PREVENTIVE MEDICINE

rotavirus vaccine

Preterm infants may be immunized with the rotavirus vaccine beginning at ≥ 6 weeks of age if clinically stable. They should be immunized on the same schedule and with the same precautions as recommended for full-term infants. All immunizations recommended at 2 months of age may be simultaneously administered to preterm infants at 2 months of chronological age except for the live oral rotavirus vaccine, which should be deferred and administered at the time of or following discharge from the NICU to prevent the potential for nosocomial spread of the vaccine virus.

HepB vaccination preemies

Preterm infants weighing < 2 kg at birth and having an HBsAg-negative mother should receive the 1st dose of HepB vaccine series starting at 30 days of chronological age—or at hospital discharge if prior to 30 days of chronological age.

At what age should HepB vaccine be given to preemies?

Prior to 1 month of age, decreased rates of seroconversion to the HepB vaccine are common among preterm infants weighing < 2 kg. However, by 1 month of chronological age, all medically stable preterm infants, irrespective of initial birth weight or gestational age, respond with seroconversion rates similar to that of term and larger (≥ 2 kg) preterm infants.

What are some things to remember about rotavirus vaccine?

The 1st dose of rotavirus vaccine (a live attenuated viral vaccine) should be administered from 6 weeks through 14 weeks 6 days of age, regardless of vaccination type. Both a 3-dose oral rotavirus vaccine (RotaTeq: 2, 4, and 6 months of age) and a 2-dose oral rotavirus vaccine (Rotarix: 2 and 4 months of age) are available. There must be a minimum interval of at least 4 weeks between doses of either rotavirus vaccine. Regardless of the product or products administered, the vaccine series must be completed by 8 months 0 days of age. The dose should not be re-administered if the infant regurgitates the vaccine. Whenever possible, the series should be completed with the same vaccine. However, if the RotaTeq vaccine is used for any dose in the series (or if the product is unknown for any dose in the series), a total of 3 doses must be administered. Preterm infants may be immunized if the infant is at least 6 weeks of postnatal age and clinically stable. The first dose of vaccine should be administered at the time of, or following discharge from the nursery. Severe combined immunodeficiency (SCID) and a history of intussusception are contraindications to the vaccine. Precautions for administration of the vaccine include immunodeficiencies other than SCID, moderate-to-severe illness, preexisting chronic intestinal tract disease, bladder exstrophy, and spina bifida. Some studies suggest that rotavirus immunization is associated with a low level of increased risk of intussusception soon after the 1st dose. The level of risk is considerably less than the risk of intussusception after immunization with RotaShield, which was withdrawn from the market in 1999 after it was linked to an increased risk of intussusception. The benefits of rotavirus immunization include prevention of hospitalization for severe rotavirus disease in the United States and of death in other parts of the world. Currently, the benefits of these vaccines far outweigh the rare potential risks.

Anatomic site if multiple IM injxns

The anterolateral thigh muscle is preferred when multiple injections are required in a single limb. The outer aspect of the buttocks is not an appropriate site for intramuscular administration of any vaccine because of its proximity to the sciatic nerve. Additionally, the relatively large amounts of subcutaneous fat in this area may adversely affect absorption and diminish immunogenicity.

What is the proper technique for blood pressure measurement with regard to dimensions of the cuff bladder and the arm?

The cuff size should have a bladder width of approximately 40% of the circumference of the upper arm, measured midway between the olecranon and the acromion. The length of the cuff bladder should encircle at least 80% of the circumference of the upper arm and the bladder width-to-length should be no less than 1:2.

Excessive tearing. Differential?

The differential diagnosis for excessive tearing includes infantile glaucoma, corneal abrasion, and the presence of a foreign body. Glaucoma presents with tearing, photosensitivity, and eventually clouding of the cornea. Corneal abrasion may occur from the infant scratching his own cornea with his fingernails or a toy when he/she is able to bring the hands toward the face. Foreign body can occur even from a piece of blanket or eyelash that falls into the eye. For this reason, an exam is indicated in any infant with the complaint of excessive tearing.

Diseases that, following the introduction of the conjugate Hib vaccine, are now only rarely caused by this organism.

The incidence of diseases such as meningitis, epiglottitis, bacteremia, septic arthritis, and cellulitis caused by Haemophilus influenzae Type b (Hib) infection dramatically declined (> 99%) following the introduction of the conjugate Hib vaccine into the routine childhood immunization schedule. The dosing recommendations for Hib vaccine vary by manufacturer and include ActHIB, administered at 2, 4, 6, and 12-15 months of age; PedvaxHIB, administered at 2, 4, and 12-15 months of age; and Hiberix, administered at 2, 4, 6, and 12-15 months of age. Hib vaccine is also a component of the combination vaccines Pentacel (DTaP-IPV/Hib), administered at 2, 4, 6, and 15-18 months of age and MenHibrix (Hib-MenCY), administered at 2, 4, 6, and 12-15 months of age. Hib-MenCY-TT is only recommended for use in children at increased risk for meningococcal disease. In the postvaccine era, nontypable H. influenzae causes the majority of invasive H. influenzae disease in the pediatric population. Nontypeable serotypes of H. influenzae commonly cause otitis media, sinusitis, conjunctivitis, and pneumonia. Although Streptococcus pneumoniae remains the most common cause of sinusitis and otitis media, the incidence of otitis media due to nontypeable H. influenzae has increased, in large part, as a result of the routine use of pneumococcal conjugate vaccine (PCV). This pattern became more evident with the 2010 introduction of PCV13, as it contains additional pneumococcal serotypes. Certain ethnic groups, including African Americans, Native Alaskans, and Native Americans, are at increased risk of invasive H. influenzae Type b disease. Other at-risk groups include those with congenital or acquired immunodeficiencies, malignancy, hemoglobinopathies, and anatomic, functional, or congenital asplenia. Neither Type b or nontypeable H. influenzae cause impetigo or scalded skin syndrome. Impetigo is caused by local infection by Streptococcus pyogenes or Staphylococcus aureus, and staphylococcal scalded skin syndrome (SSSS) is caused by some strains of S. aureus toxin.

