or school or living in a crowded setting is associated with increased exposure to viral infections. A history of travel to areas with endemic illnesses is important to elicit (e.g., area endemic for Lyme disease, malaria, or parasitic illnesses). A sexual history obtained under confidential conditions is very important for accurate assessment of the adolescent and for males who have sex with males. • Exposure history, including any known contacts with individuals with similar symptoms. In addition to suggesting a presentation consistent with epidemic illness (e.g., as occurs with viruses, such as influenza or enterovirus), provide important clues in diagnosis of infections that might otherwise not be considered. Specific questions include any contact with individuals with known illnesses or at high risk for certain illnesses, such as tuberculosis (TB) or human immunodeficiency virus (HIV) or contact with animals or animal by-products (e.g., hides, waste, blood). Other exposures of importance include environmental tobacco smoke or mold. • Complete review of symptoms. Some presenting features of the illness may be discounted or forgotten by parents or patients and are recalled only when direct questions are asked. • Diet history. Any ingestion of raw milk or undercooked or raw meats and/or fish; history of pica.

inactivated vaccine HPV

Gardasil (referred to as HPV4) is a quadrivalent vaccine that protects against the two primary oncogenic strains types 16 and 18, as well as types 6 and 11. The efficacy rate is greater than 99% after a series of three doses with antibody responses greater for females 9 through 15 years as compared with those older than 15 years or age. It is unclear about the cross-protection against cervical intraepithelial neoplasia types not included in the vaccine. There is no protection for HPV oncogenic types acquired prior to the vaccine. Cervarix (referred to as HPV2) targets HPV types 16 and 18 and is encouraged for use in females 9 through 26 years. some cross-protection against incident infection of other HPV vaccine types that also cause cancer; its efficacy rate is greater than 99% after a series of three doses for types 16 and 18. Preadolescent females (11 or 12 years; as early as 9 years) and all sexually active women (through 26 years old) are encouraged to routinely receive the vaccine benefit to any and all of the different HPVs included in the vaccine. The vaccines should not replace routine cervical cancer screening. The vaccine is offered under the VFC program for females. The FDA has approved Gardasil for males ages 9 through 26 years to prevent genital warts and male HPV- associated cancers; not recommended Gardasil as part of a male's routine immunizations. Males at greatest risk for infection and associated disease include men who have sex with men. Prevaccine Papanicolaou (Pap) or pregnancy tests are not warranted; report any exposure to these vaccines during pregnancy to the manufacturer. first dose 9yrs catch up: 2 dose series 6-12mths apart at 11-12yrs, can start at 9yrs. 15yrs or older, 3 dose series 6mths apart. if interval too short 3rd dose adm min. 12wks after 2nd dose, 5mths after first, or extra dose in 3 dose series. IM, 0.5ml, single, storage? s/e: hypersens, anaphylaxis, site reaction, H.A, fever, nausea, dizziness, diarrhea, pharyngolaryngeal pain, vomit, cough, fatigue. contraindicated: hypersens to drug, class, component, to yeast, caution immunocomp, acute illness.

imaging techniques

Plain Films diagnosis of many infections including bone, sinus, and lung infections. Computed Tomography Scans Deeper infections, such as abscesses, often require evaluation via computed tomography (CT) scanning. Magnetic Resonance Imaging Magnetic resonance imaging (MRI) is the most sensitive in the evaluation of osteomyelitis. It is also often used for brain imaging in cases of encephalitis. Ultrasound evaluate the visceral organs, including the liver, spleen, and kidney, for fluid collections suspicious of abscess. It is also commonly used in evaluating kidney anatomy in patients with initial urinary tract infections (UTIs). Echocardiography is a specialized ultrasonographic technique used in the diagnosis, evaluation, and monitoring of endocarditis or Kawasaki disease. Nuclear Imaging indium-labeled WBC scans ("tagged white cell scans"), gallium scans, bone scans, and positron-emission tomography (PET) scans. Some of these techniques may have limited use in pediatrics, although the bone scan remains useful in the diagnosis of osteomyelitis.

considerations when choosing inactive vaccines

Some of the more general side effects: • Fever and local reactions (swelling, pain, erythema), usually within the first 24 to 72 hours (diphtheria/tetanus/acellular pertussis [DTaP]; hepatitis A virus [HAV]; Haemophilus influenzae type b conjugate [Hib]; hepatitis B virus [HBV]; pneumococcal conjugate [PCV-13]; and meningococcal [can include headache and irritability] vaccines). • Sterile abscesses due to a hypersensitivity response to the vaccine itself or to an adjuvant (notably alum) (DTaP) Some general contraindications: • Anaphylaxis: To a prior dose; to neomycin, polymyxin B, or streptomycin (IPV); to alum or 2- phenoxyethanol (Havrix only for HAV). • Pregnancy (human papilloma virus vaccine [HPV]), or used cautiously (IPV) • Allergies to vaccine components or yeast (HBV and HPV vaccines) • Moderate to severe acute infection (HPV and Hib vaccines)

adverse event reporting for vaccination

The Vaccine Adverse Event Reporting System (VAERS) is a national vaccine safety surveillance program. Health care professionals are encouraged to report any adverse events that occur after the administration of any vaccine licensed in the United States. Adverse events should be reported even if the cause of the adverse event is uncertain.

vaccine shortages

The Vaccine Management Business Improvement Project is in charge of addressing all problems related to vaccine shortages including vaccine procurement, ordering, distribution, and management. federal legislative proposals are underway to ensure federal- private sector partnerships to provide necessary incentives and protections to quickly bring additional and better vaccines to market. National Center for Immunization and Respiratory Disease website (www.cdc.gov/vaccines/vac- gen/shortages). Medical providers should develop their own tracking system to recall patients whose vaccinations were delayed because of supply shortages. check with the websites of AAP, ACIP, and National Immunization Program recommendations regarding vaccine deferrals, prioritization of high-risk children, and suspensions of school and childcare entry requirements.

vaccines for children program

The Vaccines for Children (VFC) program enables medical providers to obtain all or most Advisory vaccines are provided free to children younger than 19 years of age who are Medicaid eligible, are uninsured, are Native American or Alaska Native. To date the VFC program pays for 50% of all vaccines administered to children in the U.S. under the age of 6 years. if insurance does not cover immunizations (underinsured) are eligible to receive vaccines at federally qualified health centers and rural health clinics. All states receive a set level of federal VFC funds. Some states augment that amount to cover more vaccines. Providers wishing to participate need only to contact their local state Medicaid office to enroll; they need not be a Medicaid-participating provider. Free vaccines plus their shipping costs and an administrative fee, which varies from state to state, are included in this incentive package; there is a minimum of paperwork for the provider.

live vaccines Precautions Regarding Administration of Live Vaccines

consult with infectious disease experts and authoritative reference resources when contemplating administering live vaccines to immunocompromised individuals. Recommendations differ according to the individual's degree and type of compromise. If individuals cannot produce antibodies, they are unlikely to respond to a vaccine; if a live vaccine is given while on IGIV, the virus will be neutralized by antibodies in the IGIV product. An individual with a low T-cell count or a cellular immunodeficiency can be seriously compromised if given a LAIV. *A child with DiGeorge syndrome, HIV infection, cancers, immunosuppression, or other cellular immune problems should not receive such viral vaccines until the T-cell function is within an appropriate range.

physical exam

differential diagnoses generated during the process of taking the history can stimulate the examiner to provide extra focus on certain aspects of the examination. Physical findings with infectious diseases include: • Abnormal vital signs (e.g., fever, tachypnea, low blood pressure [concerning for dehydration and/or septic shock]). • Irritability is nonspecific in ill children, but may raise concern for meningitis or Kawasaki disease. Lethargy raises concern for meningitis (particularly in infants and younger children). • A stiff or painful neck (suggestive of meningitis). • A new murmur (may herald the possibility of endocarditis or rheumatic fever). • Refusal to walk (can be a manifestation of deep tissue infections [e.g., pyomyositis], osteomyelitis, septic arthritis, or meningitis). • Skin or mucous membrane changes (exanthema or enanthema, respectively) are common with viral illness, and characteristic rashes are typically associated with specific illnesses (e.g., chickenpox).

rubella (german 3 day measles)

acute disease of childhood that occurs in two forms: postnatal and congenital. Rubella is an RNA virus of the genus Rubivirus, in the Togaviridae family. Humans are the only reservoir. spread through nasopharyngeal secretions or transplacentally during either apparent or silent infection. isolated in blood, stool, and urine of infected individuals. It also has been isolated on fomites for as long as 24 hours. immunization, the number of epidemics declined. occur in those unvaccinated, foreign-born, or from areas with poor vaccination coverage. 10% of individuals born in the U.S. older than age 5 years are susceptible. Males and females are equally affected. Primary maternal infection during the first trimester to the sixteenth week is most associated with congenital defects. There is transplacental immunity for approximately 5 to 6 months if the mother is immune. There is probable lifelong immunity for naturally occurring disease. second attacks are rare. Incubation Period 14 to 21 days (mean 18). The period of infectivity is 3 to 8 days after exposure and for 11 to 14 days thereafter. rashes are infectious approximately 5 days before the rash to 6 days beyond its appearance. Clinical Findings Postnatal disease, three stages, and splenomegaly may be present: 1. Prodrome: There are mild catarrhal symptoms (fever, GI upset, sore throat, eye pain, arthralgia). This stage is occasionally missed and occurs about 1 to 5 days prior to onset of stage 3. 2. Lymphadenopathy: Usually begins within 24 hours, but can begin as early as 7 days before the rash appears, and can last for more than 1 week. The postauricular, posterior cervical, and posterior occipital are the primary lymph nodes involved. generalized lymph node involvement, at times splenomegaly. 3. Rash: enanthem in 20% of cases just before the general rash. The enanthem, Forchheimer spots, small rose-colored to reddish spots located on the soft palate. They are not considered pathognomonic for rubella and are noted in scarlet fever and other URIs. The rubella rash can be the first obvious sign of illness. It begins on the face and can fade before it spreads to the chest during the next 24 hours. The rash is composed of discrete maculopapules that occasionally coalesce. It spreads caudally, lasting a mean of 3 days. There can be itching without a rash or a fine, branlike desquamation. A low-grade fever can occur during the eruptive phase and continue for up to 3 days. There is no photophobia; anorexia, headache, and malaise are rare. Diagnostic Studies made by clinical symptoms; however, the only reliable means to check infection is by antibody testing. Serologic testing of acute and convalescent titers at least 2 weeks apart or a single elevated IgM titer is diagnostic of recent infection. IgM remains detectable only for about 1 to 3 weeks after onset of the rash. Immunity is now more commonly tested using latex agglutination enzyme or fluorescent immunoassay, among others. Rubella-specific IgM is an important test in the newborn. Suspected rubella can be confirmed using throat, nasal, or urine specimens by inoculation of appropriate cell media; the laboratory should be notified so that specific testing on the culture can be done. Differential Diagnosis difficult to diagnose unless there is an epidemic. The rash can be confused with scarlet fever, mononucleosis, enterovirus, roseola, rubeola, erythema infectiosum, EBV, and drug eruptions. Management Treatment is supportive (e.g., antipyretics for fever control) unless complications (e.g., encephalitis) occur; severe thrombocytopenic purpura can be managed with corticosteroid therapy and platelet transfusions. Complications in postnatal rubella are rare. arthritis (most common complication; females are afflicted more often; onset is about 1 week after appearance of rash), ITP, and encephalitis (within 4 days of onset of rash). Myocarditis, pericarditis, follicular conjunctivitis, hemolytic anemia, and hepatitis are rare. Prevention Children with postnatal rubella should be kept home from school or daycare 1 week after the rash erupts. Active and passive immunization have been discussed. Reinfection illness without rash exists, the actual numbers of reinfections are unknown. Reinfection is known to occur from wild-type virus and in those previously immunized; in pregnant women reinfection can result in congenital rubella syndrome. Accidental revaccination of a pregnant woman should not be considered a reason for pregnancy termination alone; surveillance has demonstrated signs of infection in the infant but not congenital rubella syndrome.

birth-15mth schedule

birth- hep B 2mths- second hepB. first dose rota, dtap, hib, PCV13, IPV 4mths- second dose of 2mth vaccines (as above) 6mths- flu, third dose HepB, dtap, PCV13, IPV 12mths- third/fourth hib, fourth PCV13, first MMR, vari, hep A 15mths- fourth dtap 4-6yrs- second MMR, vari, fourth IPV, fifth dtap

active immunity

Inoculating a child with all or part of a modified product from a microorganism evokes an immune response. Whole organisms (live, attenuated, or killed), modified proteins, and/or sugars are used to prepare certain vaccines. The response to a live attenuated vaccine is often as protective as the natural infection. Antiinvasive, antiadherence, antitoxin, neutralizing antibodies, or other protective responses can be found soon after the vaccination is given. broader and longer-lived immunity than the inactivated types that require booster vaccines. Killed and inactivated vaccines can provide systemic protection (IgG antibodies), but may fail to provide local mucosal antibody (IgA). Thus, although protected from systemic illness, a recipient of a killed vaccine can have local colonization or infection that can be a problem during an epidemic. be aware of these components (such as antimicrobials) because of a patient's possible hypersensitivity to the ingredients. annually approve a new unified recommended childhood immunization schedule so U.S. providers can download the most recent immunization schedules at the beginning of each calendar year (http://www.cdc.gov/vaccines/recs/schedules/child- schedule.htm). There are three schedules: 0-6 years old; 7-18 years old; and a catch-up schedule for individuals 4 months to 18 years who start their vaccines late or who are delayed. Other countries- own recommendations (World Health Organization [WHO] can be consulted at www.who.int). Maternal antibodies neutralize certain vaccines, so some are delayed until the child is 1 year old (e.g., measles). Infants vaccinated in the first year of life require more inoculations than older children. Children who are not immunized in the first year of life should be vaccinated according to the most recent catch-up immunization schedule previously mentioned. Missed vaccinations should be given as soon as possible, and the entire series does not need to be repeated. Vaccines given outside the U.S. are acceptable as long as there is reliable written evidence of administration (including dates and number of doses), and the age and spacing are the same as CDC recommendations. titers can be checked or the child reimmunized. vaccines used worldwide have been produced with adequate quality control and are reliable, but vaccine handling can be suspect, If in doubt, immunize. Children adopted from overseas generally need all immunizations repeated to account for any inaccuracies in reporting or vaccine potency questions. Proper storage of vaccines and correct immunization technique are critical for optimal results. The manufacturer's package inserts provide this information. environmental pollutants on the body's immune responses to vaccinations. Increased levels of prenatal and/or postnatal polychlorinated biphenyls (PCBs) have been correlated with lowered antibody response to tetanus and diphtheria vaccines in children at 18 months and 7 years old, but not at 6 months. some general vaccination guidelines: • Vaccine doses may be given 4 days prior to or later than minimum intervals or ages to provide some schedule flexibility. • If two live virus parenteral vaccines are given less than 28 days apart, the vaccine given second should be disregarded; repeat this second vaccine at least 4 weeks later. Do not aspirate the syringe before injection (unproven necessity); do not recap the needle after use. When multiple vaccines are given on the same extremity, the sites of injection should be at least 1 inch apart; the anterolateral aspect of the thigh is the preferred site for this. use only written, dated records. Reimmunization of an immune individual is not harmful. • Reduced or divided doses of vaccines should not be given. • Techniques to decrease the pain of immunizations include applying pressure to the injection site for about 10 seconds before vaccination; putting sucrose on the tongue or pacifier of an infant; having children blow a pinwheel or bubbles during the procedure. • Those administering vaccines should know how to recognize and respond to syncope following immunization and severe allergic reactions, including anaphylaxis. Individuals with severe allergy to latex should not be administered vaccines that come from vials or syringes that contain latex (vial stoppers, syringe plungers can contain latex; see package insert). • Failure to transport and store vaccines correctly can lead to vaccine failure; designated personnel to daily monitor and document storage requirements (temperature, safety precautions). • In some circumstances (imminent travel, delayed immunizations) an accelerated schedule is available from the ACIP. • The major contraindication- anaphylaxis with a prior dose or to a vaccine component.