What is the maximum age that a patient should receive rotavirus vaccine?

The rotavirus vaccine is a live, orally administered vaccine containing several strains of rotavirus isolated from human and bovine hosts. Two formulations of rotavirus vaccine are available—a 2-dose regimen (RV1) and a 3-dose regimen (RV5). These doses are administered at 2-month intervals starting as early as 6 weeks of age. The maximum age at which the first dose may be administered is 14 weeks, 6 days; the maximum age for administration of the second or third dose is 8 months, 0 days. Although a single dose of the vaccine may confer some protection, the exact level is not known. In the United States, before the routine administration of rotavirus vaccine, nearly 95% of children acquired at least 1 rotavirus infection by 5 years of age. Rotavirus infection resulted in 55,000 to 70,000 hospitalizations and 20 to 60 deaths each year in young children. The estimated costs of this pathogen, largely because of lost productivity of caregivers of infected children, were approximately $1 billion per year. Routine administration of the rotavirus vaccine has substantially reduced the frequency of office and emergency department visits, hospitalizations, and costs associated with the infection. Evidence suggests that some protection is conferred to nonvaccinated children as well. The risk of intussusception is slightly elevated after the first dose of the vaccine, with about 1.5 excess cases per 100,000 vaccinated infants. However, because infants younger than 3 months rarely develop intussusception, the benefits of the vaccine outweigh the limited number of excess cases in this age group. As infants reach beyond age 3 months, their risk of intussusception naturally increases; therefore, the number of excess cases associated with a first dose in the vaccine series in this age group would be more substantial. This increasing risk is the reason for the maximum age restrictions for vaccine administration. The vaccine is thought to be effective in older infants, but the increased risk of vaccine-associated intussusception outweighs the benefit.

What are the proper storage conditions for live and attenuated vaccines?

The varicella vaccine must be stored in a continuously frozen state at 5° F (-15° C). Varicella vaccine should be shipped in an insulated container with dry ice only at 5° F (-15° C) or colder. It should be delivered within 2 days and frozen immediately upon arrival, stored in a frost-free freezer at an average temperature of 5° F (-15° C) or colder, and protected from light at all times. The diluent used for reconstitution should be stored separately in a refrigerator or at room temperature. After the vaccine is reconstituted, it should be injected as soon as possible and discarded if not used within 30 minutes. Inactivated vaccines (e.g., Hib, DTaP, HPV, Td, Tdap, DT, IPV, PCV13, PPSV23, MCV4, MPSV, HepA, HepB, IIV) should be shipped in insulated containers and maintained at temperatures between 35 and 46° F (2-8° C). Inactivated vaccines should be refrigerated immediately upon arrival and stored at 35-46° F (2-8° C). They should not be frozen or exposed to freezing temperatures. Other live virus vaccines (e.g., LAIV, MMR, rotavirus) also are heat sensitive. Cold temperatures (35-46° F [2-8° C]) must be maintained when transporting and storing the intranasal LAIV vaccine. A single temperature excursion up to 77° F (25° C) for 12 hours is permitted; after a temperature excursion, the vaccine should be returned immediately to the recommended storage condition 35-46° F (2-8° C) and used as soon as feasible. Subsequent excursions are not permitted. The MMR vaccine should be stored at 35-46° F (2-8° C) and protected from light at all times. The reconstituted vaccine should be stored in a dark place, administered as soon as possible, and discarded if not used within 8 hours. The rotavirus vaccine should be shipped in an insulated container and maintained at a temperature of 35-46° F (2-8° C). It should not be frozen or exposed to light and should be refrigerated until just prior to administration.

Do immunisations need to be deferred with fever?

There is no increased risk for adverse events or a decrease in vaccine efficacy following vaccination during a mild URI, otitis media or GI illness w/ or w/o fever. Deferring shots is not recommended during antimicrobial therapy.

Age for screening cholesterol

Universal screening at 9-11 years of age and again at 17-21 years of age. C

Duration between hepA and Varicella vaccines

Varicella requires 3 months between vaccines. Hepatitis A requires 6 months between immunizations.

At what age does visual acuity get to 20/20?

Visual acuity reaches the adult level of 20/20 by 3-5 years of age

What are the different ways to evaluate hearing in children?

Whispered speech testing is a simple evaluation in which the examiner whispers words a short distance from the patient and determines if the patient is able to hear and recognize the words. Whispered speech testing is far too nonspecific and would be difficult to evaluate in a child this age. Pure tone audiometry involves a spectrum of tones and volumes that may be provided to the patient through the ear canal or through application of transmitters over the mastoid process. The test relies on the patient providing a response that indicates the sound was detected, and although a child this age may be trained to respond, it would be a more involved evaluation. Otoacoustic emissions are the low-level sounds made spontaneously by the cochlea or in response to an auditory stimulus. Otoacoustic emissions testing provides information on the function of the outer hair cells of the cochlea. Pneumatoscopy with tympanograms can measure the movement of the tympanic membranes and subsequently provide information on the status of air pressure in the middle ear. Since the questioned hearing insult in this patient would be sensorineural in nature, pneumatoscopy with tympanograms and otoacoustic emissions testing do not address the most likely defect.

Can MMR or varicella immunizations be given to children who live in households with pregnant women or immunocompromised hosts?

Yes. Both the MMR and varicella vaccines are safe to administer to children living with a pregnant woman in the same household. The same holds true for children who live with an immunocompromised household member. Although both MMR and varicella are live attenuated vaccines, there is no risk that a recently immunized child will shed live-vaccine virus; therefore, there is no danger of transmission of the vaccine virus to a developing fetus. Administration of live attenuated vaccines to pregnant women is contraindicated at any stage of pregnancy. Vaccinate rubella and/or varicella nonimmune women with MMR following delivery. Women who are given MMR or varicella vaccine should not become pregnant for at least 28 days, based upon the theoretical risk of fetal infection.

Can you give a TST and a live-attenuated vaccine on the same day?

Yes. Can give say TST and MMR on same day but if not given on same day need to wait for 4-6 was after MMR given to give TST

At what ages should infants and children receive PCV13?

at 2, 4, 6, and 12-15 months of age

what are contraindications of rotavirus vaccine?

contraindications to rotavirus vaccine administration are few. Infants with a personal history of intussusception or a personal history of an anaphylactic reaction to the rotavirus vaccine should not receive the vaccine. However, a family history of intussusception or anaphylaxis is not a contraindication. The RV1 dosing tube contains latex; thus, only the RV5, whose dosing tube is latex-free, should be given to children with spina bifida, bladder exstrophy, and other infants with or who are at high risk of developing a latex allergy. Infants with severe combined immunodeficiency should not receive the vaccine because of the risk of vaccine-acquired rotavirus infection. For infants with other types of immunodeficiency, consultation with an immunologist is recommended before giving the vaccine. Administration of the rotavirus vaccine to infants with active moderate-to-severe gastroenteritis should be delayed until symptoms improve, but for those with mild symptoms, vaccination should not be delayed.

Why shouldn't PPSV23 be administered to toddlers <24 months?

due to its poor immunogenicity in that younger age group

Contraindication of DTap?

encephalopathy within 7 days after administration of a previous dose of DTaP, progressive neurologic disorder, including infantile spasms, a poorly controlled seizure disorder, or a progressive encephalopathy, anaphylaxis to previous dose of DTap, age 7 years or older should receive Tdap not DTap!

Adverse events after vaccination with DTap?

fever of 104.8° F (40.5° C) or higher; a collapse or shock-like state (hypotonic hyporesponsive episode); a seizure within 48 hours of vaccination; and persistent, inconsolable crying lasting for at least 3 hours within 48 hours of receipt of a DTaP vaccine.

Anatomic Site to inject vaccines in infants < 12 mo

in the muscles of the anterolateral thigh.

small increased risk for febrile seizures during the 24 hours after simultaneous administration of trivalent IIV and these two vaccines.

pneumococcal 13-talent conjugate (PCV13) vaccine. and the diphtheria, tetanus, acellular pertussis (DTaP) vaccine.

Contraindications to vaccines

severe reaction e.g. anaphylaxis following a previous dose. Encephalopathy within 7 days of pertussis containing vaccine .Or intussusception of SCID for rotavirus.

When can Children move to standard seat belts (from a booster seat)?

when they have reached 4' 9" tall and are between 8 and 12 years of age .

vaccine contraindicated with egg allergy

yellow fever Yellow fever vaccine contains larger amounts of egg protein than other vaccines. In individuals with a history of severe hypersensitivity reactions to egg, skin testing with the vaccine is recommended. If positive, the vaccine should be administered in graded doses by an allergist.

MMR vaccine contraindications

+HIV but no severe immuncompromise (i.e. CD4 <15% at any age or <750 at less or equal to 12 mo, <500 at 1-5 yrs, <200 at >5yo) can receive 2 doses of MMR but not MMRV.

Pneumococcal vaccines

1 dose of PCV 13 followed at least 8 weeks later by 1 dose of PPSV23 and by 2nd dose of PPSV23 at 5 years after 1st dose

Measles/varicella-containing vaccines should be deferred for ____________months after receipt of high-dose intravenous immunoglobulin (IVIG) for treatment of Kawasaki disease because of possible diminished immunogenicity and interference with the immune response.

11

At what age should children begin to have routine blood pressure measurement?

3 years of age

PPSV23, if indicated, should only be administered at least ------ weeks after PCV13 is given.