meningococcal disease

Many organisms can cause meningitis (group B streptococcus, Escherichia coli, Listeria monocytogenes, enterococci, S. pneumoniae, N. meningitidis, H. influenzae). varies with age. Epidemiology gram-negative diplococcus. It is a common commensal organism in the human nasopharynx. Groups A, B, C, W-135, and Y are largely the causes of invasive disease. Groups B, C, and Y account for 90% of invasive meningococcal. Group B is a greater threat to younger children. spread from person to person via respiratory tract secretions and in most cases causes asymptomatic colonization. persist for weeks to months. The asymptomatic carriage rate is approximately 25% in nonepidemic periods. most often during winter and early spring in children, but sporadically (97% of cases) in the U.S. Children 2 years or younger have the greatest incidence with a peak occurring in children less than 1 year old. Epidemics occur in semiclosed communities (e.g., daycare centers, schools, college dormitories, and military barracks). risk increases in environments where there is active or secondhand smoke exposure; in African-Americans, and in those from lower socioeconomic levels. Patients with functional or anatomic asplenia, sickle cell disease, agammaglobulinemia, AIDS, and complement deficiency or properdin deficiency are at increased risk for invasive or recurring meningococcal disease. Adolescents from 15 to 19 years experience another peak in incidence, and college freshmen living in dormitories have slightly less than a fourfold increase in risk than their peers who are not in college. 15 to 24 years old have the highest mortality rate as a result of septic complications despite the fact that younger children have more meningitis. N. meningitides found causative in other infections including conjunctivitis, otitis media, epiglottitis, arthritis, and pericarditis, urethritis in men (uncommon), and pelvic inflammatory disease in women (uncommon). Incubation Period 1 to 14 days. Patients are contagious until 24 hours after initiation of treatment. Clinical Findings Colonization can lead to invasive disease. Bacteremia and sepsis result and, depending on hematogenous spread, multiple patterns of illness can occur. bacteremia without sepsis, meningococcemic sepsis without meningitis, meningitis with or without meningococcemia, meningoencephalitis, and specific organ infection. Presenting symptoms of meningitis can include: • Occult bacteremia: febrile child with URI or gastrointestinal-like symptoms. maculopapular rash. Often treated as having a viral illness. Some have recovered without antimicrobial intervention, whereas others have developed meningococcal meningitis (58% of cases). • Meningococcemia: Symptoms may include fever (characteristic), chills, cold hands and feet, pharyngitis, headache, anorexia, purulent conjunctivitis, photophobia, myalgias/limb pain/refusal to walk (7%), myocarditis, malaise, stiff neck (less in infants), seizures, prostration, irritability, emesis, and a maculopapular or petechial rash (characteristic, follows other symptoms within 5 to 20 hours and occurs in about 7% of cases) quickly progress to purpura and septic shock manifested by hypertension, DIC, acidosis, adrenal hemorrhage, renal failure, myocardial failure, and coma. Fever and irritability may be the only initial symptoms in young children, whereas fever and headache are more typical in older children and adolescents. Diagnostic Studies positive culture or Gram stain from blood, CSF, synovial fluid, sputum, or petechial or purpura lesion scraping. Latex agglutination testing is not recommended. PCR testing is used widely in the United Kingdom and is useful when antibiotics are given before testing, and organism growth has been suppressed. A CBC shows leukopenia or leukocytosis with increased bands and neutrophil percentages, hypoalbuminemia, hypocalcemia, metabolic acidosis with increased lactate levels, decreased platelets, and elevated ESR and CRP. Differential Diagnosis septicemia caused by other invasive bacteria (e.g., pneumococcus or H. influenzae, viral meningitis, TB brain abscess, chronic otitis media, and sinusitis). Collagen-vascular diseases, primary hematologic and oncologic disease, erythema nodosa, erythema multiforme, RMSF, mycoplasma, lead encephalopathy, coxsackievirus, echovirus, rubella and rubeola infections, Henoch-Schönlein purpura, ITP, viral exanthems, typhus, typhoid, TSS, rat bite fever, gonococcemia, S. aureus endocarditis, and Kawasaki syndrome. Management IV antibiotics are started pending culture results; cefotaximine or ceftriaxone are drugs of choice. If susceptibility is confirmed, aqueous penicillin G (250,000 to 300,000 units/kg/day IV divided every 4 hours for 5 to 7 days) has been the drug of choice for infants and children. Alternative drugs (and for those with penicillin allergies) include cefotaxime, ceftriaxone, chloramphenicol (hematologic concerns with this drug), or ciprofloxacin. respiratory isolation until 24 hours after the induction of treatment. Some N. meningitidis strains in the U.S. are partially resistant to penicillin, but no treatment failures have been reported. Early dexamethasone given within minutes before antimicrobials may reduce the incidence of residual neurologic and audiologic complications, in children remains controversial. Activated protein C for meningococcal sepsis also remains controversial. Control Measures Exposed contacts must be carefully monitored. Household, school, or child contacts who develop a febrile illness must be evaluated for invasive disease promptly. High-risk household contacts have 500 to 800 times the risk as do those in the general community. • Chemoprophylaxis should be given within 24 hours of identification of the index case. At-risk individuals include close contacts (household, daycare, nursery school, those who shared oral secretions [kissing, shared utensils or toothbrushes]) of the index case 7 days before the onset of symptoms are at increased risk of invasive disease. Airline travel of greater than 8 hours while sitting next to an infected individual qualifies an individual for prophylaxis. Casual contact with the index case, casual contact with a high-risk contact, or medical personnel (unless they performed mouth-to-mouth resuscitation, intubation, or suctioning before antibiotic therapy was instituted) are usually not considered high risk. Oral rifampin, 10 mg/kg/dose PO (maximum dose 600 mg) twice daily for a total of four doses is the prophylactic treatment of choice for those older than 1 month. Infants younger than 1 month old should be given 5 mg/kg/dose PO twice daily for a total of four doses. Ceftriaxone (125 mg IM for those less than 15 years old; 250 mg IM for those older than 15 years) in a single dose is as effective as oral rifampin; it can be given to pregnant women. Ciprofloxacin (500 mg PO in a single dose) can be given to nonpregnant adults 18 years and older (it can be given for those 1 month old or older but this is not routinely recommended; dose 20 mg/kg PO [maximum 500 mg]). Azithromycin (500 mg single dose) is effective but not recommended for routine use (Pickering et al, 2009). • Prophylaxis during outbreak: Vaccine with serogroups A, C, Y, and W-135, in conjunction with chemoprophylaxis, is advisable to prevent extended outbreaks. No vaccine covers serogroup B infection. Complications Complications are caused by inflammation, intravascular hemorrhage, necrosis in multiple organ systems, and shock. Skeletal deformities and limb amputations are not infrequent. Meningitis can lead to ataxia, seizures, pneumonia, deafness (5% to 10%), arthritis and pericarditis, visual field defects, palsies and paralysis, developmental delays, and hydrocephalus. The fatality rate from meningococcemia is approximately 40% in the U.S. and about 10% from invasive meningococcal disease.

barriers to vaccination

five indications for delay: shortages of vaccines, vaccine refusal, vaccine schedule changes, and unique immunization needs of special populations. Shortages- increasing manufacturing capacity to respond to both seasonal and pandemic influenza vaccines by securing adequate egg supplies year-round; providing better guidance for and contracts with vaccine manufacturers; and focusing on cell-based vaccines. guidelines for priority administration. Product recalls, new vaccines, changing immunization schedules, program funding issues, and provider confusion can lead to inadequate immunization rates and levels of disease protection. inadequate reimbursement, storage and stocking issues, documentation hassles, language barriers, counseling issues, and safety concerns as reasons for not offering vaccinations onsite. System barriers such as vaccine costs, a lack of centralized vaccine registry and universal vaccination records, and the complexity of the immunization schedule may also affect immunization rates. raising immunization rates- community partnerships that involve school-based immunization programs. Such programs reach a large population of underimmunized children. They also bypass difficulties, such as lack of adequate insurance or lack of priority on the part of families for preventive care measures. Parents refuse vaccinations for their children based on many issues: concerns of vaccine safety, including safety of vaccine ingredients; inadequate safety testing; concerns that they may cause learning disabilities; and concerns that they are painful. cynical belief that vaccines are recommended for the profit of pharmaceutical companies, medical providers, and government agencies. The success of vaccine programs has decreased the incidence of disease leaving many people with no experience or awareness of the seriousness of vaccine-preventable diseases. believe that vaccine-preventable diseases are not very serious and that natural immunity is superior to immunity from a vaccine. religious reasons for avoiding vaccinations, and others believe that the number of vaccines given overloads or weakens a child's immune system. negative and high- profile media attention concerning a risk of autism (not supported by evidence) associated with vaccination despite overwhelming evidence that no such association exists. Some helpful points: • Listen: Understand that parents may not use the same decision-making processes that medical providers use. • Be familiar with common myths regarding the dangers of vaccines and be prepared to address them. Inform concerned parents that all childhood vaccines are available in thimerosal-free forms. • Be honest and respectful when discussing the known risks and benefits of vaccination and attempt to correct misperceptions or misinformation. • Emphasize risk associated with disease is far greater than the risk of a serious adverse vaccine reaction. • Provide parents with printed educational materials from a reliable source, such as the local health department, and encourage parents to visit reputable websites for more information (e.g., the Immunization Action Coalition, the National Network for Immunization Information, the CDC, and the American Academy of Pediatrics [AAP]). Some medical providers have explored the option of dismissing patients from their practice because of parental refusal of vaccinations. Dismissal may adversely affect access to care and health outcomes for a child. opportunity for education, the development of respectful communication and an ongoing relationship may help parents to reconsider their choices about immunization. When parents decline immunization- document vaccine discussions and ask parents to sign a vaccine refusal form (available at www.cispimmunize.org/pro/pdf/RefusaltoVaccinate_2p ageform.pdf). The AAP discourages patient dismissal but supports it when there is a substantial level of distrust, notable differences in the philosophy about care, or poor communication between provider and patient or family.

use of antibiotics

often prescribed for conditions that do not require their use and likely to contribute to the emergence of resistant bacteria. The CDC has a task force dedicated to tracking the emergence of drug- resistant pathogens and preventing their spread (www.cdc.gov/drugresistance/actionplan/taskforce). risk factors- pressure from the parents to prescribe antibiotics. educate patients and parents about the role and efficacy of antibiotics and to assume a more "targeted therapy" approach when prescribing. The CDC provides brochures, posters, and information sheets that may be helpful in explaining the importance of judicious use of antibiotics. Knowledge about emerging resistance patterns, local epidemiology, and susceptibility patterns of bacterial agents within their practice communities. unexpected benefit found from the flu vaccine has been that the number of antibiotic prescriptions written for respiratory infections has decreased. resulted in lowered overall rates of antibiotic-resistant bacteria.

safe storage and handling of vaccines

CDC makes the following recommendations for vaccine storage units: • Use purpose-built units designed to either refrigerate or freeze (can be compact, under-the- counter-style or large units) Household combination refrigerator/freezer • If a purpose-built unit is not available, use a stand-alone household unit • If you must use a household-grade, combination refrigerator/freezer unit, only use the refrigerator compartment for storing vaccines These units have cold spots and temperature fluctuations, and air circulating from the freezer could expose refrigerated vaccines to freezing temperatures Use a separate stand- alone freezer to store frozen vaccines Do not store any vaccine in a dormitory- style or bar-style combined refrigerator/ freezer unit under any circumstances These units have a single exterior door and an evaporator plate/cooling coil, usually located in an ice maker/freezer compartment These units have been shown to pose a significant risk of freezing vaccines, even when used for temporary storage (Note: not all small storage units are dormitory- or bar-style units Compact, purpose-built units for biologics can be used to store vaccines ) • Make sure the storage unit has enough space to store the largest inventory you might have at the busiest point in the year (e g , flu season) without crowding • Remove any deli, fruit, and vegetable drawers from refrigerator units This provides extra space for water bottles to help maintain stable temperatures and prevents use of the drawers for storing food, beverages, or vaccines • Use safeguards to ensure the doors of the unit remain closed (for example, self-closing door hinges, door alarms, door locks, etc ). CDC recommends DDLs with the following features: • Detachable probe that best reflects vaccine temperatures (e g , a probe buffered with glycol, glass beads, sand, or Teflon®)† • Alarm for out-of-range temperatures • Low-battery indicator‡ • Current, minimum, and maximum temperature display§ • Recommended uncertainty of +/-0 5° C (+/-1° F) • Logging interval (or reading rate) that can be programmed by the user to measure and record temperatures no less frequently than every 30 minutes Refrigerated vaccines should be stored between 2° C and 8° C (36° F and 46° F), with a desired target temperature of 4.4° C (40° F) Measles, mumps, and rubella (MMR) vaccine may be stored in either a refrigerator or freezer Some diluents must be refrigerated, while others may be stored in the refrigerator or at room temperature (no warmer than 25° C [77° F]) † Best practices for storing vaccine and diluent in a refrigerated unit include: • Always store vaccines in their original packaging with lids closed until ready for administration. This protects them from light and provides additional thermal protection/stability Never store loose vials or manufacturer-filled syringes outside of their packaging This increases the risk of administration errors, exposes vaccine to light, and makes it more difficult to track expiration dates and manage inventory • Place water bottles on the top shelf and floor and in the door racks.‡§ Putting water bottles in the unit can help stabilize temperatures that can be destabilized by frequently opening and closing unit doors or a power failure It can also prevent vaccines from being stored in areas where there is a greater risk of temperature excursions (such as the top shelf, floor, and door) Place water bottles carefully so they cannot dislodge, preventing the door from closing securely or weighing the door down so the seals are not tight Label all water bottles, "DO NOT DRINK " Vaccines and diluents must be carefully unpacked, stored at recommended temperatures, and documented immediately after they arrive. Do not place an unopened and/or unpacked shipment box in a vaccine storage unit. You should account for and document every dose of vaccine on a stock record, including: • Date of delivery (and initials of the person who unpacked the delivery) • Vaccine and diluent name and manufacturer • Number and expiration date for each lot (including expiration dates based on beyond use date guidance in the product information) • Number of doses received • Condition of each vaccine and diluent upon arrival (i e , did vaccine arrive in good condition at the proper temperature?) • CCM reading if included in the shipping container (and actions taken if the monitor was triggered, signaling a possible temperature excursion) • Number of doses used (i e , administered, wasted, compromised, expired, or transferred [and destination]) • Balance of remaining doses after subtracting the amount used CDC does not recommend any shipment of vaccines from your vaccine supply or any routine transport of vaccines. Vaccines that will be used at an off-site or satellite facility should be delivered directly to that facility. If that is not possible, transport of vaccines should be done using a portable vaccine refrigerator with a TMD placed with the vaccines. If this is not available, qualified containers and pack-outs can be used with a TMD. If you must transport vaccines, transport only what is needed for the workday. The total time for transport and workday should be a maximum of 8 hours. If you must transport vaccines in non-commercial vehicles, use the passenger compartment—not the trunk. Immediately upon arrival at an off-site/satellite facility, vaccines should be stored in an appropriate storage unit with a TMD. If the device displays min/max temperatures, they should be checked and recorded. If the device does not display min/max temperatures, then the current temperature should be checked and recorded a minimum of 2 times (at the start and end of the workday) .

specific viral diseases enterovirus non polio enterovirus

Epidemiology Of the more than 90 serotypes of nonpolio RNA enteroviruses (e.g., coxsackieviruses and echoviruses), 10 to 15 serotypes account for most diseases. They are grouped into four species—human enteroviruses (HEVs) A, B, C, and D. Hand-foot-mouth, herpangina, pleurodynia, acute hemorrhagic conjunctivitis, myocarditis, pericarditis, pancreatitis, orchitis, and dermatomyositis-like syndrome are manifestations of infection. These enteroviruses are also the most common cause of aseptic meningitis; they have also been associated with paralysis, neonatal sepsis, encephalitis, and other respiratory and gastrointestinal symptoms. The specific serotype may not be unique to any given disease (Abzug, 2007). As evidenced by the name, enteroviruses concentrate on the gastrointestinal tract as their primary invasion, replication, and transmission site; they spread by fecal- oral contamination, especially in diapered infants. They are also transmitted via the respiratory route and vertically either prenatally or in the parturition period. They have a worldwide distribution, occurring in temperate climates during the summer and fall, and in tropical climates year-round. Transplacental transmission can occur due to exposure to maternal blood or secretions during delivery in a mother infected with HEV and who lacks antibodies to that particular serotype. Transplacental infection can lead to serious disseminated disease in the neonate that involves multiorgan systems (liver, heart, meninges, and adrenal cortex). Nonpolio enteroviral infection is not a reportable disease nor is it routinely tested for in the clinical setting, so the overall incidence rate is not known (CDC, 2006a). The National Enterovirus Surveillance System (NESS) of the CDC has an ongoing surveillance system and encourages practitioners to test for enterovirus in patients diagnosed with aseptic meningitis. In known cases, infants less than 12 months have the highest prevalence rate (>25%), and HEVs account for 55% to 65% of hospitalizations for suspected infant sepsis. In addition to younger age, illness occurs more frequently in males, those living in crowded, unsanitary conditions, and in those of lower socioeconomic status (Abzug, 2007). Infection can range from asymptomatic to undifferentiated febrile illness to severe illness. Young children are more likely to be symptomatic. Incubation Period Incubation period is 3 to 6 days (less for hemorrhagic conjunctivitis). After infection, the virus is shed from the respiratory tract for up to 3 weeks and fecally for up to 7 to 11 weeks; it is viable on environmental surfaces for long periods (Abzug, 2007). Clinical Findings History General symptoms include: • A mild upper respiratory infection (URI) is common and may include complaints of sore throat, fever, vomiting, diarrhea, anorexia, coryza, abdominal pain, rash, and headache. • Nonspecific febrile illness of at least 3 days: In young children, there is an undifferentiated abrupt-onset febrile illness (101° to 104° F [38.5° to 40° C]) associated with myalgias, malaise, irritability; fever may wax and wane over several days. • Onset of viral symptoms within 1 to 2 weeks after delivery for neonates infected transplacentally (risk of severe disease is higher than for those acquiring the virus postnatally) (CDC, 2008a). Physical Examination General findings: Mild conjunctivitis, pharyngeal infection, cervical adenopathy. Other findings include (Abzug, 2007; CDC, 2008a; Pickering et al, 2009): • Skin: Rash may be macular, macular-papular, urticarial, vesicular, or petechial. May imitate the rash of meningitis, measles, or rubella. • Herpangina: There is a sudden onset of high fever (up to 106° F [41° C]) lasting 1 to 4 days. Loss of appetite, sore throat, and dysphagia are common, with vomiting and abdominal pain in 25% of cases. Minute vesicles (from 1 to more than 15 lesions of 1 to 2 mm each) appear and enlarge to ulcers (3 to 4 mm) on the anterior pillars of the fauces, tonsils, uvula, and pharynx and the edge of the soft palate. The vesicles commonly have red areolas up to 10 mm in diameter. The entire course usually lasts 3 to 7 days with complete recovery. • Acute lymphonodular pharyngitis: This manifests as an acute sore throat lasting approximately 1 week. • Handfootmouth disease: This is a clinical entity evidenced by fever, vesicular eruption of the buccal mucosa of the mouth, and a maculopapular rash involving the hands and feet. The rash evolves to vesicles, especially on the dorsa of the hands and the soles of the feet, and lasts 1 to 2 weeks (see Color Plate). • Aseptic meningitis: There are the usual signs of fever, stiff neck, and headache. Altered sensorium and seizures are common. Most cases appear in epidemics or as unique cases; most patients recover completely. • Paralytic disease: A Guillain-Barré-type syndrome has been described. • Congenital or neonatal infection: The neonatal infection often manifests as a sudden onset of vomiting, coughing, anorexia, fever or hypothermia, rash, jaundice, irritability, cyanosis, tachycardia, and dyspnea. It is often mistaken for pneumonia. The later three symptoms can progress to myocarditis and congestive heart failure. Infants can go into cardiac collapse, have hepatic and adrenal necrosis, suffer intracranial hemorrhage, and die. For those who survive severe disease, the recovery can be rapid. • Acute hemorrhagic conjunctivitis: Characterized by sudden eye pain, photophobia, blurred vision, tearing, and conjunctival erythema and infection. Most patients recover in a few weeks. • Pleurodynia (Bornholm disease or devil's grip): This condition usually occurs in epidemics, but some isolated cases can occur. It is most often caused by type B disease, but echoviruses have been implicated. There may be a prodrome before the onset of chest pain ushered in by headache, malaise, anorexia, and myalgia. The onset of chest or upper abdominal pain can be sudden, is pleuritic in nature, and is aggravated by deep breathing, coughing, or sudden movements. The pain occurs in waves of spasms that last several minutes to several hours and is described by patients as feeling like being stabbed with a knife or being squeezed in a vise. It can be mistaken for coronary artery disease, pneumonia, or pleural inflammation. Low to high fever occurs, and a pleural friction rub often is heard. The disease generally lasts from 3 to 6 days (up to a few weeks). • Orchitis: This type B infection is clinically similar to mumps. • Myocarditis or pericarditis: HEVs are associated with 25% to 35% of cases of myocarditis and pericarditis of identified cause. Symptoms can range from mild to severe (sudden death), and male adolescents and young adults are particularly vulnerable (Abzug, 2007). • Respiratory symptoms are frequently reported before the onset of fatigue, dyspnea, chest pain, congestive heart failure (CHF), and dysrhythmias. Wheezing, asthma exacerbation, apnea, respiratory distress, pneumonia, otitis media, bronchiolitis, croup, parotitis, and paroxysmal thoracic pain may be seen. Diagnostic Studies PCR is highly sensitive for all enteroviruses, results can be available in hours, and the test is more sensitive than cell culture. Cultures can be obtained from throat, stool, rectum, cerebrospinal fluid (CSF), and blood; sensitivities range from 0% to 80% (Pickering et al, 2009). CBC is usually normal. Serology for serotype-specific IgM antibody or other testing is less useful than culture or PCR. Differential Diagnosis The differential diagnosis includes other causes of the aforementioned conditions (e.g., viral or bacterial infections [pneumonia, meningitis, sepsis], or connective tissue diseases). Management There is no specific therapy available. IGIV has been used and proven helpful in some cases. Antiviral therapy is being developed. The antiviral, pleconaril, is being studied for use in neonates with life-threatening disease (CDC, 2008a). Prevention Enteric precautions and good handwashing are the only efficient control measures.