8

Appropriate catch-up immunization schedule for an 8 yr old

A 2nd dose of hepatitis B, IPV, and MMR may be administered 4 weeks after the 1st dose of each vaccine. Children 7-10 years of age who have not completed their immunization schedule with DTaP before 7 years of age should receive a single dose of Tdap. If further dose(s) of tetanus and diphtheria toxoids are indicated in a catch-up schedule, a Td vaccine is recommended 4 weeks after the Tdap vaccine. A final 2nd dose of Td is indicated 6 months after the 1st. For a child under 13 years of age, 3 months are required between the 1st and 2nd doses of varicella vaccine; the minimum interval between doses 1 and 2 drops to 1 month in those 13 years of age and older. The minimum interval between the 2 required doses of hepatitis A vaccine is 6 months. Hib and PCV13 vaccines are not indicated in immunocompetent children 5 years of age and older.

What are the important time intervals to remember for vaccine catch up?

A 4-week-interval is recommended for children "catching up" who are younger than 7 years of age. At the 2nd visit, the patient needs to receive DTaP, HBV, IPV, and MMR vaccines. For her 2nd varicella vaccine, wait 3 months; for her 2nd hepatitis A vaccine, wait 6 months. Because of her age, she does not require rotavirus, Hib, or pneumococcal vaccines. Board Testing Point Know the time interval for "catchup" immunizations.

Varicella vaccine

Additional contraindications to the vaccine include severe allergic reaction (i.e., anaphylaxis), severe immunosuppression, pregnancy (or possibility of pregnancy within 4 weeks), and recent administration of immunoglobulin. Of note, HIV infection is a misperceived contraindication. Varicella vaccine should be considered for HIV-infected children with a CD4+ T-lymphocyte percentage of ≥ 15%. The live-attenuated varicella vaccine is routinely recommended at 12-15 months of age. A 2nd dose of vaccine is recommended at 4-6 years of age but may be administered at an earlier age (i.e., during a varicella outbreak) providing a 3-month interval has passed since administration of the 1st dose. The monovalent varicella vaccine is preferred for the 1st immunizing dose since the risk of a febrile seizure in toddlers is slightly higher 1-2 weeks after immunization with the combined measles, mumps, rubella, and varicella (MMRV) vaccine. However, MMRV generally is preferred for the 2nd dose at 4-6 years of age to minimize the number of injections. MMRV is not approved for those > 12 years of age.

Catch up 10 yo boy with no vaccines

Administer hepatitis B, MMR, Tdap, IPV, and hepatitis A vaccines today. After he gets his immunizations today, he needs to return in 4 weeks. At that point, he will get Td, hepatitis B, IPV, and MMR. Hepatitis A booster will be in 6 months. The patient does not require the larger "D" component of diphtheria at his age, and his initial tetanus vaccine should be a Tdap while those afterwards should be Tds. Hib is not required for children older than 5 years of age. He does not require varicella vaccine because of his documented varicella infection. HPV is approved for boys aged 11-21 years of age, although it can be given as early as 9 years of age.

Tetanus immunization requirements following a wound.

Adolescents 10-18 years of age who require a tetanus toxoid-containing vaccine as part of wound management should receive a single dose of Tdap (rather than Td) if they have not received Tdap previously. Patients with clean, minor wounds who have previously received ≥ 3 doses of a tetanus-containing vaccine require tetanus prophylaxis only if the last tetanus-containing vaccine dose was ≥ 10 years ago. Those patients with wounds contaminated with dirt, feces, saliva, and/or soil who have previously received ≥ 3 doses of a tetanus-containing vaccine require tetanus prophylaxis only if the last tetanus-containing vaccine dose was ≥ 5 years ago. Tetanus immunoglobulin (TIG) is indicated in wounds contaminated with dirt, feces, soil, or saliva (and in puncture wounds, avulsions, burns, and frostbite) only in individuals who have previously received < 3 doses of a tetanus-containing vaccine. TIG is not indicated for tetanus prophylaxis in any clean, minor wound, including in individuals who have previously received < 3 doses of a tetanus-containing vaccine. Because pertussis often occurs among adolescents and young adults, Tdap (rather than Td) is recommended at the 11- to 12-year-old visit with catch-up vaccination throughout adolescence. Tdap can be administered regardless of time since receipt of the last tetanus toxoid-diphtheria (Td)-containing vaccine. A 2nd dose of Tdap is not routinely recommended, with the important exception that a dose of Tdap be administered during each pregnancy, optimally at 27-36 weeks of gestation, irrespective of the mother's prior history of receiving Tdap.