spacing live and killed vaccines

Simultaneous administration (that is, administration on the same day) of the most widely used live and inactivated vaccines does not result in decreased antibody responses or increased rates of adverse reaction. Simultaneous administration of all vaccines for which a child is eligible is very important in childhood vaccination programs because it increases the probability that a child will be fully immunized at the appropriate age. two live parenteral vaccines or LAIV adm. not during same visit- if administered at an interval of less than 4 weeks, then the vaccine given second should be repeated in 4 weeks or confirmed to have been effective by serologic testing of the recipient (serologic testing is not recommended following LAIV, varicella, or zoster vaccines).

herpes family of viruses

The herpes family of viruses is large. They have several features in common: all infect humans, the infection is lifelong, the viruses establish latency, and reactivation is controlled by immune function. Most active infections are self-limited. Infection becomes serious and dangerous when the cellular immune system is not working properly or when it is naïve (newborn). This family of viruses includes herpes simplex virus (HSV), VZV, Epstein-Barr virus (EBV), CMV, roseola (human herpesvirus 6 and 7 [HHV-6 and HHV-7, also known as exanthema subitum or sixth disease]), and human herpesvirus 8 (HHV-8, also known as Kaposi sarcoma-associated herpesvirus). HSV, VZV, and roseola are discussed in the following sections. The reader should consult other resources for a discussion about herpesvirus 8.

inactivated vaccine hepatitis B virus

Two recombinant HBV vaccines, composed of HBsAg protein, are licensed in the U.S. They are equally immunogenic and interchangeable. The seroconversion rate is 90% to 95%. Immunogenicity appears to be 20 or more years. Routine booster doses are not recommended except for patients receiving hemodialysis or for other immunocompromised patients whose annual anti-HBs levels have fallen to less than 10milli-international units/mL. Pregnancy and lactation are not contraindicated for vaccination. recommendations call for universal immunization of all newborns weighing equal to or more than 2000 g prior to hospital discharge (those preterm weighing <2000 g should wait a month), young children, and adolescents not previously vaccinated. specific individuals who should receive HBV: • Hemophiliac patients and other recipients of certain blood products • Intravenous (IV) drug users • Heterosexual persons with a history of multiple sex partners in the previous 6 months or with recent sexually transmitted infections • Men who have sex with men • Household and sexual contacts who are chronic carriers of HBV or who are HBsAg positive • Adoptees from foreign countries; household members of adoptees and those foreign born from HBV-endemic, high-risk countries or children born to first- generation immigrants from endemic areas • Alaska Native and Pacific Islander children • Specific infants, children, and other household contacts in populations of high HBV endemicity • Staff and residents of residential institutions for the developmentally disabled • Staff and attendees of nonresidential daycare and school programs for the developmentally delayed if an identified HBV carrier is known to attend or poses risk of infecting others • Hemodialysis patients • Health care workers and others with occupational risk • International travelers who travel to areas of high or intermediate HBV endemicity and who otherwise may be at risk • Inmates in juvenile detention and other correctional facilities Either HBV vaccine plus HBIG or HBV vaccine alone can be used effectively for postexposure immunoprophylaxis if given within 12 to 24 hours of exposure first dose at birth catch up: unvaccinated- complete 3 dose series 2 dose series separated by at least 4mths of adult recombivax HB children 11-15 4wks btw 1,2 dose, 8wks and atleast 16 wks after first dose btw 2,3 dose minimum age for final dose- 24wks. IM, 0.5ml, storage? s/e: hypersens, anaphyl, erythema multiform, erythema nodosum, SJS, thrombocytopenia, neurotox, GBS, encephalopathy, seizures, HZ, meningitis, lymphadenopathy, hypotension, alopecia, site reaction, fatigue, fever, dizziness, H.A contraindicated: hypersens to class, drug, compon, to yeast, caution hypersens to latex (prefilled syringed), immunocomp, acute illness, pts >60y/o. When multiple vaccines are given on the same extremity, the sites of injection should be at least 1 inch apart; the anterolateral aspect of the thigh is the preferred site for this.

specific viral disease varicella

common highly contagious virus belonging to the herpesvirus family. Chickenpox is the primary illness. It derives its name from the propensity of the lesions to resemble chickpeas. Shingles (herpes zoster) is the reactivation infection of latent VZV acquired during varicella infection. Humans are the only reservoir of infection; spread by direct contact, droplets, and airborne transmission. Victims of shingles are also infectious and can cause primary varicella illness. Immunity is usually lifelong. Symptomatic reinfection is rare, but asymptomatic reinfection occurs and symptoms are usually mild. Immunocompromised patients are at risk of developing generalized zoster. peak in those ages 10 to 14 years, overall incidence has decreased in all age groups from prior prevaccine levels. endemic in most large cities. Epidemics occur but at irregular intervals; the greatest incidence is in late winter and spring in temperate climates. Since the advent of the varicella vaccine hospitalizations have decreased by about 75%. Mild varicella breakthrough infection 1/5 previously vaccinated, due to the efficacy of the vaccine against mild disease. Incubation Period 10 to 21 days (mean of 14 to 16 days). communicability is 1 to 2 days before the rash erupts until all lesions have crusted over (about 3 to 7 days). prolonged in those who received varicella immune globulin or IGIV. Clinical Findings The following two phases are seen in varicella: 1. Prodrome: Not always present. low-grade fever, listlessness, headache, backache, anorexia, mild abdominal pain, and occasionally URI symptoms. 1 to 2 days before onset of the second phase. 2. Rash: Classic appearance. It is centripetal, beginning on the scalp, face, or trunk. Crops of generally highly pruritic lesions progress from spots to "teardrop vesicles" that cloud over and umbilicate in 24 to 48 hours. After a few days all morphologic forms can be seen simultaneously. Scabs 5 to 20 days, high fever, to 105° F (40.6° C). The more severe the rash, the higher the fever. Lesions can develop on all mucosal tissues, mouth, pharynx, larynx, trachea, vagina, and anus. Vaccinees that exhibit mild varicella infection rarely have more than 50 lesions. Diagnostic Studies clinical picture is easily recognized, except in the case of exposure of pregnant women. PCR or direct fluorescent antibody done from scrapings of a vesicle base during the first 3 to 4 days posteruption. Tzanck smears of lesions demonstrate multinucleated giant cells containing intranuclear inclusion bodies, but are not specific for VZV. Serial IgG antibody titers from acute and convalescent samples can also be compared for diagnosis confirmation. cultured from vesicular fluid, CSF, and biopsy of tissue but is less sensitive than the PCR. The WBC within normal limits. Differential Diagnosis The rash is classic; therefore, the diagnosis is usually not a problem. Occasionally, impetigo, cigarette burns, and insect bites can cause some confusion in children with a mild rash. confused with varicella- eczema herpeticum, HSV, and Stevens-Johnson syndrome. Management benign infection in normal children. Treatment is supportive and includes management of itching with antihistamines or oatmeal baths, acetaminophen for fever, and anti staphylococcal penicillin or cephalosporins for bacterial superinfections until the bacterial agent has been identified. Children with fever for more than several days, or increasing temperatures 4 or more days after the appearance of the rash, should be evaluated closely for invasive disease. Aspirin is contraindicated- possibility of Reye syndrome. The use of ibuprofen for fever has been questioned, possible causal relationship with bacterial superinfection. Intravenous acyclovir is efficacious for immunocompromised individuals and for those with severe disease. varicella immune globulin; not effective after the disease has progressed. Oral acyclovir is expensive and is not routinely recommended for most children, otherwise healthy children within 24 hours after eruption of the rash, there is a modest decrease in the symptoms and duration of the illness. It can also be considered for use in pregnant women esp second or third trimester. For pregnant women exposed to varicella, VariZIG or IGIV can be considered. The safety to the fetus of acyclovir in the first trimester is uncertain. Complications pyoderma- serious invasive disease with Streptococcus and Staphylococcus; ITP; pneumonia (smoking is a risk factor); CNS complications (e.g., encephalitis and Reye syndrome); and, rarely, glomerulonephritis, orchitis, hepatitis, toxic shock, osteomyelitis, necrotizing fasciitis, myositis, myocarditis, arthritis, and appendicitis. Primary varicella mortality rates of fewer than 2 to 3 per 100,000 cases with the lowest mortality rates in children 1 to 9 years old. highest rates in infants, adults, and immunocompromised. Congenital Varicella directly tied to the timing of the maternal infection. Infection early in pregnancy (7-20 weeks of gestation) can result in 1% to 2% of infants exhibiting significant physical anomalies, CNS complications, and scarring (referred to as congenital varicella syndrome). Those exposed in utero after 20 weeks of gestation may have unapparent varicella and zoster early in life. no time for maternal antibodies to develop and cross the placenta- newborns should be given IGIV (or VZIG if available) as soon as possible if their mothers develop varicella 5 days or less before the delivery or within 2 days postpartum. Despite VZIG, 50% of infants may still develop mild varicella infection. Prevention • Children exposed to chickenpox can attend school for about 1 week. show signs of illness- kept home for 1 week. no rash- they may return to school. active disease- home until all lesions dry. • Exposed patients: Use of varicella immune globulin has been discussed and can cause asymptomatic infection. Those who received immune globulin should obtain age-appropriate varicella immunization (unless contraindicated) within 5 months. immunocompromised- varicella titer may be obtained 2 months after varicella immune globulin to assess immune status. results are not always reliable in these individuals; alternative- these individuals can be considered for future varicella immune globulin if exposed. . • Varicella vaccine as previously discussed.

zidovudine regimen to decrease risk of perinatal transmission HIV

• Zidovudine (ZDV) syrup, 2 mg/kg/dose PO every 6 hours daily∗ within 6-12 hours of birth † and continuing for the first 6 weeks of life∗ • Rapid HIV-1 DNA PCR testing should be performed on all infants born to a mother whose HIV-1 serostatus is unknown (and also performed on the mother) within 8-12 hours of birth so that appropriate antiretroviral prophylaxis can be started. Some states require such testing on all newborns if mother has refused testing. • Two alternative dosing regimens can be found at www.aidsinfo.nih.gov/ContentFiles/PerinatalGL.pdf. DNA, Deoxyribonucleic acid; HIV, human immunodeficiency virus; PCR, polymerase chain reaction. ∗ For full-term infants unable to tolerate oral intake, intravenous (IV) dosage of ZDV is 1.5 mg/kg every 6 hours. For infants <35 weeks of gestation dosage is 1.5 mg/kg/dose IV, or 2 mg/kg/dose PO, every 12 hours, advancing to every 8 hours at 2 weeks of age if >30 weeks of gestation at birth or at 4 weeks of age if <30 weeks of gestation at birth. † Prophylaxis starting after 48 hours of birth is not likely to prevent the transmission of HIV.

inactivated vaccine meningococcal

13 serotypes of Neisseria meningitidis, serogroups B, C, Y, and W135 are most often associated with meningococcal disease. Serogroups B, C, and Y each cause one third of the diseases in the U.S., serogroup A is rare. younger than the age of 1 year are attributed to serogroup B. C, Y, and W135 cause three fourths of infections in those 11 years and older. no vaccine for serogroup B, whereas the other four serogroups are covered by current vaccines. disease associated with high morbidity and mortality in those who are infected, though only 1400 to 2800 infections are diagnosed annually. Three vaccines are available, some age restrictions. These include two quadrivalent conjugate meningococcal vaccines (MCV4) (meningococcal [Men] ACWY [Groups A, C, Y and W-135]-D [Menactra] and meningococcal [Groups A, C, Y and W-135] oligosaccharide diphtheria CRM197 conjugate vaccine [MenACWY-CRM, Menveo]) and meningococcal polysaccharide vaccine (MPSV4)- given to high risk for contracting meningococcal infection, adolescents; college freshmen living in dormitories; military recruits; those with functional asplenia or persistent deficiencies (and including infants 9-23 months); and travelers to hyperendemic or epidemic countries. MenACWY-D can be given to infants as young as 9 months and up through the age of 55 years if at high risk; MenACWY-CRM is given to those 2 to 55 years of age; and MPSV4 is only used if MCV4 is unavailable and for those older than 55 years of age. Either MenACWY-D or MenACWY-CRM is indicated for routine vaccine for those 11-12yrs, booster given at age 16 years or at age 13-18 years if not previously vaccinated. prior GBS infection should not receive MCV4. Any possible cases of GBS following vaccination should be reported to VAERS; as an alternative, MPSV4 can be considered. Depending on when an individual was initially vaccinated with MCV4 or MPSV4 and risk factors, re-immunization may be recommended every 5 years if risk remains. first dose: 6wks hib-mency 2mths menacwy-crm, menveo 9mths menacwy-D, menactra 10yrs serogroup B, MenB catch up: menactra or menveo at 13yrs-18yrs if not previously vacc. if first dose at 13-15yrs, booster at 16-18yrs 8wks btw. if first dose at 16yrs or older, no booster needed. MenACWY-D older than 9mth, MenACWY-CRM older than 2mths, 6wks first dose, 8wks btw 1,2 dose. IM, 0.5ml, single vacc, storage? s/e: anaphylaxis, angioedema, GBS, transverse myelitis, encephalomyelitis, site reaction, H.A, fatigue, irritability, malaise, arthralgia, diarrhea, anorexia, rigors, fever, vomit, rash, myalgia. contraindicated: hypersens to drug, class, component, caution immunocomp, acute illness. When multiple vaccines are given on the same extremity, the sites of injection should be at least 1 inch apart; the anterolateral aspect of the thigh is the preferred site for this.

live vaccine rota virus

4/5 children are likely to be infected with a rotavirus before 5 years old. There are two rotavirus vaccines licensed in the U.S., oral human- bovine reassortant pentavalent rotavirus (RV5) and oral human attenuated rotavirus (RV1). both effective vaccine formulations; contraindications: history of intussusception or severe combined immunodeficiency disease. Dosing differs between the two. Both vaccines demonstrate similar safety and efficacy profiles; the AAP has no preference. Ideally the same vaccine should be used, but this is not absolute given extenuating circumstances (vaccine name unknown or unavailable). Children with immune deficiencies may be those with the greatest need for disease protection and those at highest risk for serious effects from a live virus vaccine. Consultation with an immunologist may be helpful in particularly complex situations. first dose 6wks catch up: max age for dose 14wks and 6days, not initiated if 15wks or older. max age for final dose, 8mths. 4wks btw 1,2 dose and 2,3 if 3 dose series. 1ml susp., single, storage? s/e: intussusception, kawasaki dz, ITP, hematochezia, vomit, irritability, diarrhea, flatulence contraindicated: hypersens to drug, class, component, sever combined immunodiff, intussusception hx, GI malformation w/ intussusception risk, diarrhea, vomit, caution in GI disorder, hypersens to latex, acute illness, immunocomp, or close contact with immunocomp. When multiple vaccines are given on the same extremity, the sites of injection should be at least 1 inch apart; the anterolateral aspect of the thigh is the preferred site for this.

CBC

A complete blood count (CBC), From an infectious disease standpoint, the white blood cell (WBC) count is generally the most useful piece of information obtained from the CBC. It is often elevated (leukocytosis) in bacterial infections and may be decreased (leukopenia) in some viral infections. A differential WBC count is often obtained along with a CBC; bacterial infections often (but not always) cause increases in the neutrophil (or polymorphonuclear cell) count and may cause an elevation in bands (immature neutrophils). Medications may also commonly affect the WBC count. The clinical state of the patient may also need to be considered in the interpretation of the white count (e.g., overwhelming bacterial sepsis can lead to decreased WBCs). Although acute infection generally does not affect the hemoglobin or hematocrit levels, chronic inflammatory disease processes commonly cause low red cell levels (anemia). The platelet count is often elevated (thrombocytosis) during acute infection.

common distribution site of normal microflora

Aerobic Bacteria Gram Positive Staphylococcus aureus Skin, hair, naso- oropharynx, lower GI, cerumen Rarely found in the vagina and conjunctiva; trachea, bronchi, lungs, and sinuses are normally sterile; has potential for being a pathogen. Staphylococcus epidermidis Skin, hair, naso- oropharynx, adult vagina, urethra, conjunctiva, ear (including cerumen), lower GI Occasionally found in the vagina of prepubertal females; found in low numbers in "normal" urine, probably as result of contamination from urethra and skin areas Streptococci • Streptococcus saprophyticus Skin, hair, naso- oropharynx, lower GI, cerumen, mouth, nasal passages, nasopharynx Occasionally found in urethra and conjunctiva; group B uncommonly found in oropharynx and postpubertal vagina • S. mitis Skin, conjunctiva, nasopharynx; less commonly in adult vagina and urethra Uncommon in GI tract • S. mutans Mouth; less common in pharynx Has the potential of being a pathogen • S. pneumoniae (Pneumococcu s, Diplococcus) Nasopharynx, mouth; rarely found in conjunctiva, ear, vagina Has the potential of being a pathogen • S. pyogenes (group A) Mouth, pharynx; rarely skin, conjunctiva, ear, adult vagina Has the potential for being a pathogen • S. viridans Nasopharynx, mouth, skin Bifidobacterium bifidum Lower GI Enterococcus faecalis Lower GI, postpubertal vagina; occasionally found in mouth, urethra Rarely found in pharynx; has potential of being a pathogen Propionibacterium acnes Skin Gram Negative Acinetobacter johnsonii Skin, urethra, adult vagina Corynebacterium Skin, cerumen, naso- oropharynx, mouth, lower GI, urethra, adult vagina Citrobacter diversus Lower GI Enterobacter Lower GI, prepubertal vagina, mouth, axillary area Has the potential of being a pathogen Escherichia coli Lower GI, vagina, mouth, urethra Has the potential of being a pathogen Haemophilus influenzae Nasopharynx, but not commonly; rarely conjunctiva, ear Has the potential of being a pathogen Kingella kingae (formerly referred to as Moraxella kingae) Pharynx Has the potential of being a pathogen (cause of invasive infections in young children) Klebsiella pneumoniae Nose, colon, axillary area Lactobacillus spp. Pharynx, mouth, lower GI, adult vagina Moraxella catarrhalis Nasopharynx Morganella morganii Lower GI Mycobacterium spp. Skin, lower GI, urethra; rarely nasopharynx, mouth Mycoplasma Mouth, naso- oropharynx, lower GI, vagina; rarely urethra Neisseria spp. (e.g., N. mucosa) Nasopharynx (90%-100% of population); less commonly in conjunctiva, mouth, urethra, vagina N. meningitidis occurs in nearly 100% of the population as normal flora in the pharynx; less commonly in nose, mouth, vagina; N. meningitidis has the potential for being a pathogen Proteus spp. Lower GI, vagina, skin, nasopharynx, mouth Pseudomonas aeruginosa Lower GI, but not commonly; rarely in pharynx, mouth, urethra; lungs of patients with cystic fibrosis (CF) Has the potential of being a pathogen Anaerobic Bacteria Bacteroides spp. Lower GI, urethra; rarely adult vagina Has the potential of being a pathogen Clostridium spp. Lower GI; rarely mouth Less commonly found in adult vagina, skin; can be found in small numbers in urine, but is probably a contaminant. Has the potential for being a pathogen. Streptococcus spp Mouth, colon, adult vagina Spirochetes (a distinct form of bacteria) Pharynx, mouth, lower GI Fungi Actinomycetes spp. Pharynx, mouth Skin, conjunctiva, mouth, lower GI, adult vagina Candida albicans Can be found in voided urine, but is a contaminant Cryptococcus spp. Protozoa Skin Mouth, lower GI, adult vagina Viruses GI, Gastrointestinal; MRSA, methicillin-resistant Staphylococcus aureus. ∗ Normal microflora in humans consist of indigenous microorganisms that colonize human body tissues and live in a mutualistic state without producing disease. An individual's microflora depends on genetics, age, sex, stress, nutrition, and diet. A pathogen is a microorganism (or virus) than can produce disease. Normal flora can become pathogens when a host is compromised or weakened (endogenous pathogen); other microorganisms can invade a host during times of disease only (obligate pathogens) or lowered resistance (opportunistic pathogens). More than 200 species of bacteria are known to comprise the normal microflora. Skin microflora can also include yeast (Malassezia furfur), molds (Trichophyton mentagrophytes var. interdigitale), and mites (Demodex folliculorum). The The role of viruses as normal flora is undetermined. ∗ Normal microflora- indigenous microorganisms that colonize human body tissues and live in a mutualistic state without producing disease. depends on genetics, age, sex, stress, nutrition, and diet. A pathogen is a microorganism (or virus) than can produce disease. Normal flora can become pathogens when a host is compromised or weakened (endogenous pathogen); other microorganisms can invade a host during times of disease only (obligate pathogens) or lowered resistance (opportunistic pathogens). Skin microflora can also include yeast (Malassezia furfur), molds (Trichophyton mentagrophytes var. interdigitale), and mites (Demodex folliculorum). The spinal fluid, blood, urine, and tissues are normally sterile; the cervix is normally sterile, but can demonstrate flora similar to those in the upper area of the vagina. Antibiotics can have a minor to major effect on the microflora (e.g., ampicillin has a major effect; erythromycin a moderate effect; and sulfonamides and penicillins have minor effects). Skin and mucosal surfaces provide a barrier to invasion by microorganisms, and antibodies and immune cells allow the body to defend itself in general and specific ways against invasion by pathogens. Microorganisms may breach the immune barrier by binding to cell surface structures; for example, influenza virus uses its hemagglutinin protein to attach to cell membranes and invade respiratory mucosa. Disease caused by microbial pathogens can result from destruction of infected cells and tissues and from disruption of normal cell functions. Some disease symptoms are caused by the immune system response to infection, which can result in local or systemic inflammatory responses.

Acute Herpetic Meningoencephalitis

After the neonatal period, infection with HSV-1 is a leading cause of intermittent, nonepidemic encephalitis in children and adults in the U.S. Encephalitis can be focal, mimicking a mass lesion. Diagnosis is made by brain biopsy. In contrast, HSV meningitis is usually a relatively benign disease most often caused by HSV-2.

procalcitonin

Along with CRP and WBC, serum procalcitonin (Pro-CT) is considered a promising biomarker for differentiating certain viral infections from serious bacterial infections; in some cases it has proven to be a better marker of sepsis than the erythrocyte sedimentation rate (ESR), WBC, CRP and interleukin-6 (IL-6). Procalcitonin is a protein that has activity similar to a hormone and a cytokine. It is produced by several cell types and many organs in response to proinflammatory stimuli, particularly due to bacteria. It may prove to be a valuable tool when the ability to draw and process blood cultures is limited. bacterial pneumonia; fever without origin in children 1 week or less of age or 1 month to 36 months of age; bacterial infection in febrile neutropenic children with cancer; diarrhea-associated hemolytic-uremic syndrome; bacterial causes of acute hepatic disease; septicemia versus systemic inflammatory response syndrome; bacterial versus aseptic meningitis; and various diseases that involve inflammatory processes (e.g., Crohn disease, systemic lupus erythematosus [SLE])

vaccine controversies

As reported in the Institute of Medicine (IOM) Immunization Safety Review Committee's intensive review (IOM, 2004) and reaffirmed by the AAP (2010a), there has been no substantiated evidence of a causal relationship between thimerosal-containing vaccines or measles, mumps, rubella (MMR) vaccine and "pervasive developmental disorders," such as autism, attention- deficit/hyperactivity disorder (ADHD), speech/language delays, childhood disintegrative disorder, Asperger syndrome, or Rett syndrome. no general connection, no biologic mechanism consistent with a relationship between immunization or an adverse event, or insufficient causal evidence between hepatitis B and demyelinating diseases of the central nervous system (CNS) and peripheral nervous system (multiple sclerosis, acute disseminated encephalomyelitis, optic neuritis, transverse myelitis, Guillain-Barré syndrome [GBS], and brachial neuritis). role that multiple vaccines might play in causing type 1 diabetes or serious infections, a causal relationship was dismissed. some mixed evidence among studies regarding a possible connection between multiple vaccines and asthma. The Immunization Safety Review Committee concluded that further research in all these areas was warranted given the public concern with vaccine safety, the threat of increased populations going unvaccinated because of these fears, and the resulting resurgence of preventable diseases. The AAP, IOM, and CDC are good resources. Vaccines that are thimerosal-free or contain trace amounts are on the CDC's recommended list, 2 exceptions- Multidose vials of inactivated flu vaccine and multidose vials of one of the meningococcal vaccines contain thimerosal. There are thimerosal-free alternatives available for each of these products.

live vaccine tuberculin skin testing *implications for testing

BCG vaccine can produce a mild to severe hypersensitivity reaction, giving a false-positive reaction in children who receive the Mantoux skin test, however, prior BCG vaccination should receive the skin test. The size of the reaction can vary depending on several factors: the age of the BCG vaccine itself, its quality, the strain of M. bovis used, the number of past doses of BCG vaccine received, nutritional status, immunologic factors, infection with environmental mycobacteria, and the frequency of skin testing (boosts the response). The degree of positivity decreases over time, depending on the age at vaccination. The role of the skin test is limited in TB-endemic countries. who should be tested? higher risk for being infected with TB bacteria, including: People who have spent time with someone who has TB disease People from a country where TB disease is common (most countries in Latin America, the Caribbean, Africa, Asia, Eastern Europe, and Russia) People who live or work in high-risk settings (for example: correctional facilities, long-term care facilities or nursing homes, and homeless shelters) Health-care workers who care for patients at increased risk for TB disease Infants, children and adolescents exposed to adults who are at increased risk for latent tuberculosis infection or TB disease high risk for developing TB disease include: People with HIV infection People who became infected with TB bacteria in the last 2 years Babies and young children People who inject illegal drugs People who are sick with other diseases that weaken the immune system Elderly people People who were not treated correctly for TB in the past *TB tests are generally not needed for people with a low risk of infection with TB bacteria.

live vaccine Bacille Palmette-Guerin

Bacille Calmette-Guérin (BCG) live vaccine was developed in the early part of the twentieth century to prevent the spread of TB. The vaccines in use worldwide differ in composition and efficacy because of the differing attenuated substrains of Mycobacterium bovis from which they are derived. Two BCG vaccines are licensed for use in the U.S. The WHO does not recommend any particular BCG over another (WHO, 2009). The vaccine is widely recommended at birth as a public health measure in more than 100 countries in order to prevent disseminated and other potentially fatal effects from Mycobacterium tuberculosis disease (meningitis and miliary) in infants and children. The efficacy of BCG in this population is approximately 75%. For all populations worldwide, the efficacy is closer to 50% (WHO, 2009). The vaccine does not protect against primary or reactivation of latent infection. Countries have their own immunization schedules regarding BCG vaccination. The vaccine is ideally given to infants at birth. Until 2 months of age, healthy infants may be given BCG without having a tuberculin skin test (TST), unless suspected of having congenital infection; after that, a TST is required prior to vaccination with BCG. In infants who are exposed to smear-positive pulmonary TB shortly after birth, 6 months of prophylactic isoniazid should be given prior to receiving the BCG vaccine (WHO, 2010). New recombinant BCG and live attenuated TB vaccines are currently under development using state-of-the-art technology. In the U.S., BCG use is not generally recommended. BCG is considered in special circumstances for infants and children with negative TST who: (1) live with persons with infectious pulmonary TB who are untreated or ineffectually treated; cannot be removed from those persons; and are without a source of long-term primary treatment; or (2) live with persons who have drug- resistant forms of TB (to isoniazid and rifampin) and cannot be separated from those persons. Before administering BCG in the U.S., pediatric TB experts should be consulted. Health care workers in high- risk settings also may be candidates for BCG (Pickering et al, 2009). A complete guideline for the use of BCG is available from the WHO.

pathogenesis

Bacteria are the dominant life form on earth. They are often controlled by viruses. Humans become colonized with bacteria on the skin and mucosal surfaces (including the upper respiratory and gastrointestinal tracts) shortly after birth. generally harmless and may be beneficial because many normal flora can minimize colonization. Infectious agents cause disease when the balance between harmless colonization and protective immunity is disrupted in favor of harmful proliferation of a microorganism. Dangerous viruses meet all three criteria at once (rare): inflicting serious harm, going unrecognized by the immune system, and being able to efficiently spread.

Deoxyribonucleic acid testing

Deoxyribonucleic acid (DNA) testing has become increasingly common in the in-patient setting and is being used more frequently in clinical practice. These tests generally rely on polymerase chain reaction (PCR) to amplify pathogen-specific DNA, followed by detection using labeled DNA or ribonucleic acid (RNA) probes. Specimens of fluid or tissue may be evaluated by PCR. Pathogens that are commonly detected by PCR include Neisseria gonorrhoeae, Chlamydia trachomatis, HIV, Bordetella pertussis, herpesviruses, and enteroviruses.

inactivated vaccines DTaP

Diphtheria and tetanus toxoids with acellular pertussis vaccine (DTaP) are used in the U.S. for children less than 7 years old. Tdap is given to those 7 years of age or older. The DTaP has fewer side effects than the whole-cell vaccine. another country, DTP is an acceptable alternative, in the U.S., DTaP would be given. Combination vaccines are available that include DTaP, HiB, and other vaccines; single DTaP products cannot be mixed with any other vaccine. duration of immunity after pertussis infection has not been established, but it is believed to be short. highly effective vaccines as proven by the rarity of these diseases in the U.S. All of the available vaccines are equally effective, but differ slightly in their components. controlling pertussis in young infants may depend on older children and adults receiving a booster with Tdap rather than with Td. recommendation-those needing a booster (or for wound management) be given a single dose of Tdap. This includes 7-10 year olds who may be underimmunized or whose immunizations history is incomplete, adolescents, those pregnant, and adults (including if ≥ 65 years and older in contact with infants under 12 months of age and health care workers of any age). Tetanus prophylaxis as part of wound management is based on age, nature of the wound, type of prior tetanus-diptheria toxoid vaccine, and vaccine reaction history. ∗ In those ≥7 years old, (including adolescents, those pregnant, adults, those ≥65 years in contact with infants >12 months old and healthcare workers of all ages), Tdap is preferred for prophylaxis as a booster dose if not given prior (applies if Td has been previously given; there is no minimum interval necessary between Td and Tdap); any subsequently needed prophylaxis or catch-up doses would be given as Td per catch-up schedule or every 10 years if caught-up. In children younger than 7 years old, use DTaP (DT if pertussis is contraindicated). † If tetanus immune globulin (TIG) is not available, intravenous immunoglobulin (IVIG) can be substituted. catch up- 5th dose Dtap not necessary if 4th administered by 4years or older. Tdap if older than 7. 4 week intervals btw doses 1-2, 2-3, 6mth interval btw doses 3-4, 4-5. first dose 6wks IM route, 0.5ml, storage? S/E: hypersens, seizures, GBS, brachial neuritis, encephalopathy, infantile spasms, irritable, injection site reaction, crying/persistent, myalgia, drowsiness, anorexia, fever, vomit contraindicated: hypersens, encephalopathy 7 days after petuss vacc, neuro disorder, infantile spasm, epilepsy, caution- hypersens to latex- prefilled syringe form, pertuss vacc reaction, GBS within 6wks prior pertuss vacc, seizure risk, immunocomp, acute illness. for pediatric vaccine: same as above. for adult vaccine same as above as includes: s/e: myocarditis, facial palsey, henoch-schonlein purpura, headache, myalgia, muscle weakness, fatigue, rigors, diarrhea, abd pain, arthralgia, lymphadenopathy, rash. When multiple vaccines are given on the same extremity, the sites of injection should be at least 1 inch apart; the anterolateral aspect of the thigh is the preferred site for this.

pandemic influenza viral infections

Influenza virus is an orthomyxovirus of three antigenic types, A, B, and C. Types A and B are responsible for epidemic disease; type C is attributed to sporadic mild influenza-like illness in children. Type A is further classified into two surface proteins—hemagglutinin and neuraminidase. Three hemagglutinin subtypes and two neuraminidase types are known to cause disease in humans (e.g., H1N1, HIN2, H3N2). Influenza A viruses can originate from swine and domestic or wild avian sources. highly contagious disease and is spread person to person by direct contact, droplet contamination, and fomites recently contaminated with infected nasopharyngeal secretions.