Flu shot recommendations

All children between 6 months of age and 8 years of age who have not previously been immunized against influenza require 2 doses of inactivated influenza vaccine (IIV) or 2 doses of live attenuated influenza vaccine (LAIV) administered at least 1 month apart. Unimmunized children ≥ 9 years of age require only 1 dose of influenza vaccine. When 2 doses of the vaccine are required, the 1st dose should be administered as soon as the seasonal vaccine becomes available, followed by a 2nd dose as soon as possible after 4 weeks have passed. Infants and children through 8 years of age have reduced or no protection until about 2 weeks after the 2nd dose. IIV is indicated in individuals ≥ 6 months of age, including those with chronic medical conditions and during pregnancy. Conditions associated with an increased risk of severe complications from influenza include asthma or other chronic pulmonary diseases, immunosuppressive disorders, hemodynamically significant cardiac disease, hemoglobinopathies, chronic renal disease, chronic metabolic disorders, diseases requiring long-term salicylate therapy, and conditions that may compromise respiratory function/handling of secretions. IIV is available in both trivalent (IIV3) and quadrivalent (IIV4) formulations. The trivalent vaccine protects against the 2 most common circulating A strains and one of the two circulating B strains. The quadravalent vaccine contains the 2 common A strains for the season and both B strains. IIV4 is likely provides broader protection than IIV3, especially if the circulating B strain is not included in the IIV3. Neither vaccine formation is preferred over the other. For the 2018-2019 influenza season, the AAP recommends administration of IIV for all children (> 6 months of age) and adolescents, particularly those with underlying medical conditions placing them at increased risk of complications from influenza. LAIV is only recommended in healthy children > 2 years of age who would not otherwise receive an influenza vaccine (e.g., due to vaccine refusal).

Pneumococcal vaccine for patients with sickle cell anemia

All children should receive PCV13 at 2, 4, 6, and 12-15 months of age. PCV13 contains 13 pneumococcal serotypes that cause the majority of invasive pneumococcal diseases in children, including meningitis and bacteremia. Since the introduction of this vaccine, the incidence of invasive pneumococcal disease has markedly decreased. After completion of the PCV13 series, high-risk children ≥ 24 months of age should receive PPSV23. PPSV23 should be given ≥ 8 weeks after the last dose of PCV13. High-risk children who are immunocompromised, have sickle cell disease, or functional or anatomic asplenia should receive a 2nd dose of PPSV23 five years after the 1st dose. A 2nd dose is not indicated for immunocompetent children with cochlear implants, chronic illness or cerebrospinal fluid leaks. Children 6-18 years of age at enhanced risk for invasive pneumococcal disease who previously received no prior PCV13 immunizations should receive a single dose of PCV13; for those in this age group who have received a previous dose of PPSV23, the single dose of PCV13 should be administered at least 8 weeks after the PPSV23 dose.

MMR

All infants 6-11 months of age should receive 1 dose of MMR vaccine.

appropriate immunization schedule for prevention of perinatal transmission of hepatitis B virus in low birth weight infants born to mothers who are HBsAg positive.

All infants weighing < 2 kg who are born to HBsAg-positive mothers should receive immunoprophylaxis with HBV and HBIG (injections given at different injection sites) within 12 hours after birth. The birth dose of HBV should not be counted toward completion of the HBV series, and 3 additional doses of HBV should be administered beginning when the infant is 1 month of age (HBV vaccine to be given at 1, 2-3, and 6 months of age). Only monovalent HBV should be used from birth through 6 weeks of age. Additional doses of HBIG are not indicated.

Pre-term births HBSAg+ mothers

All preterm infants weighing < 2 kg born to HBsAg-positive mothers should receive both the HBV vaccine and hepatitis B immunoglobulin (HBIG) within 12 hours of birth in order to decrease perinatal transmission of hepatitis B. However, the birth dose should not count toward completion of the HBV vaccine series (i.e., 3 additional doses of vaccine should be administered). It is recommended that all infants born to HBsAg-positive mothers also receive postimmunization testing for both HBsAg and anti-HBs at 9-18 months of age to document response to the vaccine. Testing for HBsAg will identify those infants who become chronically infected despite immunization. Vaccine nonresponders (i.e., those with anti-HBs concentrations < 10 mU/mL) who also remain negative for HBsAg should receive an additional 3-dose series of HBV vaccine.

A 3-year-old boy, recently adopted from Honduras, is diagnosed with varicella. His adoptive mother provides daily care to several neighborhood children in her home while their parents are at work; none of the children are immunocompromised. In how long should children exposed to the index case receive varicella immunization?

All unimmunized contacts of the index case ≥ 12 months of age with no prior history of natural varicella infection should receive varicella vaccine within, at most, 5 days of exposure.

Avulses permanent teeth. How to store? How long remains viable?

An avulsed permanent tooth remains viable for little more than 2 hours. Ideally, the tooth should be replanted within 20 minutes. First, rinse with water while holding by the crown to avoid damaging the root. When possible, the tooth should be reinserted and held in place prior to arrival at a dental office. However, if the child will not cooperate by holding the tooth in place or allowing it to be held in place by another, an alternative method is recommended in order to avoid the risk of aspiration, and that is to place the tooth in cold cow's milk, which avoids the risk of aspiration and provides a safe isotonic solution that does not harm the root. Upon arrival at a dental office, the tooth is generally immediately replanted if the injury occurred within an hour; if more than an hour has passed, the tooth is first soaked in a dental fluoride solution for 20 minutes, rinsed with saline, and then replanted. Avulsed primary teeth should not be replanted. Replanted permanent teeth require regular follow-up evaluations for 2-3 years to assess the outcome of the procedure. It is important to keep the tooth moist. However, root surface cells do not tolerate water. Other solutions may damage the dental pulp and are therefore also not recommended.

During which age ranges should PPSV23 be given, if indicated?

Between 2 and 5 years of age.

Anatomjc site for vaccine i June for toddlers and above

Both the deltoid muscle of the arm and the muscles of the anterolateral thigh

Best way to evaluate hearing in a child with meningitis?