herpes simplex virus

Epidemiology HSV is among the most widely disseminated infectious agents in humans; it is a double-stranded DNA virus. HSV has two antigenic types. HSV-1 is associated chiefly with nongenital infections of the mouth, lips, eyes, and CNS. HSV-2 is most commonly associated with genital and neonatal infection (accounts for 75% of neonatal cases; the rest are attributed to HSV-1). Both types are equally devastating to a newborn. There can also be mixing and matching of both HSV types in different mucus membrane locations. Type 1 strains can be found in the genital tract (autoinoculation or oral-genital contact). Type 2 lesions found in the mouth or pharynx usually result from oral sexual activity. Primary infection with type 1 virus typically is the causative agent in those 6 months to 5 years old and most often presents as gingivostomatitis. Distribution is worldwide, but the infection is more frequent in crowded environments. It is spread by intimate, direct contact usually by an adult with or without symptoms. There is no seasonal variation. Type 2 infections usually occur as a result of sexual activity. Sexual molestation must always be ruled out when the infection is found in non-neonates; for this reason determining the type of virus is always important. Neither type is transmitted by inanimate objects, such as toilet seats (Pickering et al, 2009). Neonatal HSV-2 infection is primarily transmitted from the mother as the infant passes through an infected birth canal with viral migration via the neonate's conjunctiva, nose and/or mouth mucosa, or broken skin (e.g., from forceps or a scalp electrode). Infection can also occur with cesarean births. Risk of infection for an infant born to a mother with a primary genital infection is 25% to 60%. The risk for infants born to mothers with recurrent HSV genital infection is approximately 2%. The incidence is 1 in 3000 to 20,000 live births. However, about 75% of infants with congenital HSV infection are born to women without a history or clinical findings of active infection during pregnancy (Pickering et al, 2009). Postnatal transmission is described, but is less common. Mothers can inoculate their babies from oral, breast, or skin lesions. Fathers also can inoculate infants with nongenital lesions from their mouths or on their hands. There can be lateral transmission from an infected baby in the nursery due to inadequate hand hygiene by hospital personnel. Incubation Period Period of communicability for types 1 and 2 (when not in the neonatal period) is 2 days to 2 weeks (Pickering et al, 2009). Some cases of congenital infection occur more than 6 weeks after birth. Infection can be transmitted during either primary or recurrent infections, whether symptomatic or asymptomatic. Clinical Findings Manifestations are determined by the port of entry of the host, age, state of health, and immune competence. Eczema alone or in combination with other manifestations is also a complicating factor. Specific clinical findings, diagnosis, and treatment of gingivostomatitis, neonatal herpetic infection, eczema herpeticum, herpes vulvovaginitis, and herpes keratoconjunctivitis are discussed in other chapters. diagnostic tests If suspicious for neonatal infection, intrapartum cultures from mother and child should be obtained on the day of delivery at 12 and 24 hours or earlier. Tests may include viral culture, cytology-Pap smears, Tzanck stains, ELISA, fluorescent techniques, glycoprotein G assay, blood or CSF PCR in neonates, or histologic evaluation and viral culture from a brain biopsy in cases of encephalitis. Cultures in neonates need to be taken from skin vesicles, mouth, nasopharynx, eyes, blood, rectum, and CSF. Serologic tests are not helpful in neonates. If encephalitis is suspected, an electroencephalogram (EEG) and MRI of the brain are performed. In disseminated disease, elevated transaminase and/or radiographic evidence of HSV pneumonitis may be seen. Differential Diagnosis The diagnosis is usually not a problem if vesicles are present. Coxsackievirus can cause a vesicular stomatitis. Management Treatment is supportive except in life-threatening illness, neonatal infection, or disease in immunocompromised patients, at which time parenteral acyclovir is the treatment of choice. The role of long-term suppressive or intermittent acyclovir for neonatal HSV is unknown and under study (Pickering et al, 2009). Any lesion found should be cultured. In a woman with primary genital infection, cultures and empiric parenteral acyclovir for the newborn are often given. Infants born to women with active recurrent genital infection are generally not given empiric antiviral medication, but instead are closely monitored by parents, caregivers, and providers over the following 6 weeks. Careful hand hygiene before and after handling newborns and refraining from kissing or nuzzling (masks can be worn until lesions have crusted) by those with active infection are basic preventive measures. Complications Usually the infection is mild. Major problems have been discussed. Bacterial superinfection is always a problem. There is an increased incidence of cervical cancer in women with HSV-2 infections. Prevention • All pregnant women must be asked about HSV infection in themselves and all sexual partners. • Signs and symptoms of HSV should be carefully monitored throughout pregnancy. • During labor all women must again be questioned about HSV and carefully examined for signs and symptoms of infection. Cesarean delivery is indicated in women with apparent infection unless membranes are ruptured for more than 4 to 6 hours. Scalp monitoring should be avoided. • Toddlers and infants with primary gingivostomatitis who are drooling should be excluded from childcare centers if they cannot control their saliva. Children with recurrent "fever blisters" may attend school. Covering recurrent HSV lesions with a bandage is appropriate for children with active nonmucosal involvement. • Wrestlers should be excluded from competition until lesions have healed (Pickering et al, 2009). (See also Table 13-6).

hepatitis c virus

Epidemiology Hepatitis C virus (HCV), a single-stranded RNA virus with seven genotypes in the Flaviviridae family, causes the chronic form of what used to be called non-A, non-B hepatitis. From 75% to 85% of infected individuals develop chronic infection. The incidence in the U.S. is approximately 1.3% and remains fairly stable (CDC, 2010g). The risk factors associated with HCV are illicit IV drug use (75%, with an estimated one third of injection drug users between 18 and 30 years old infected), imprisonment, occupational (1%) or sexual exposure (1% to 10%), and transfusions or organ recipients prior to 1992 (rare now). Hemophiliacs treated with inadequately screened blood products are at high risk; those on chronic hemodialysis have moderate risk (10% to 20%). Perinatal transmission by non-HIV-infected women is approximately 5% to 6%; HIV-positive mothers have a greater likelihood of transmitting the virus to their infants. Vaginal birth and breastfeeding do not contribute to higher rates of transmission, and women with HCV alone should not be discouraged from experiencing either (Pickering et al, 2009). Studies demonstrate an increased incidence of transmission to female infants. It is postulated that this may be a reflection of hormonal or genetic differences in susceptibility or response to the infection; there is greater mortality in utero for males infected with the virus than for females (Beasley, 2005). Incidence of persistent hepatitis infection in children is from 50% to 60%, typically asymptomatic. HCV infection has the highest rate of developing into chronic infection than all of the other hepatitis infections; 70% to 80% of adult cases are characterized by chronic infection and liver disease, whereas the incidence of these complications in children is thought to be lower (Pickering et al, 2009). Incubation Period HCV has an incubation period ranging from 2 weeks to 6 months (average 45 days). Clinical Findings Onset of symptoms is often insidious, and most children are asymptomatic. Flulike prodromal symptoms followed by jaundice occur in 20% to 30% of cases (CDC, 2010g). Chronic hepatitis with cirrhosis is a late occurrence, often 20 to 30 years later. Fulminant infection is uncommon. Diagnostic Studies There is no serologic marker for acute infection. Confirmation of HCV using IgG antibody enzyme immunoassay for anti-HCV or nucleic acid assay to detect HCV RNA are diagnostic. False-negative results can occur, however, early in the infection. The majority of individuals seroconvert within 15 weeks postexposure or within 5 to 6 weeks after the onset of illness symptoms. A newborn can be anti-HCV positive from maternal transfer for up to 18 months, so testing should ideally be done after that time. Liver function tests are indicated; liver biopsy is confirmatory. Differential Diagnosis Differential diagnoses include HAV and HBV and other causes of chronic hepatitis. See section on differential diagnosis of HAV. Management Treatment of acute HCV is supportive; there is no effective treatment to prevent the progression to cirrhosis, liver failure, or hepatocellular cancer. Chronic HCV infections in children respond to therapy with nonpegylated interferon alfa-2b therapy and ribavirin (for use in children 3 to 17 years). HAV and HBV vaccines should be given to prevent further liver complications. Liver damage can be exacerbated by comorbid conditions such as cancer, iron overload, thalassemia, or HIV. Drugs such as acetaminophen or antiretroviral medications need to be closely monitored; patients should have serum hepatic transaminases monitored closely. Breastfeeding by an HCV-positive mother is not contraindicated unless she has cracked or bleeding nipples. Children with HCV infection need not be excluded from daycare facilities (Pickering et al, 2009). Individuals with HCV should be discouraged from using alcohol (to prevent further liver injury) and from sharing razors and toothbrushes; condom use should be encouraged. Prognosis The course of HCV is generally mild even with cirrhosis. Liver transplantation is an option, although reinfection is common and gradually progressive. The outcome of chronic HCV disease in children is less known. Prevention IG is not recommended for prophylaxis after exposure. There is no HCV vaccine.

infectious mononucleosis syndrome

Epidemiology IMS is caused by the Epstein-Barr family of herpesvirus in more than 90% of cases; the remaining cases are attributed to acute CMV, Toxoplasma gondii, adenovirus, viral hepatitis, HIV, and possibly rubella. Its distribution is worldwide, with more than 95% having been infected (Jenson, 2007). Older children and adolescents in poor urban settings or developing countries are seropositive for EBV. In these children primary infection tends to produce only mild symptoms and is subclinical. Exposure occurs in infancy or early childhood. In more developed countries infection in those less than 4 years of age is rare; one third of cases occur during adolescence or young adulthood (Jenson, 2007). The mode of transmission is personal contact, usually from deep kissing; by penetrative sexual contact; or from the exchange of saliva among children. The virus can live outside the body in saliva for several hours (Pickering et al, 2009). About 20% to 30% of healthy immune individuals shed EBV at any one time. From 60% to 90% of EBV-infected individuals on immunosuppressive therapy, including those on steroids, shed virus (Jenson, 2007). Incubation Period Because IMS virus is found in the saliva and blood of both clinically ill and asymptomatic infected persons for many months, the period of communicability is difficult to assess. The period of incubation is thought to be from 30 to 50 days. It is only mildly contagious. Clinical Findings IMS is the "great impostor" and can mimic any disease imaginable. It is a disease of the primary lymphoid tissue and peripheral blood. Lymphoid tissue—regional lymph nodes, tonsils, spleen, and liver—is enlarged. Atypical lymphocytes are seen in the peripheral blood. Almost all body organs are involved, including but not limited to the lungs, heart, kidneys, adrenals, CNS, and skin. Symptoms are variable and can last up to 2 to 3 weeks. Clinical presentation can include the following (Jenson, 2007; Johannsen and Kaye, 2009): • Fever: Moderate to high fever (<103° F [39.4° C]) is common (>90%). In severe cases, fever can reach 104° to 105° F (40° to 40.6° C). Fevers usually wane over a 10- to 14-day period. • Sore throat: Usually begins a few days after the fever with an average incidence of about 80%. The throat is very painful for 7 to 10 days. There is marked tonsillar enlargement, grayish exudates (in approximately 30% of cases), ulceration, and pseudomembrane formation. Petechiae are found on the palate (in approximately 25% to 60% of cases). The airway can be compromised (<5% of cases) and is an indication for hospitalization. • Lymphadenopathy: Anterior and posterior cervical and submandibular nodes are more commonly involved, less so the axillary and inguinal nodes. Epitrochlear lymphadenopathy is highly suggestive of the disease. Nodes are firm but usually nontender, are discrete, and range from 1 to 4 cm in size (up to 90% incidence). • Splenomegaly: Occurs typically 2 to 3 cm below the costal margin in approximately 50% of cases. Rupture is rare. • Hepatomegaly: 10% to 15%; jaundice occurs in about 5% of cases. • Skin rash: Occurs in 3% to 15% of cases, usually on the trunk, arms, and palms. It can be maculopapular, urticarial, scarlatiniform, hemorrhagic, or nodular (rarely petechial, vesicular, or hemorrhagic) and usually occurs during the first few days of symptomatology onset and lasts 1 to 6 days. The rash occurs more frequently in patients taking ampicillin (up to 100%); probably represents a form of arteritis or vasculitis rather than hypersensitivity to ampicillin, and typically starts 5 to 10 days after the drug has begun. A symmetric rash of erythematous papules with or without coalescence on the cheeks, extremities, and buttocks (looks like atopic dermatitis) is associated with EBV infection as well (the Gianotti-Crosti syndrome). • Vision: Perceptual distortions in size, shapes, and spatial relationships can occur. Periorbital edema has been reported in 30% of cases. Other systemic manifestations can include myalgia, arthralgia, headache, chest pain, nausea, anorexia, vomiting, ocular pain, photophobia, conjunctivitis, gingivitis, abdominal pain, orchitis (rare), diarrhea, cough, pneumonia, myocarditis, pericarditis, rhinitis, epistaxis, bradycardia, aseptic meningitis, GBS, Bell palsy, Reye syndrome, and acute cerebellar ataxia (Johannsen and Kaye, 2009). Diagnostic Studies The CBC has a classic picture of more than 10% atypical lymphocytes and lymphocytosis; elevated liver enzymes are typical. Monospot and the serum heterophile test are positive in 85% of infected patients older than 4 years (often negative in those less than 4 years of age). Children older than 4 years usually must be ill for approximately 2 weeks before seroconverting. Viral culture and Epstein- Barr-specific core and capsule antibody testing are usually used for diagnosis if the primary screening test results are negative, and there is continued suspicion of IMS (e.g., in younger children). Depending on the specific EBV antigen system tested, levels can be detectable for years after infection. Differential Diagnosis IMS is in the differential diagnosis of almost every infectious disease. Conditions and infections typically associated with a mononucleosis-like syndrome are gram-positive alpha-beta hemolytic streptococcal pharyngitis, leukemia, lymphoreticular malignancies, adenoviruses, toxoplasmosis, CMV, rubella, HIV, hepatitis, SLE, drug reactions, and diphtheria. Management Treatment is supportive with adequate bed rest (for debilitating cases), over-the-counter pain relievers, fluids, and calories. Corticosteroids and acyclovir are not recommended for routine uncomplicated disease; penicillin products should not be given. Contact sports and strenuous exercise should be avoided for 4 weeks and especially in those with hepatosplenomegaly. (See Chapter 13 for return-to-play sports participation after hepatosplenomegaly.) Symptoms generally resolve within 2 to 4 weeks; fatigue and weakness may persist for up to 6 to 12 months after severe infection. Complete recovery can be expected in more than 95% of cases without any specific treatment (Johannsen and Kaye, 2009). Complications Clinically healthy patients experience few sequelae. Rare complications include splenic rupture, neurologic complications (from aseptic meningitis, encephalitis, myelitis, optic neuritis, cranial nerve palsies, GBS), thrombocytopenia, agranulocytosis, hemolytic anemia, orchitis, myocarditis, or chronic IMS. The virus also seems to increase the risk for Hodgkin disease. Death is rare. There is no convincing evidence that supports an association between EBV infection or reactivation to chronic fatigue syndrome (Johannsen and Kaye, 2009). Prevention Persons with a recent history of IMS or an infectious mononucleosis-like disease should not donate blood or organs.

specific viral disease measles- rubeola

Epidemiology Measles (rubeola) is a Morbillivirus in the Paramyxoviridae family and is similar to mumps and influenza. There is only one antigenic type. Measles is typified by a rash, indicating viremia. It is a serious illness in children! high mortality and morbidity rates worldwide. Humans and primates are the only known reservoir, sources- respiratory secretions, blood, and urine of infected persons. transmitted through droplet contact, fomites, and, aerosol transmission. Peak incidence during the winter and spring months. The failure rate after the first vaccine at 12 months old is approximately 5%; after the second vaccine the failure rate is about 2%. Modified measles can manifest in children who have been passively immunized with IG after exposure to the disease, infants with partial maternal immunity, abbreviated version of typical disease. Incubation Period 8 to 12 days. A person is contagious 1 to 2 days before the onset of symptoms or 3 to 5 days before the rash, and 4 days after the appearance of the rash, or roughly 14 days. modified measles can persist as long as 20 days. no carrier state; disease or two vaccinations usually confer lifelong immunity. Clinical Findings three stages: 1. Incubation period: There are no specific symptoms. 2. Prodromal period: This is the first sign of the illness, 4 to 5 days. URI symptoms, low to moderate fever (greater than 101° F [38.3° C]), and cough, coryza, and conjunctivitis (the "three C's" of measles). enanthem can be found on the oral mucosa opposite the lower molars. These Koplik spots last 12 to 15 hours. small, irregular, bluish white granules on an erythematous background and are pathognomonic of measles infection. 3. Rash stage: The rash of unmodified measles, third or fourth day of the illness. As the rash appears, temperature rises, often to 105° F (40.5° C). first, behind the ears and on the forehead. It is maculopapular. Papules enlarge, coalesce, and move progressively downward, engulfing the face, neck, and arms over the next 24 hours. By the end of the second 24 hours, the rash has spread to the back, abdomen, and thighs. As the legs become more involved, the face begins to clear. approximately 3 days. Respiratory symptoms are most severe on day 3 of the rash. The more severe the rash, the more severe the illness. It can become hemorrhagic. This type of measles can be fatal because of disseminated intravascular coagulation (DIC). After the fourth day of the rash stage, the rash begins to fade. The disease peaks; defervescence occurs. After the rash clears a residual light pigmentation occurs, lasting approximately 1 week, that desquamates. Maternal antibody level and improperly given vaccine can alter the presentation and clinical course. modified measles, the prodrome period can be as early as 1 to 2 days with normal to low-grade fever. URI symptoms are minimal to absent. Koplik spots usually do not appear. rash so mild, often missed. Diagnostic Studies A single measles IgM antibody level is useful if drawn when symptoms suggest this disease; the reactivity is low after more than 30 days. Confirmation by viral isolation from urine, blood, throat or nasopharyngeal secretions or from serial IgG antibody titers that compare acute and convalescent serum specimens. Measles is a reportable disease in the U.S. Differential Diagnosis Any viral rash (e.g., roseola, rubella, echovirus, coxsackievirus, IM, adenovirus, and EBV), toxoplasmosis, scarlet fever, Kawasaki syndrome, meningococcemia, Rocky Mountain spotted fever, drug rashes, and serum sickness are included in the differential diagnosis. Management Treatment is supportive (antipyretics, bed rest, adequate fluids, air humidification, warm room, darkened room if photophobia is present). Bacterial superinfections (e.g., ear infections, bronchopneumonia, encephalitis) are treated with appropriate antibiotics. All children with encephalitis, severe pneumonia, or compromised immune systems should be managed in consultation with an infectious disease expert. Children in the U.S. and in countries where malnutrition is an issue are at greater risk for death or morbidity with measles infection. These children, and those with severe measles, have lower vitamin A levels. Use of vitamin A is now recommended for all children- Dose once daily for 2 days: less than 6 months of age, 50,000 international units; 6 through 11 months of age, 100,000 international units; 12 or more months of age, 200,000 international units. Complications Bacterial superinfection and viral complications can manifest as a URI, obstructive laryngitis, otitis, mastoiditis, cervical adenitis, bronchitis, transient hepatitis, and pneumonia (the largest cause of fatalities in infants). The causative organism can be the measles virus itself or group A beta-hemolytic streptococci (GABHS), pneumococci, H. influenzae, or S. aureus. Infection can exacerbate underlying TB. Other complications include myocarditis, purpura fulminans ("black measles," characterized by multiorgan bleeding), encephalitis (one in 1000 cases) and other neurologic sequelae, and subacute sclerosing panencephalitis (fatal complication of wild-type measles; more prevalent in males, in rural and poorer areas, and in Hispanic children). usually no complications with modified measles. Care of Exposed Individuals This is done with active and passive immunization.

specific viral disease mumps

Epidemiology Mumps is an acute generalized viral disease with painful enlargement of one or more salivary glands (usually parotid glands). Mumps is in the Paramyxoviridae family. Only one serotype, humans are the only natural reservoir. The source of infection is the saliva of infected persons. spread by direct contact, aerosol transmission, fomites, and possibly, urine from infected individuals. Viremia exists, and the virus is found in blood, urine, CSF, saliva, and upper respiratory secretions. Infection is more often an outcome of undervaccination of susceptible individuals. decreased by more than 99% in the U.S. since the advent of the mumps vaccine. during all seasons but is most common during late winter and spring; both sexes equally. crosses the placenta, and infection during the first trimester increases the risk of spontaneous abortion. Incubation Period 12 to 25 days (usually 16 to 18 days). communicability 1 to 2 days before glandular swelling up to 5 days after the onset of swelling. 1/3 patients are asymptomatic but infectious. One attack usually confers lifelong immunity. Transplacental antibodies protective for 6 months. Clinical Findings two clinical stages: 1. Prodromal stage: Rare in children but can cause fever, headache, anorexia, neck or other muscular pain, and malaise. 2. Swelling stage: 24 hours after the prodromal stage, one (in 25% of patients) or both of the parotid glands begin to painfully swell in a characteristic manner. If both glands are affected, one generally swells before the other. The gland fills the space between the posterior border of the mandible and mastoid, pushing downward and forward to the zygoma. The ear is pushed forward and upward, few hours to a few days. The enlarged glands usually return to normal size in 3 to 7 days. Rarely a maculopapular, pink discrete rash is seen on the trunk. Pain on the affected side can be elicited by eat something sour, "pickle sign." The Stensen duct is red and swollen. Fever is usually moderate and rarely high; maybe afebrile. Little pain is associated with submandibular infection. redness subsides more slowly. The Wharton duct is frequently swollen. If sublingual salivary glands are involved, there is bilateral swelling in the floor of the mouth. Edema caused by lymphatic obstruction of the manubrium and upper chest is reported. Diagnostic Studies These include viral isolation and culture, and serologic tests (enzyme immunoassay for IgG and IgM antibodies and specific mumps antibody). Leukopenia with relative lymphocytosis and an elevated amylase are typical. Differential Diagnosis Cervical or preauricular lymphadenitis, CMV, HIV, enteroviruses, tumor, suppurative parotitis by either bacterial or viral (coxsackievirus, parainfluenza 1 and 3) infection, idiopathic recurrent parotitis, parotid ductal obstruction, Mikulicz syndrome, uveoparotid fever, and cancer (especially lymphosarcoma) are included in the differential diagnosis. Management Treatment is supportive (antipyretics, bed rest as needed, diet appropriate for chewing discomfort). Corticosteroids or nonsteroidal antiinflammatory drugs (NSAIDs) are given to manage arthritic complications. Manage orchitis with bed rest and scrotal elevation. Complications meningoencephalitis (mostly males older than 20 years); orchitis and/or epididymitis (14% to 35% incidence in adolescents and adults); oophoritis (7% incidence in postpubertal women; fertility is not affected); severe pancreatitis (rare); thyroiditis (uncommon in children); myocarditis; deafness (1 in 15,000 cases—transient or permanent); ocular complications (swelling of the lacrimal glands or optic neuritis); arthritis (rare in children); thrombocytopenia and hemolytic anemia (usually self-limited); mastitis (rare); and glomerulonephritis (rare). Prevention School and daycare students kept home until 9 days after the onset of parotid swelling. Active and passive immunization have been discussed.

specific viral disease typical influenza

Epidemiology occur in the winter months, last approximately 4 to 8 weeks, and peak 2 weeks after the index case. some epidemics have lasted 3 months as a result of more than one strain of virus circulating within a community. Children shed the virus longer than adults and, therefore, are particularly prolific transmitters within a community. highest incidence of the illness occurs in healthy infants and children 5 to 14 years old, with an incidence of 10% to 40%. Children younger than 2 years old (especially infants less than 6 months old), those 65 years and older, and those with chronic diseases, high rates of hospitalization. mortality figures are high for children with predisposing conditions, most fatalities occur among previously healthy children with no known risk factors; children who had not been immunized against influenza. Incubation Period 1 to 4 days. infectious 24 hours before the onset of symptoms. Viral shedding usually peaks by day 3 and ceases 7 days after the onset of illness. Clinical Findings Influenza patients are sick! Sudden onset of high fever (102° to 106° F [38.8° to 41° C]), headache, chills, coryza, vertigo, sore throat, pain in the back and extremities, and dry hacking cough that can resemble pertussis occur. Vomiting, diarrhea, and croup occur in young children. Infants can appear septic. Conjunctival infection, epistaxis, and myocarditis (evident by weak heart sounds and rapid, weak pulse) are common. severe infection, involvement of the lower respiratory tract with atelectasis or infiltrates. Severe myocardial involvement can cause distention of the right side of the heart and CHF. Diagnostic Studies Rapid influenza diagnostic test (RIDT) results are variable, sensitivities of 44% to 97% (depending on degree of influenza activity) and specificities from 76% to 100% when compared with viral cultures based on test and specimen type. Results of RIDTs are available in 15 minutes or less; some are approved for outpatient clinical use. based on whether the result would result in a change in the clinical care of that individual or for others at high risk. Special viral cultures taken from the nasopharyngeal cavity by swab or aspiration within 72 hours of the onset of illness can isolate the virus in 2 to 6 days to confirm the diagnosis. Direct fluorescent antibody (DFA) and indirect immunofluorescent antibody (IFA) test results can be obtained within 3 or 4 hours and are available from hospital-based laboratories. There are numerous serologic tests: viral agglutination, complement fixation, neutralization, or enzyme immunoassay (EIA). RT-PCR is both sensitive and specific. A CBC shows leukopenia. Differential Diagnosis other viral respiratory infections (common cold, parainfluenza, RSV, avian flu based on risk factors), allergic croup, epiglottitis, and bacterial URIs. Management Treatment is supportive (bed rest, fluids, antipyretics). Given its expense, treatment or prophylaxis with antiviral therapy (amantidine, rimantadine, zanamivir, oseltamivir) should be reserved for the following: • Children at risk of severe or complicated influenza infection (e.g., immunocompromised) • Healthy children with moderate or severe illness • Individuals within environments or family or social situations for which an illness would prove detrimental treatment should be started within 48 hours of symptom onset and continued until the patient is asymptomatic for 24 to 48 hours. There is no approved antiretroviral for infants younger than 12 months of age. The effectiveness of the antivirals can vary from year to year based on the virus and strains in play for that season. CDC website- antiviral recommendations each influenza season. Complications Complications include Reye syndrome, respiratory infections (acute otitis media [AOM], pneumonia), acute myositis, toxic shock, myocarditis, and cystic fibrosis (CF) and asthma exacerbations followed by bacterial superinfection, usually with H. influenzae. Do not give aspirin to influenza sufferers! Prevention Influenza vaccine should be widely promoted. Antiviral prophylaxis against specific types of influenza infections. The prophylactic doses same as active influenza treatment. all health care providers receive yearly influenza vaccine to protect themselves and prevent the spread of this disease to their patients and families. ethical obligation.

documenting vaccinations

Health care providers who administer vaccines covered by the National Childhood Vaccine Injury Act are required to ensure that the permanent medical record of the recipient indicates: Date of administration Vaccine manufacturer Vaccine lot number Name and title of the person who administered the vaccine and address of the facility where the permanent record will reside Vaccine information statement (VIS) Date printed on the VIS Date the VIS was given to the patient or parent/guardian Always provide a personal vaccination record to the patient or parent that includes the names of vaccines administered and the dates of administration. Personal vaccination records or forms can vary between states. Immunization information systems (IISs) are confidential, computerized databases that record and consolidate information on all vaccine doses administered by participating providers. Using an immunization information system to document vaccines administered can help to keep patient vaccination records up to date and give all medical providers that care for a patient access to complete and accurate information about the patient's immunization history

hepatitis D virus

Hepatitis D virus (HDV) is caused by an RNA virus that is structurally different from HAV, HBV, and HCV. HDV infection is uncommon in children but must be considered in cases of fulminant hepatitis or hepatic failure. It cannot cause infection unless the patient also is infected with HBV, which it needs to replicate. Transmission is through parenteral, percutaneous, or mucosal contact (including sexual) with infected blood and can be acquired either as a coinfection with or superinfection in an individual with chronic HBV. Incubation is 2 to 8 weeks. In the U.S., it is diagnosed most commonly in drug users, individuals with hemophilia, and immigrants from southern Italy and parts of Eastern Europe, South America, Africa, and the Middle East. Mother-to-newborn transmission is uncommon (Pickering et al, 2009). Infection is detected using IgM antibody to HDV. There is no vaccine against HDV. However, HBV vaccine is preventive of HDV because HDV requires comorbidity with HBV to be infective. Those with chronic HBV should take precautions against being infected.

hepatitis E virus

Hepatitis E virus (HEV) is an RNA virus in the family Hepeviridae; certain strains can also have zoonotic hosts (e.g., swine, nonhuman primates). It is passed via the fecal-oral route. Contaminated water is the most common reservoir. It is an acute infection whose symptoms resemble those of other viral hepatitis. Symptomatic individuals are usually older adolescents and young adults; pregnant women are particularly vulnerable to more serious illness (notably in the third trimester). Children are either asymptomatic or experience mild symptoms. If symptoms appear, they do so within 15 to 60 days (mean 40 days) after exposure. Endemic areas include India, the Middle East, parts of Africa, Southeast Asia, and Mexico. Most cases in the U.S. are found in immigrants or visitors from these locations. Clinical symptoms (jaundice, malaise, anorexia, fever, abdominal pain, arthralgia) are similar to HAV, but often more severe. Laboratory studies include IgM and IgG anti- HEV, but these can be unreliable. Definitive diagnosis is determined by the detection of viral RNA in serum or stool using reverse transcriptase-PCR assay. Treatment is supportive; there is no approved vaccine in the U.S. Good hand hygiene is crucial. Chronic infection is rare, and recovery is usually complete. The overall mortality rate is 4% or less; however, in pregnant women the mortality rate ranges from 10% to 30% (CDC, 2009c).

recommendations from excluding children from daycare

Illness prevents the child from participating in program activities. • Illness results in greater care need than the childcare staff can provide without compromising the health and safety of the other children. • Child has fever, unusual lethargy, irritability, behavioral changes, persistent crying, difficulty breathing, intermittent abdominal pain, or other signs of possible severe illness. • Diarrhea (defined as an increased number of stools in comparison with the child's normal pattern, with increased stool water or decreased form) that is not contained by diapers or toilet use; blood or mucus in stool. • Persistent abdominal pain lasting more than 2 hours • Vomiting more than two times in the previous 24 hours • Mouth sores associated with an inability to control drooling of saliva • Rash or known methicillin-resistant Staphylococcus aureus infection with fever or behavioral changes • Purulent conjunctivitis with fever and/or behavioral changes • Scabies prior to starting treatment

prevention of infection through the use of vaccines

Immunization- body is artificially induced to mount a defense against certain foreign antigens. primed to provide future protection with the next exposure to these same antigens. achieved by either (1) active immunization that involves introducing either a vaccine or toxoid (inactivated toxin) or by (2) passive immunization that involves administering an exogenous antibody, such as an immune globulin (IG). Childhood immunization- mainstay of preventive disease control, also cost effective. efforts must be maintained and strengthened Active immunization has been achieved by the administration of live attenuated and inactivated forms of vaccines. Vaccines exist to combat infections from Haemophilus influenzae type B (HiB), meningococcus, diphtheria, pertussis, tetanus, polio, measles, mumps, rubella, human papillomavirus (HPV), hepatitis A and B (HA and HB), influenza, varicella, rabies, typhoid, zoster, Japanese encephalitis, rotavirus, yellow fever, and pneumococcus; all but five are on the routine recommended vaccine schedule for all or specific populations of children and adolescents. still encounter children with these illnesses because not all routine vaccines have been given as part of preventive health care during childhood or adolescence. educate parents and patients about the need to keep immunizations current; parents may question this need because many of these diseases have low rates of occurrence in the U.S. global travel leaves underimmunized populations vulnerable to preventable diseases from endemic countries. Preventable epidemics may result.

infections in children in childcare settings

In the U.S., approximately 15.6 million preschoolers (41% infants; 53% toddlers) with working parents spend significant "care time" in settings outside of their homes (Schwartz, 2010; Sosinsky and Gilliam, 2007; Waggoner- Fountain, 2007). This population is more immunologically susceptible to illness because of their ages, hygiene habits, dietary factors (including nutritional deficits that may be a result of hunger) (Schwartz, 2010), chronic disease status, and close proximity to one another. Transmission depends on the prevalence in the population, infectivity, and survival characteristics of the organism. The environment enhances easy exposure to many infectious agents, whether spread from diapers, airborne, or from play surfaces. Although any illness can present and spread in a childcare setting, the diseases are primarily respiratory and gastrointestinal in nature. Children in such settings are 2 to 18 times more likely to suffer from a myriad of infectious diseases; receive two to four times more antibiotic treatments; and acquire antibiotic-resistant organisms more frequently than children not in childcare (Waggoner-Fountain, 2007). Infections typically spread in childcare settings are listed in Table 23-4. With the increase in drug resistance, these infections are eliciting great concern. In addition to educating parents about ways to decrease the incidence and transmission of infectious diseases, including the vaccination of children, health care providers can be a valuable resource for helping establish written policies for childcare settings in their communities. These policies should address prevention and control of infectious agents and include: • Current immunization records of children and staff • Provisions for exclusion of ill children and staff • Instructions on cleaning potentially contaminated areas • Procedures for changing diapers and their disposal; those primarily handling food should not change diapers • Procedures regarding the handling of food and pets • Guidelines for identifying and reporting infectious diseases Some general guidelines for exclusion are included in Box 23-1. Children should not be excluded for (Pickering • Yellow or green nasal discharge • Nonpurulent conjunctivitis without fever or behavioral change • Exanthem without fever or behavioral changes; erythema infectiosum (fifth disease) in an otherwise healthy individual • Fever of less than 101° F (38.5° C) without other illness symptoms • HB carrier status • Most viral infections (e.g., CMV, mononucleosis) • Nits, if being treated • HIV infection • Scabies, after treatment started

infectious disease and immunization

Infections are among the most common reasons for sick visit. Although viruses are the most frequent cause of childhood infectious illnesses, bacterial infections (particularly of the skin and mucosal surfaces) are also common. distinguish serious infections from those that resolve with minimal or no intervention is an important skill. effectively communicate with, educate, and support the often frustrated and anxious parents. include preventive education, including vaccinations, in the routine delivery of primary health care.

vaccine safety and resources for providers

Informed consent is critical when discussing the benefits and risks of vaccination. The National Childhood Vaccine Injury Act of 1986 (Public Law 99-660, amended by Public Law 101-239) calls for standardized consent forms (Vaccine Information Statement [VIS]). All practitioners are required to use these forms to fulfill their duty to warn the public about possible adverse events. VIS forms are available in 30 different languages on the CDC website. The act also requires that the vaccine lot number, site of inoculation, and name of the person administering the vaccine be included in the medical record. Some state laws require a parental signed consent form. People administering vaccines should be knowledgeable about the signs and symptoms of an allergic reaction and be prepared to treat such a reaction. The National Childhood Vaccine Injury Act also requires health care providers to report vaccine-related adverse events that occur after immunization so that unexpected patterns and safety concerns can be addressed. The suspected events are to be reported to the USDHHS Vaccine Adverse Event Reporting System (VAERS), using their standard confidential form. Information on which vaccine-associated injuries are reportable as well as official report forms can be downloaded from www.vaers.hhs.gov or from the U.S. Food and Drug Administration (FDA) website. In 2001 the CDC established the Clinical Immunization Safety Assessment (CISA) network in response to the realization that many adverse events became evident only after completion of prelicensure studies of vaccines and that many primary care providers would not necessarily be privy to such events. CISA develops research protocols around any given adverse event; helps understand the adverse event at the possible genetic, population, or subpopulation level; establishes risk levels; and serves as a referral source for clinicians. Providers can receive vaccine safety information, including how to manage postvaccine adverse events from the CDC.

vaccines to come

Modern vaccinology research is addressing new vaccine development including Shigella conjugate vaccine for children; vaccines for herpes simplex virus types 1 and 2; cytomegalovirus (CMV) (to prevent congenital CMV); Marburg virus (a hemorrhagic fever disease); dengue fever; hantavirus; HIV; West Nile virus (WNV); Lassa fever; drug-resistant pneumococci and staphylococci; enterococci (for traveler's diarrhea prevention); severe acute respiratory syndrome (SARS); Ebola; and urinary tract infections. Several different types of cancer vaccines are under investigation. Other studies are ongoing to develop a conjugate group B streptococcus vaccine for pregnant women to provide passive immunity to their fetuses, a vaccine to cover more serotypes of Haemophilus influenzae, and live and subunit parainfluenza type 3 vaccines. New vaccine delivery systems are being investigated that include skin-patch vaccines (undergoing human trials against the flu and traveler's diarrhea), edible vaccines, and needle-free injections. DNA technology is also being explored for use in encoding host immunogenic antigens.

clinical findings

Most infectious illnesses in pediatrics are diagnosed solely based on history and physical examination. Laboratory testing is generally reserved for unusual, serious, or difficult to diagnose cases.