Brainstem auditory-evoked responses would provide the most accurate and specific information regarding the possibility of sensorineural hearing loss in this patient.

children with which immune deficiency are at increased risk of invasive meningococcal disease?

C5-C9 deficiency Explanation Children with persistent complement deficiencies or properdin deficiency are at increased risk of invasive meningococcal infections. Meningococcal vaccines are licensed against serotypes A, C, Y, and W-135. Two serogroup B meningococcal vaccines were recently (October 2014; January 2015) licensed, though these are only recommended for high-risk children 10 years of age and older.

A 28-month-old boy presents for his first health maintenance examination after arriving in the United States from Honduras with his adoptive parents. His parents are unaware of any chronic medical problems. He takes no daily medications, appears well, and has a normal physical examination. Review of his immunization status reveals that he has not been vaccinated with either the Haemophilus influenzae Type b (Hib) conjugate vaccine or pneumococcal conjugate vaccine (PCV13)

Children with an incomplete series of Hib conjugate vaccination who are 15-59 months of age should receive a single dose of Hib conjugate vaccine; no additional doses are required. A single dose of PCV13 is recommended for all healthy children 24-59 months of age who are incompletely immunized. The primary series of Hib conjugate vaccine, administered before 7 months of age, requires 2 doses (at 2 and 4 months of age) or 3 doses (at 2, 4, and 6 months of age), depending upon the vaccine preparation; a booster dose is required at 12-15 months of age, administered at least 8 weeks after the final dose in the primary series. Children who receive their 1st dose of Hib conjugate vaccine at 7-11 months of age should receive 2 doses of the vaccine at 4-week intervals, followed by a booster dose at 12-15 months of age, at least 8 weeks after the 2nd dose of the primary series. If the first dose is administered between 12 and 14 months of age, 1 additional dose, administered at least 8 weeks after the 1st dose, is required. Hib vaccine is not generally recommended for healthy children ≥ 5 years of age. Children < 24 months of age should receive a total of 4 doses of PCV13. The first 3 doses of PCV13 should be administered at 2, 4, and 6 months of age; the 4th dose should be administered at 12-15 months of age but at least 8 weeks after the 3rd dose. If the 1st dose of PCV13 is received between 7 and 11 months of age, 2 doses, 8 weeks apart, followed by a 3rd dose at age 12-15 months of age is required. If the 1st dose of PCV13 is received at 12-24 months of age, a 2nd dose, administered at least 8 weeks after the 1st dose, is required.

A 4-year-old previously unimmunized boy, adopted from an orphanage in Peru, receives the initial doses of several vaccines during a health maintenance visit at a clinic specializing in the care of internationally adopted children. His adoptive parents are anxious for him to be up to date with all recommended childhood immunizations as soon as possible. Which of the following vaccines requires a minimum interval of at least 12 weeks between the 1st and 2nd dose in this patient?

D Varicella Explanation The minimum interval between the 1st and 2nd varicella vaccine is 12 weeks for those beginning the series at < 13 years of age and 4 weeks for those who begin the series at ≥ 13 years of age. When indicated, the minimal interval between the 1st and 2nd doses of MMR, PCV13, and Hib vaccines is 4 weeks. When administering a combination vaccine (e.g., DTaP-IPV-HepB), the minimum interval between doses is equal to the greatest of the minimal intervals of any of the individual components. The minimal interval between the 1st and 2nd doses of all 3 components of this vaccine is also 4 weeks. The minimum age for administration of a combination vaccine is the oldest age for any of the individual components (e.g., DTaP-IPV-HepB may not be administered at < 6 weeks of age because all components except for HepB are not indicated for infants < 6 weeks of age). There are 2 exceptions to the recommendation that infants and children not be vaccinated at an earlier age than the recommended minimum interval or age. First, during a measles outbreak, the MMR vaccine may be administered prior to 12 months of age. However, the dose should not count toward the 2-dose measles vaccine series, and the child should be reimmunized at 12-15 months of age, followed by a 3rd dose of MMR as early as 4 weeks after the 2nd dose. Second, administering a dose a few days earlier than the minimum interval or age is unlikely to adversely affect the immune response. Vaccine doses administered ≤ 4 days prior to the minimum interval or age may be considered valid; however, the 4-day window allowance is generally not considered valid by state and local school districts for MMR.

nasolacrimal duct obstruction

Dacryostenosis, or congenital nasolacrimal duct obstruction, occurs in approximately 6% of newborns. It occurs when the epithelial cells lining the nasolacrimal gland fail to canalize. Signs include overflow of tears and production of mucinous material from the lacrimal sac. Infection or inflammation may occur in the nasolacrimal sac or surrounding tissues. Rarely, periorbital cellulitis occurs.

How are HepB vaccine seroconversion rates affected by age/weight in neonates

Decreased seroconversion rates have been documented among some preterm infants weighing < 2 kg following administration of hepatitis B virus (HBV) vaccine at birth. However, by 1 month of chronological age, all medically stable preterm infants, irrespective of initial birth weight or gestational age, respond with seroconversion rates similar to those with birth weights > 2 kg or born at term. A 2nd dose is recommended 1-2 months after the 1st dose (minimum interval 4 weeks); a 3rd dose should be administered at least 8 weeks after the 2nd dose (and at least 16 weeks after the 1st dose) and no earlier than 24 weeks of age.