inactivated vaccine Hib

Of the six serotypes of H. influenzae, type B is the most virulent, accounting for pneumonia, bacteremia, meningitis, epiglottitis, septic arthritis, cellulitis, otitis media, purulent pericarditis and other less common infections, notably in those under the age of 4 years. before vaccine- it was the most common cause of bacterial meningitis in children in the U.S. vaccine resulted in a phenomenal 99% decrease in the incidence of HIB disease in children less than 5 years. Most new cases in the U.S. now occur in those underimmunized or in infants who have not completed their primary series. problematic pathogen in countries that do not have this vaccine routinely available. Guidelines for chemoprophylaxis are available for exposed, unimmunized household contacts younger than 4 years of age who are at risk of invasive HIB disease. first dose 6wks catch up: 4wks btw dose 1,2 if before 1st birthday, 8wks if 1st was btw 12 and 14mths, no further dose if 1st dose adm 15mths or older. 4wks btw 2,3dose if younger than 12mths and first dose younger than 7mths (acthib, pentacel, or hiberix) or unknown, 8wks btw 2,3 dose if 12-59mths (final dose, 8wks btw 3,4 dose 12-50mths with 3 doses before 1st birthday, final dose. IM, 0.5ml, storage? s/e: anaphylax, angioedema, seizures, apnea, fever, fussy, injection site reaction, anorexia, restless, drowsy, diarrhea, vomit contraindicated: hypersensitivity to drug, class, component, to tetanus, caution hypersens to latex, GBS within 6wks tetanus vacc, immunocomp, acute illness When multiple vaccines are given on the same extremity, the sites of injection should be at least 1 inch apart; the anterolateral aspect of the thigh is the preferred site for this.

respiratory syncytial virus prophylaxis

One product is on the U.S. market for use in infants at high risk for adverse outcomes after RSV infection: palivizumab. Palivizumab, a humanized mouse monoclonal antibody, has the benefit of being administered IM rather than IV. It is given in five monthly IM injections during RSV season (usually November through March or April depending on the region) and is generally well-tolerated. Palivizumab has been shown to be safe and effective in reducing RSV hospitalizations in high-risk infants by 39% to 82%. Recurrent RSV infection can occur in the same child— even if he or she has received palivizumab—due to more than one RSV circulating within any given community. It has a high cost-to-benefit ratio. Consider RSV prophylaxis for the following children (Pickering et al, 2009): • Infants born at or before 28 weeks of gestation during RSV season until they are 12 months old • Premature infants (from 29 weeks to 32 weeks of gestation) if they will be younger than 6 months old during RSV season. • Children younger than 2 years old with chronic lung disease (CLD) who required treatment for their CLD within 6 months of the onset of RSV season (including oxygen therapy) • Infants born between 32 and 35 weeks of gestation if RSV season occurs before they are 3 months old, and they are either in group childcare or have siblings less than 5 years of age. • Children younger than 2 years of age with hemodynamically significant cyanotic or complicated congenital heart disease • Infants born less than 35 weeks of gestation with neuromuscular disorder or congenital anomalies that compromise handling of respiratory secretions Consult the AAP Red Book (Pickering et al, 2009) for more specific and latest recommendations, including the length of prophylaxis. Adverse reactions may include otitis media, rhinitis, upper respiratory tract infection, apnea, rash, and injection site reaction; alanine aminotransferase (ALT) and aspartate aminotransferase (AST) lab levels may increase and hemoglobin/hematocrit levels may fall. Once opened, a vial of palivizumab must be used within 6 hours (there is no preservative). It can be given concurrently with other vaccines.

passive immunity: the immunoglobulins

Passive immunization entails immunizing an individual with a solution of preexisting antibodies to prevent or amend an infectious disease. sera of pooled human IG, illness-specific human IG, antibodies formulated from animals, or monoclonal antibodies. Passive immunization is reserved for patients who suffer from immunodeficiencies in whom a live or attenuated vaccine could be dangerous or who have a problem making antibodies. IG is also indicated for nonimmunized or underimmunized patients who have been exposed to an infectious disease and whose incubation period is not long enough to allow complete active immunization. Patients at high risk for developing severe complications from an infectious disease should receive passive immunization when exposed. disease-produced toxins benefit from antitoxin passive immunization. A poisonous snakebite, tetanus, diphtheria, and botulism are examples of this. IG manufactured in the U.S. is screened for HIV-1 and HIV-2, syphilis, human T-lymphotropic viruses (HTLV-1, HTLV-2), WNV, hepatitis B and C, most for Trypanosoma cruzi (Chagas disease), and selected ones for CMV. IGIV and other preparations administered IV or IM to undergo procedures to inactivate or remove viruses. IGs are given either IM or IV (IGIV). Most adverse reactions from IG involve localized pain at the injection site. also, flushing, headache, chills, sweating, and shock. should not be given to people who have had prior adverse reactions to IG. Systemic reactions may occur, so administering personnel should be prepared to handle acute reactions and, in specific individuals, vasomotor or cardiac complications (e.g., elevated blood pressure, cardiac failure, or both). Some hyperimmune globulin preparations from human donors provide "superimmunity" products include those for HB (HBIG), rabies (RIG), tetanus (TIG), varicella-zoster (VariZIG), botulinum antitoxin (BIG), and cytomegalovirus (CMV-IGIV). Equine-derived antisera are available for botulism, tetanus, diphtheria, and rabies. more severe adverse reactions (including fatal anaphylaxis). They should be used with caution and only after hypersensitivity testing to animal sera is completed by a specialist. IGIV was originally used to provide immunogenicity to individuals with primary immunodeficiencies. effective, and it is FDA-approved for children with Kawasaki disease, HIV, immune-mediated thrombocytopenia, secondary immunodeficiency from chonic lymphocytic leukemia, and stem cell transplantation. IGIV has also been used with varied efficacy in low-birth-weight (LBW) infants, GBS, toxic shock, severe anemia caused by parvovirus B19 infection, and unresponsive neonatal alloimmune thrombocytopenia. Off-label use is discouraged.

Human Immunodeficiency Virus

Pathophysiology and Epidemiology HIV-1 and HIV-2 are retroviruses that cause disease in humans. Both serotypes cause clinically indistinguishable disease; most of the infections in the U.S. are attributed to HIV-1, less commonly to HIV-2. Retroviruses are RNA viruses that must make a DNA copy of their RNA in order to replicate. They do this by integrating into a target CD4+ T cell and then using the reverse transcriptase enzyme to convert their RNA into DNA within the cell nucleus. With transcription and translation, the HIV genes convert into messenger RNA, which can leave the nucleus with the viral genome code inside. Eventually new virions bud from the CD4+ T cells, infect other cells, and the cycle is repeated. HIV persists in infected individuals for life; latent virus protein remains in cells of the blood, brain, bone marrow, and genital tract even when the plasma viral load cannot be detected. Although there are AIDS-like syndromes in other primates and felines, infection cannot be obtained from pets, animals, or insects. Humans are the only known reservoir for HIV-1 and HIV-2. The mode of transmission is intimate sexual contact, sharing of contaminated needles for injection, transfusion of contaminated blood or blood products, perinatal exposure, and breastfeeding. HIV has been isolated from blood (lymphocytes, macrophages, and plasma), CSF, pleural fluid, cervical secretions, human milk, feces, saliva, and urine. However, only blood, semen, cervical secretions, and human milk are implicated in transmission. From 2006 through 2009, the annual estimated number and rate of diagnoses of HIV infection in the United States remained stable in the 40 states withconfidential named-based reporting systems; approximately 79% of those infected are aware of their HIV status (CDC, 2010i, 2011). The risk of sexual transmission from just one episode of intercourse with an infected person is low. The highest per-act risk for transmission is from blood transfusion, needle sharing between drug users, receptive anal intercourse, and percutaneous needle injuries (CDC, 2006b). Accidental needlesticks in occupational settings rarely account for seroconversion and have a low infectivity rate. Less than 1% of the documented cases occurred this way. Transmission from accidental needlesticks from nonoccupational sources has not been documented. Transmission of HIV from a human bite (even when saliva is contaminated with blood) is extremely rare (CDC, 2010i). Transmission from antibody-screened blood transfusions in the U.S. is about 1 per 60,000 units (Yogev and Chadwick, 2007). In the U.S., one of the expanding HIV-positive groups is adolescents 15 to 19 years old; rates are stable for those younger than 15 years. Racial and ethnic disparities of infection are present, with African Americans, Native Americans/Alaska Natives, Asians, and Hispanic males having higher rates, as well as men who have sex with men and those who live in urban areas (CDC, 2010i). Adolescent males are more likely to acquire the virus from male-to-male transmission; female adolescents acquire it via heterosexual transmission (72%) and IV drug use (26%) (Luzuriaga and Sullivan, 2008). Because of the long incubation period (8 to 12 years), these adolescents may not experience symptoms until they are in their 20s or 30s. A small number of children have been reported to have acquired HIV from sexual abuse (Yogev and Chadwick, 2007). The transmission of HIV to infants can occur in several ways: in utero (5% of cases), intrapartum (13% to 18%; from infected blood and cervicovaginal secretions in the birth canal), or postpartum via breast milk (33% to 50%) (Shetty and Maldonado, 2008). If the mother has been infected with HIV during pregnancy, transmission is rare if she has low or undetectable serum levels of HIV around the time of labor and delivery. The transmission rate is higher if her initial HIV-1 infection occurs during the third trimester, when her viral load may be high but her immune activation has not fully responded (Pickering et al, 2009). Risk of an untreated HIV-infected woman giving birth to an infected infant is 15% to 30% (Luzuriaga and Sullivan, 2008). In vaginal twin deliveries, the firstborn twin has a greater risk of developing HIV than the second. Elective cesarean delivery appears to reduce the risk of fetal infection by 87% in conjunction with zidovudine for both the mother and infant. The mother's age, advanced infection, low CD4+ T-lymphocyte count, maternal drug use, premature rupture of membranes greater than 4 hours, low birthweight, premature birth before 34 weeks, and viral load are other risk factors for increased transmission of the virus (Yogev and Chadwick, 2007). Infection through postpartum human milk transmission can be as high as 33% and 50% in some undeveloped countries; rates can depend on the maternal state of infection, length of time she has been breastfeeding, and the presence of breast abscesses, mastitis, or nipple sores. Most HIV-1 transmission is found to occur in the initial few months of breastfeeding; the risk decreases thereafter (Luzuriaga and Sullivan, 2008). Transmission has not been reported in an infant after a single exposure to HIV-infected human milk (Havens, 2003). Transmission has been reported, however, in infants who were fed premasticated food by HIV-1 infected caregivers with bleeding gums or oral sores (Pickering et al, 2009). In developing countries where pediatric AIDS is pandemic, treatment regimens— out of nutritional necessity—have traditionally included breastfeeding plus short-term antiretroviral drug treatment for women and infants. Incubation Period The incubation period is variable. The onset of symptoms of HIV infection in infants untreated perinatally is approximately 12 to 18 months; some appear within the first few months of life. Seroconversion occurs within 5 weeks in 50% of those exposed to HIV; 95% will seroconvert within 5 months (Sykes and Truax, 2010). HIV infection can have a long latency period (longer than 5 years). Intrauterine transmission usually occurs by 10 weeks of gestation and is associated with early, severe disease in the newborn. Fifteen percent to 20% of HIV- infected children die before 4 years old (median age 11 months), whereas 80% to 85% of untreated children will experience delayed symptoms and can survive beyond 5 years of age (Pickering et al, 2009; Yogev and Chadwick, 2007). Clinical Findings HIV infection is often experienced as an influenza-like illness (fever, rash, sore throat, lymphadenopathy, and myalgias) for 2 to 4 weeks. These symptoms can suggest a nonspecific viral process, and a provider may not consider HIV in the differential diagnosis. At this point, the asymptomatic infection may continue for a few months to up to 15 years, depending on the viral load. The CD4+ T cells start declining at an average rate of about 50 cells/μL/year. There are four HIV infection clinical categories for children with HIV infection, ranging from "no signs or symptoms" to "severe signs and symptoms." These categories are paired with the degree of age-specific CD4+ T-lymphocyte count and total percentage of lymphocytes to determine the stage of disease and management strategies. Newborn examinations are usually normal. Lymphadenopathy is often the first symptom, then hepatosplenomegaly. Some have failure to thrive, chronic or recurrent diarrhea, pneumonia (Pneumocystis jiroveci peaks at 3 to 6 months of age), oral candidiasis (in 15% to 40%), recurrent bacterial infections, chronic parotid swelling, and progressive neurologic deterioration. Those with high HIV loads develop symptoms earlier, including failure to thrive and encephalopathy. Other opportunistic diseases are Mycobacterium avium infection, severe CMV after 6 months old, EBV, VZV, disseminated histoplasmosis, RSV, Mycobacterium tuberculosis, and measles (despite vaccination). Children—other than infants—generally have more recurrent bacterial infections, parotid gland swelling, lymphoid interstitial pneumonitis, or neurologic deficiencies that can progress to encephalopathy. Streptococcus pneumoniae, HIB, Staphylococcus aureus, and Salmonella organisms are common infections in pediatric AIDS patients. Sinusitis, cellulitis, glomerulopathy (especially in those of African descent), cardiac hypertrophy, anemia, CHF, and purulent middle ear infections are common. Malignancies are uncommon in pediatric AIDS. Diagnostic Studies Babies who are considered to have been exposed to HIV in utero demonstrate a positive virologic assay test (HIV- 1 DNA PCR is the preferred assay) within 48 hours of birth; those who acquire the infection in the intrapartum period test negative on this test in the first week but positive before 90 days of life. Maternal HIV IgG can persist for as long as 15 to 18 months. The HIV-1 proviral DNA assay (HIV-1 DNA PCR) identifies HIV-infected newborns early in the neonatal period, is one of the most sensitive tests, and is the only one recommended for infants less than 1 month. All the other assays have problems with false-positives, sensitivity, variable results, excessive length of time for results to be reported, or expense (Pickering et al, 2009). Table 23-6 lists recommended testing times and tests available. • Positive DNA PCR at 48 hours implies in utero transmission. • About 93% of infected infants have a positive DNA PCR at 2 weeks of age. • About 95% of infected infants will have a positive DNA PCR at 1 month of age. ∗ The following tests for HIV-1 are not recommended for use in those younger than 1 month of age: HIV culture; HIV p24 antigen assay; ICD p24 antigen assay; HIV-1 RNA PCR (the best option to use for children >18 months). Data from Pickering LK, Baker CJ, Kimberlin DW, et al: Children in outof home child care. In Red Book 2009: Report of the Committee on Infectious Diseases ed 28, Elk Grove Village, IL, 2009, American Academy of Pediatrics, pp 380400. Lymphopenia occurs as the disease progresses. There are decreased circulating CD4+ cells (T-suppressor, T- helper cells), and the helper-suppressor ratio is less than 1. The CDC defines an individual as suffering from autoimmune deficiency disease (e.g., AIDS) when their CD4+ T cell count is less than 200/mm3. Some AIDS patients become seronegative late in the disease because the weakened immune system cannot manufacture antibodies. Differential Diagnosis The differential diagnosis includes other causes of immunologic deficiency, such as recent therapy with an immunosuppressive agent, lymphoproliferative disease, congenital immunologic states, inflammatory bowel disease, DiGeorge syndrome, ITP, chronic allergies, CF, graft-versus-host reaction, congenital CMV, toxoplasmosis, ataxia, or telangiectasia. Management Any information about HIV is subject to change, and the provider is cautioned to check with the CDC regarding any changes in HIV or AIDS diagnosis, treatment, and specific immunization precautions and regimens (Sherman, 2010). Treatment goals include suppressing viral replication to undetectable levels; restoring/preserving immune function; reducing HIV- associated sequelae; minimizing drug toxicity; promoting normal growth and development; and promoting quality of life (Pickering et al, 2009; Yogev and Chadwick, 2007). Initiation of antiretroviral treatment depends on the age, immune status, viral load, and clinical categories previously mentioned. Current drug regimens include combination therapy with at least three oral ARV drugs. The mainstays of therapy are the reverse transcriptase inhibitors (RTIs), nucleoside reverse transcriptase inhibitors (NRTIs) or non-NRTIs (NNRTIs), and the protease inhibitors. An injectable fusion inhibitor is also available for use in children. Treatment regimens require frequent laboratory studies and possible ARV changes throughout the life of the individual. Primary care providers can manage infants born to HIV-infected women in consultation with an HIV or infectious disease specialist. Established protocols for the HIV-infected mother and her newborn are available. Box 23-2 outlines the protocol for the HIV-exposed newborn. The infant should be discharged from the hospital with the full 6-week course of antibiotics in hand, not just a prescription, with complete instructions for administration. This helps ensure greater compliance and continuity of prophylaxis because some insurance companies do not start paying for outpatient treatment of an infant for several weeks after birth (AAP, 2008). Treatment of a child (versus newborn) infected with HIV should only be undertaken in concert with pediatric HIV specialists because drug regimens are constantly being revised. Treatment of associated conditions with appropriate medical therapy is indicated using IGIV, antifungals, antivirals, antimycobacterials, and nutritional counseling. The CDC, AAP, and/or AIDS Treatment Information Service are excellent sources for the latest information regarding treatment. Many centers have ongoing clinical trials for which patients may be eligible. An important role of the primary care provider in HIV treatment is helping to boost adherence rates. In addition, side effects must be monitored closely because many of the ARV drugs can interact with other commonly prescribed medications. The treatment regimens are highly challenging for parents because of complex dosing schedules and unwillingness of children to take the required medications. Many preparations are not offered in liquid form or the taste is not attractive to children. To enhance compliance, some clinicians use tools such as computer-assisted age-dependent programs; electronic pillboxes; routinely measuring drug levels; developing simpler drug protocols; studying possible social and economic factors that predict compliance and individualize patient care accordingly; and referring families to support networks. (See Appendix A for some helpful information about increasing medication adherence rates.) Adolescents can present a particular noncompliance risk because of denial and fear of their infection, substance abuse and addiction, misinformation, distrust of and inexperience with the medical system, self-esteem issues, unstable living situations, and lack of familial and social support systems. It is important for the provider to be nonconfrontational yet discuss risk factors and advocate for family planning services and needle exchange programs, postexposure prophylaxis (PEP) regimens, and prompt involvement in new treatments as they become available. Complications HIV becomes a multisystemic illness with multiorgan complications.

acetaminophen prophylaxis after vaccination

Research is questioning the wisdom of recommending prophylactic administration of acetaminophen prior to or following vaccines. Significantly lower antibody responses were detected in infants and children vaccinated with a 10-valent pneumococcal nontypeable H. influenzae protein D-conjugate vaccine (PHiD-CV) coadministered with the hexavalent diphtheria/tetanus- 3-component acellular pertussis/hepatitis B/inactivated poliovirus-types 1, 2, 3/HIB (DTaP-HBV-IPV/HIB) combination and oral rotavirus vaccines given at the recommended scheduling for primary and booster doses.

techniques to adm immunizations

Rotavirus (RV1, RV5)- Oral DTaP, DT, HepA, HepB, Hib, HPV, IIV3, IIV4, RIV3, ccIIV3, IPV,* MenACWY, MenB, PCV13, PPSV23,* Td, Tdap, TT- Intramuscular injection ZVL, IPV,* MMR, PPSV23,* VAR- Subcutaneous injection Fluzone ID- Intradermal injection combination vaccines: DTaP-IPV, DTaP-IPV-HepB, DTaP-IPV/Hib, HepA-HepB- Intramuscular injection MMRV- Subcutaneous injection multiple injections: infants and younger children receiving more than two injections in a single limb- the thigh is the preferred site because of the greater muscle mass. older children and adults- the deltoid muscle can be used for more than one intramuscular injection. Best practices for multiple injections include: Label each syringe to identify the vaccine it contains. Separate injection sites by 1 inch or more, if possible. Administer vaccines that may be more likely to cause a local reaction (e.g., tetanus-toxoid-containing and PCV13) in different limbs, if possible. Use combination vaccines (e.g., DTaP-IPV-HepB or DTaP-IPV/Hib), if appropriate, to decrease the number of injections. Evidence-based strategies to reduce procedural pain include: Breastfeeding Giving sweet-tasting liquids (orally) Injecting vaccines rapidly without aspiration Injecting the most painful vaccine last Using tactile stimulation (rubbing/stroking near the injection site before and during injection) Distracting the patient (done by either the parent or clinician) Having the patient seated rather than lying down Using topical anesthetics

CRP

The C-reactive protein (CRP) is among the serum measures known as "acute phase reactants," increase in the setting of acute inflammation. Serious bacterial infections are more likely to lead to an increased CRP than other types of infections. it is generally uncommon for a viral infection to result in a CRP more than about 10 mg/dL in young children. In addition, CRP is sometimes a beneficial tool for monitoring the body's response to treatment in certain infections. elevated in osteomyelitis before antibiotic treatment, but usually falls rapidly with effective therapy. Inflammatory processes other than infection may lead to an elevated CRP, including trauma, rheumatologic diseases, and oncologic diseases. Persistent elevations of CRP may be related to adiposity. different laboratories may report CRP in different units (usually either mg/L or mg/dL; 10 mg/L equals 1 mg/dL).