Vaccination for infant born to mom with HbSAg

Explanation Regardless of birth weight, an infant born to an HBsAg-positive mother should receive 0.5 mL hepatitis B immune globulin (HBIG) and, at a different site, monovalent hepatitis B (HepB) vaccine , as soon as possible after delivery, preferably within 12 hours of birth. The schedule for subsequent doses depends upon the infant's birth weight: Birth weight ≥ 2 kg (4.4 pounds): Administer a 2nd and 3rd dose at 1 and 6 months of age, respectively. Birth weight < 2 kg (4.4 pounds): Administer 3 additional doses at 1, 2-3, and 6 months of age or at 2, 4, and 6 months of age respectively.

Most common side effect of pertussis vaccine?

Extreme irritability and crying for an extended period of time (≥ 3 hours)

What is more common following administration of the quadrivalent measles-mumps-rubella-varicella vaccine (MMRV) when compared to simultaneous administration of monovalent varicella vaccine and the measles-mumps-rubella (MMR) vaccine?

Febrile Seizure

How doesn't varicella present in previously vaccinated children?

Following exposure to wild-type varicella-zoster virus, previously vaccinated children may develop varicella—so called "breakthrough varicella." Breakthrough disease is defined as a rash caused by wild-type varicella virus occurring > 42 days post vaccination. The typical rash associated with breakthrough disease is predominantly maculopapular rather than vesicular, usually limited to < 50 lesions, and is less contagious than wild-type infection. Children with breakthrough disease should be excluded from school and day care until no new maculopapular lesions are occurring and, if present, all vesicles have crusted over. The live-virus varicella vaccine is 95% effective in preventing severe disease and 80% effective at preventing all disease. The varicella vaccine is routinely recommended at 12-15 months of age and 4-6 years of age. The minimum interval between dose 1 and 2 of varicella vaccine is 3 months in children ≤ 13 years of age and 28 days in those > 13 years of age. A possible side effect of the varicella vaccine is a maculopapular rash located predominantly at the site of injection. However, the lesions associated with breakthrough varicella are typically maculopapular and can be located anywhere on the body. Herpes zoster is typically localized to 1-3 dermatomes. Although breakthrough lesions in the vaccinated child are maculopapular, wild-type varicella lesions in the unvaccinated child are vesicular. The hallmark of natural varicella infection is a rash in various stages of healing (vesicles, pustules, and crusting over).

Pertussis Vaccination

For children ≥ 7 years of age who have never received a pertussis-containing vaccine, or for those who are not fully immunized (total of 5 doses) with DTaP vaccine prior to 7 years of age, a single dose of Tdap vaccine (preferably the 1st) should be included in the catch-up series. If additional doses are needed, Td vaccine should be used. If the first dose of DTaP/DT or Tdap/Td was administered at ≥ 1 year of age, as in this case, a Td vaccine is indicated in 4 weeks, followed by a 2nd Td vaccine 6 months after the 1st Td. In the catch-up series, a 4th dose is only required if the 1st dose of DTaP/DT was administered at < 1 year of age. For children who receive Tdap as part of a catch-up series at 7-10 years of age, an adolescent Tdap vaccine dose at 11-12 years of age may be administered. For women of child-bearing age, a single dose of Tdap is recommended during each pregnancy, preferably at 27-36 weeks gestation. Tdap is indicated in each pregnancy even if the woman has a previous history of pertussis infection or vaccination and even if consecutive pregnancies occur within 12 months. DTaP vaccines are only indicated for children < 7 years of age. Pertussis is characterized by 3 distinct stages: The catarrhal stage, which begins after a 3- to 12-day incubation period, characterized by nondescript upper respiratory symptoms; individuals with pertussis are most infectious during this stage. The paroxysmal stage, characterized by a dry, intermittent, irritating, "hacking" cough followed by inexorable paroxysms, posttussive emesis/exhaustion, and often an inspiratory "whoop." A convalescent stage—often lasting several months—characterized by a gradual decrease in the number and severity of paroxysms.

HPV vaccine schedule for less than 15 yo vs greater than 15.

For persons initiating vaccination < 15 years of age, the recommended immunization schedule is 2 doses of 9vHPV vaccine. The 2nd dose should be administered 6-12 months after the 1st dose (0, 6- to 12-month schedule). For persons initiating vaccination at ≥ 15 years of age, the recommended immunization schedule is 3 doses of 9vHPV vaccine. The 2nd dose should be administered 1-2 months after the 1st dose, and the 3rd dose should be administered 6 months after the 1st dose (0, 1- to 2-, 6-month schedule). If the vaccination schedule is interrupted, as in this patient's case, the series does not need to be restarted.

Is there a limit to duration between live vaccines?

If live vaccines are not administered during the same visit they should be separated by > or equal to 4 weeks.

What factors affect immunogenicity/seroconversion rates of vaccines?