ESR

The ESR is another measure of inflammation and reflects the observation that red blood cells (RBCs) settle more rapidly when acute phase proteins (such as fibrinogen) are present in serum than when they are not. Although the ESR is not a specific test for infection, it is useful in helping evaluate fever of unknown origin and, like CRP, can be used to monitor response to therapy. A low sedimentation rate (<10 mm/hr) is unlikely if the cause of prolonged unexplained fever is a bacterial infection. Bartonella infection, mycobacterial infection, or abscesses are typically associated with an elevated ESR. Similarly, viral infections result in mean ESR values around 20 mm/hr (90% <30 mm/hr), with the exception of adenovirus, which may be associated with values higher than 30 mm/hr. The ESR can be more than 60 mm/hr in children with fever of unknown origin with mycobacterial infection, collagen vascular disease, or inflammatory pseudotumor During the waxing and waning period of infection, the ESR tends to increase and resolve more slowly as compared with CRP values. evaluate the effectiveness of therapy when long-term antibiotics are needed. managing diseases (such as osteomyelitis) treatment is judged, in part, by the normalization of the ESR. Like CRP, the ESR is often elevated in noninfectious conditions, causing inflammation, particularly rheumatologic diseases, for which ESRs greater than 100 mm/hour are common. Anemia also causes nonspecific increase.

avian influenza

The avian influenza A viral strain of H5N1 has the potential to acquire genes from the influenza virus that affects other species. spread quickly and has morphed into a more pathogenic virus than when it first emerged in 1996. little natural immunity, still restricted and uncommon, and the virus has not yet mutated to be efficiently transmitted from person to person. only known direct contact with sick or dead poultry or wild birds or who have visited live poultry markets are most at risk for acquiring the virus. Human cases reported in Asia, Africa, the Pacific, Europe, and Near East. Indonesia and Vietnam have had the highest number of cases. Humans who acquire the disease are severely ill, in contrast to those who experience mild symptoms with the typical "flu." Fever, malaise, myalgias, and respiratory symptoms progress to pneumonia, then to respiratory and multiorgan system failure, and then to death. Diarrhea can occur. mortality rate in humans has been approximately 60%, with fatalities highest in those 10 to 19 years. The development of a vaccine to fight H5N1 is ongoing. If avian influenza is suspected- CDC website for guidance in obtaining specimens, monitoring suspected cases, and precautions by those traveling to endemic locales. The U.S. has banned importation of birds (dead or alive) and bird products (including hatching eggs) from H5N1- affected countries, list on CDC)

recurrent infections

The body does not truly eradicate the virus; the virus lies dormant, and recurrent infections are common. Recurrent infections occur either as herpes labialis (aka "fever blister") or genital herpes. Some incidence of recurrent aseptic meningitis can be attributed to HSV infection.

neonatal infection

The neonate is always symptomatic. Infection is evidenced by skin vesicles or scarring, eye findings (chorioretinitis, keratoconjunctivitis), microcephaly, or hydranencephaly at birth. Those with skin, eye, and mouth (SEM) involvement usually are symptomatic by 5 to 11 days after birth, with 80% to 85% having skin lesions; if left untreated the disease can progress to encephalitis or disseminated disease. Infants with CNS (encephalitis) disease generally show symptoms suggestive of bacterial meningitis at 8 to 17 days after birth; about 60% will have skin lesions. With untreated CNS disease, half will die; those that survive generally demonstrate neurologic sequelae. Infants with disseminated infection are symptomatic at 5 to 11 days after birth. Symptoms are similar to that of bacterial sepsis, with 75% having skin lesions; the mortality rate is 90% if untreated (20% if treated) with severe neurologic sequelae in survivors (Stanberry, 2007) (see also Chapter 38).

cultures, stains, antimicrobial susceptibility testing

The usefulness of microbiologic testing is absolutely dependent on the quality of the sample obtained for evaluation and on the correct choice of test for the given clinical situation. Bacterial infections occurring in an otherwise normal child typically result in migration of WBCs to the site of infection, especially neutrophils. The presence of pus can assist in the diagnosis of some infections. Staining methods- fungal or other infections are suspected. Antigen detection immunofluorescence or antibody assays (e.g., complement fixation tests [CFTs], immunofluorescence [IF] techniques, enzyme-linked immunosorbent assays [ELISAs])-viral infections. Additional testing of bacteria may be done on cultured samples to evaluate susceptibility to the more common antibiotics that could be used. MRSA, providers need to know the resistance patterns within their communities. may be susceptible to doxycycline, trimethoprim-sulfamethoxazole (TMP- SMX), or clindamycin; however, susceptibility testing for a given isolate is needed to be sure that an appropriate antibiotic has been chosen.

inactivated vaccine pneumococcal

There are 91 known serotypes of pneumococcus, and there has been a shift in the pneumococcal strains responsible for illness- more illness is ascribed to the serotype 19A, which was not covered by the previous pneumococcal conjugate vaccine, PCV7. Pneumococcal conjugate vaccine 13 (PCV13), covering 6 additional serotypes, vaccine provides protection against serotype 19A and has replaced PCV7. Children under 5 years of age who have completed the four-dose PCV7 series should receive a single PCV13 dose. have not completed their PCV7 series should complete with PCV13. Older children and adolescents (6 to 18 years) with certain medical conditions may benefit from PCV13 vaccine even if they have previously completed a series of PCV7 or the 23-valent pneumococcal polysaccharide vaccine (PPSV23). 23Valent Polysaccharide Pneumococcal Vaccine (PPSV23) broader coverage against 23 pneumococcal serotypes rather than the 13 in PCV13. adm to children 2 years and older and adults at high risk or presumed high risk of pneumococcal disease. The number of doses varies according to the number of prior PCV7 or PCV13 vaccines given and the age of the child. Children younger than 2 years of age have shown poor immunogenicity to this vaccine; duration of protection relatively short. first dose at 6wks catch up: 1 dose PCV13 healthy child 24-59mths not completely vaccinated. 4wks btw 1,2 dose if first dose before first bday. 8wks after if first dose at or after first bday- final dose. no 2nd dose if first dose at 24mths or older. 4wks btw 2,3 dose if younger than 12mths & previous dose younger than 7mths. 8wks if previous dose btw 7-11 mths, wait until 12mths- final dose, or if 12mths/older and one dose before 12mths. 8wks btw 3,4 dose (final dose), only if 12-59mths, 3 doses before 12mths, or child at high risk who received 3 doses at any age. PCV23 IM/SC, 0.5ml, storage? s/e: hypersens, radiculopathy, GBS, cellulitis, thrombocytopenia w/ prior stable ITP, hemolytic anemia w/ prior hematologic disorders, site reaction, H.A, fatigue/asthenia, myalgia, rigors, fever, nausea, vomit, arthralgia, rash. contraindicated: hypersens to drug, class, component, concurrent XRT, caution immunocomp, acute illness, chronic CSF leak When multiple vaccines are given on the same extremity, the sites of injection should be at least 1 inch apart; the anterolateral aspect of the thigh is the preferred site for this.

live vaccine smallpox vaccine

There is one smallpox vaccine licensed in the U.S. containing a live vaccinia virus to protect against variola major and variola minor. Smallpox vaccine should not be routinely given. In the case of a smallpox outbreak, high- risk individuals will be vaccinated per CDC guidelines issued at the time. Containment of an outbreak is discussed later in this chapter under Infectious Agents Used in Bioterrorism, Smallpox.

Traumatic Herpetic Infection

This is a localized infection that occurs in a susceptible child because of an abrasion, teething, laceration, or burn that is inoculated with herpesvirus by an orally infected parent who kisses the "booboo." Vesicles appear at the site of the lesion. There may be fever, constitutional symptoms, and regional lymph node involvement.

general management strategies preventing spread of infection

Thorough and frequent handwashing is the most effective means of preventing the spread of infection. educating parents and patients and demonstrate proper handwashing during the care of their patients. Alcohol-based hand rubs may be substituted for soap and water in most cases as long as the ethanol content is at least 40% but preferably at least 60% or more. ineffective against controlling the spread of Clostridium difficile. gloves and washing hands with soap and water after being in contact with individuals with C. difficile- associated disease. **Specific guidance that should be given to children and parents includes: • Hands should be washed after using the bathroom, before meals, and before preparing foods. scrubbing with soap and water for at least 20 seconds (the time it takes to sing "Happy Birthday" twice), rinsing with warm water, and drying completely. • Avoiding finger-nose and finger-eye contact, particularly if exposed to someone with a cold. • Using a tissue to cover the mouth and nose when coughing or sneezing may help prevent the spread of pathogens. If a tissue is unavailable, the upper sleeve should be used (not the hands).

inactivated vaccine Hepatitis A Virus

children- to prevent transmission to adults in whom the illness is likely to be serious. Current guidelines include universal vaccination for those 1 to 18 years old and for other subsets of the population. The two inactivated HAV vaccines licensed in the U.S. have seroconversion rates of greater than 99% after the second vaccine. They are conjectured to provide immunity for up to 14 to 20 years in children and for a minimum of 25 years in adults. A recommendation for a booster dose has not been determined. HAV vaccine can be administered simultaneously with other childhood vaccines, but should be given at a separate injection site (intramuscular [IM] injection in the deltoid). The risk of vaccination to a pregnant woman is considered low to nonexistent. Seroconversion of immunocompromised patients (including those with HIV) may be suboptimal. Recommendations target the following: Those traveling to countries where HAV is endemic (notably Central or South America, Mexico, Asia [except Japan], Africa, and eastern Europe [see www.cdc.gov/travel]) Children and adolescents residing in and in contact with others from communities with a high incidence or outbreak of HAV Children in diapers in daycare centers with high rates of HAV Men who have sex with men Severe illness (e.g., chronic liver disease) Illicit-drug users (using injectable or noninjectable drugs) Those with blood-clotting disorders (e.g., hemophiliacs) Healthy persons who are older than 1 year who are household members and close contacts, including baby sitters, during the 60-day period after the arrival of an international adoptee. The use of postexposure IG versus a single dose of HAV vaccine shows equal efficacy for preventing symptomatic disease if given within 14 days of exposure. first dose at 12mths catch up: 6mth btw 1,2 dose IM, 0.5ml, combination (twinrix) with hep b, storage? s/e: anaphylax, angioedema, erythema multiform, hepatotoxic, thrombocytopen, neurotoxic, GBS, encephalopathy, seizures, lymphadenopathy, site reaction, irritability, anorexia, fatigue, headache, fever, malaise, nausea. contraindicated: hypersens to drug, class, component, to neomycin, caution to latex (prefilled syringe), in immunocomp, acute illness. When multiple vaccines are given on the same extremity, the sites of injection should be at least 1 inch apart; the anterolateral aspect of the thigh is the preferred site for this.

diagnostic aids laboratory studies

clarify a diagnosis or rule out a serious illness that may be under consideration. The following factors should be considered when determining which diagnostic tests: • The quality of the specimen sent to the lab strongly affects the reliability of the results. • The timing of sample collection affects the degree to which the results help in diagnosis. Bacterial cultures collected after the administration of antibiotics may remain negative. • The amount of any specimen can affect the laboratory's ability to process the sample correctly. • Microbiologic samples can require special handling and should be transported to the laboratory promptly. The laboratory should be contacted if there is any question regarding the collection and transport of samples. • Be prepared to prioritize test requests when only a limited quantity of specimen can be collected.

special populations

immunocompromised- hepB routine, Dtap routine, IPV routine, flu routine, hep A routine, meningococcal routine, Tdap routine. precaution for rota- contraindicated and SCID (severe combined immunodeficiency) MMRV contraindicated. may need extra- pneumococcal, conjugate/polysaccharide and HPV preterm can delay until after DC from NICU minor acute illness- use clinical judgement, may vaccinate unless febrile pain/fever- tx fever with tylenol chronic illness- need more pneumonia, Hib meningococcal (sooner if risk factors present), liver disease need more Hep A. medical, religious, philosophical- need written statement of request and must be submitted to government monitoring.

postexposure prophylaxis after non occupational exposure

not to inform the school, parents should get assurance that the school will notify them of any communicable disease outbreaks (e.g., varicella, measles) or physical altercations with others. • Routine screening of school-age children for HIV antibodies is not indicated. Postexposure Prophylaxis After Nonoccupational Exposure The primary care provider may be faced with having to assess and counsel parents after their child has had an accidental puncture wound from a discarded needle found on a street, public transportation, or playground; from a wound obtained from a bite, a fight, or during a sports activity; from sexual abuse; or from exposure to breast milk from an HIV-infected woman. Though transmission is extremely rare, the provider needs to be able to address the situation with a level of understanding of the risks and current recommendations of the CDC (Fig. 23-3). The body fluids of an HIV-infected person do not all carry the same amount of viral load or risk. For example, exposure to blood of a known HIV-infected person carries the highest risk, whereas blood-free saliva, semen or vaginal secretions, and human milk carry a low risk; urine, feces, and vomitus are unlikely to transmit the virus (CDC, 2005). Syringes that might have been used and discarded by an HIV-infected, injection-drug user generate the most concern by parents. The following information is useful when counseling parents: • HIV viability is vulnerable to drying. • The smaller the needle bore, the more limited the amount of blood present. • Health care professionals stuck with a needle after withdrawing blood from an individual with full- blown clinical AIDS have a 0.3% HIV transmission risk (Levine, 2008). Most syringes (approximately 96%) used for IM or subcutaneous injection by an HIV-infected individual will not have discernible HIV RNA (CDC, 2005). There has been no documented transmission of HIV from an accidentally found, discarded needle. • One is more likely to face greater risk from biting an individual who is HIV positive (saliva contaminated with HIV-infected blood) than from having been bitten by one infected with HIV (saliva not contaminated by infected blood). The provider and parent must weigh the unproven safety and benefits of participating in the PEP regimen against the significant toxicity of the drugs themselves. If instituted, PEP therapy needs to start within 72 hours after exposure and continue for 28 days. Close follow-up for support, medication monitoring (adherence and toxicity), and serial HIV antibody screening are needed (Box 23-3 provides some management strategies). Consult the CDC concerning the current PEP prophylaxis antiretroviral drug therapy recommended.

inactivated vaccine polio

recommended vaccine for polio changed to inactivated polio vaccine (IPV). IPV is the only polio vaccine available in the U.S.; seroconversion to each of the three serotypes of polio ranges from 99% to 100% after three doses. If mass vaccination is needed to control wild polio outbreaks of paralytic polio, OPV would be considered a public health intervention because IPV does not protect against intestinal infection with wild virus. The need for booster dosages of enhanced IPV has not been determined; immunity is believed to possibly be lifelong. The CDC provides guidelines for when polio vaccinations should be considered for those immunocompromised or at risk of imminent exposure from travel or outbreak, including adults. first dose 6wks catch up: can give first dose anytime, minimal interval 4wks btw 1-2 dose, 6mths btw 2-3 dose, 4th dose not indicated if 3rd adm after 4yrs age. 4th dose required if 3rd adm before 4yrs or less than 6mths after 2nd dose. IM/SC, 0.5ml, available in combination vacc (kinrix, pediarix, pentacel, quadracel), storage? s/e: hypersens, anaphylaxis, seizures, irritability, fatigue, inject site reaction, anorexia, fever, vomit. contraindicated: hysens to drug/class/component, 2-phenoxyethanol, formaldehyde, neomycin, streptomycin, polymyxin B, anaphyl reaction within 24hr dose, febrile illness, caution in immunocomp. When multiple vaccines are given on the same extremity, the sites of injection should be at least 1 inch apart; the anterolateral aspect of the thigh is the preferred site for this.