If not administered during the same visit, an inactivated vaccine may be given at any time before or after a different inactivated vaccine or a live-virus vaccine. Immune globulin preparations interfere with the serologic response to MMR and varicella vaccines for variable periods, depending on the dose of immune globulin administered. Recommended intervals between immune globulin/blood-product administration and measles immunization are published. Tuberculin skin testing may be performed on the day of immunization with MMR; otherwise testing should be delayed for 4-6 weeks because MMR immunization may temporarily suppress tuberculin skin test reactivity.

Immunoglobulin and MMR

Immune globulin products and MMR should not be administered simultaneously. If MMR is given first, immune globulin should not be administered for 2 weeks. If immune globulin is given first, the interval between immune globulin and MMR vaccination is dependent upon the product, the dose, and the indication. Suggested intervals between administration of immune globulin preparations for various indications and vaccines containing live measles virus range from 3-11 months; the same holds true for monovalent varicella vaccine and MMRV. In addition to idiopathic thrombocytopenic purpura, other indications for immune globulin treatment include prophylactic treatment following potential or confirmed exposure to hepatitis A, hepatitis B, tetanus, varicella, rabies or measles, blood transfusion, and Kawasaki disease. The concentration of measles antibody in immune globulin preparations varies considerably. The rate of antibody clearance following receipt of an immune globulin preparation can also vary. Daily therapy with inhaled steroids is not a contraindication to vaccination with MMR and other live vaccines. Patients receiving 2 mg/kg/day, ≥ 20 mg/day of oral prednisone, or an equivalent for ≥ 2 weeks should not be vaccinated with any live vaccine. Vaccination should be delayed for at least one month following discontinuation of oral corticosteroids. An anaphylactic reaction to baker's yeast is a contraindication to hepatitis B vaccination. With the exception of OPV, a live vaccine may be administered to any individual living with an immunocompromised household member. However, it is recommended to avoid contact with severely immunocompromised patients for 7 days following vaccination with live attenuated influenza vaccine. Seizure disorder is not a contraindication for MMR vaccination. Poorly controlled seizures of uncertain etiology, developmental delay of uncertain etiology or an evolving neurological disorder represent contraindications to DTaP.

Vaccines for adolescents

In adolescents who have previously received Td but not Tdap, a single dose of Tdap to provide protection against pertussis is recommended regardless of the interval since the last tetanus or diphtheria toxoid-containing vaccine. The preferred age for Tdap is 11-12 years, with a booster dose of Td every 10 years thereafter. Children between 7 and 10 years of age who have not completed their primary DTaP immunization schedule (i.e., 2, 4, 6, 12-15 months, and 4-6 years of age) or have an unknown vaccine history should receive a single dose of Tdap; if additional tetanus and diphtheria toxoid doses are required, Td should be used. When feasible, adolescents requiring tetanus prophylaxis for wound management who have yet to receive Tdap (such as the patient in this question who has received the only tetanus toxoid-containing vaccine after laceration repair) should receive a single dose of Tdap rather than Td. A single dose of Tdap should also be administered to pregnant adolescents during each pregnancy (preferably between 27 and 36 weeks of gestation), regardless of prior vaccination status. In addition to Tdap, both the meningococcal conjugate vaccine (MCV4) and the human papillomavirus (HPV) vaccine are routinely recommended at 11-12 years of age. A booster dose of MCV4 is recommended at 16 years of age. If the 1st dose of MCV4 is administered at 13-15 years, a booster dose is recommended at age 16-18 years. For persons initiating vaccination with HPV at < 15 years, the recommended schedule is 2 doses of HPV vaccine at 0 and 6-12 months. For persons initiating vaccination at ≥ 15 years, the recommended schedule is 3 doses of HPV vaccine at 0, 1-2, and 6 months.

current recommendations for statin therapy in children and adolescents.

In children who are ≥ 10 years of age and have LDL-C levels of 130-159 mg/dL, statin therapy is recommended if 2 or more high-risk factors for cardiovascular disease or conditions, or 1 high-risk and 2 or more moderate-risk factors or conditions are present. Both a BMI ≥ 97th percentile and either Type 1 or type 2 diabetes mellitus are considered high-risk factors. Other high-risk factors include hypertension requiring pharmacotherapy (BP ≥ 99th percentile + 5 mmHg), cigarette smoking or exposure to 2nd hand smoke, chronic renal disease, postrenal or heart transplant, and Kawasaki disease with current coronary aneurysms. Moderate-risk factors include Kawasaki disease with regressed coronary aneurysms, hypertension not requiring drug therapy, BMI ≥ 85th to <97th percentile (in adolescents ≥ 12 years of age), HDL cholesterol < 40 mg/dL, chronic inflammatory disease (e.g., juvenile idiopathic arthritis), HIV infection, and nephrotic syndrome. Additional risk factors are a positive family history of premature coronary artery disease (myocardial infarction, angina, intervention for coronary artery disease, stroke, or sudden cardiac death) in a 1st or 2nd degree male relative < 55 years of age or female relative < 65 years of age, or a family history of dyslipidemia or total cholesterol > 240 mg/dL in either parent. Pharmacotherapy is typically recommended when lifestyle changes fail to achieve target LDL-C levels after 3-6 months. Adverse effects of statin medications include anorexia, nausea, myalgias, and elevated liver transaminases. Rhabdomyolysis is a rare but potentially life-threatening side effect of all statins. Serum creatine kinase, liver function tests, and a fasting lipid panel should be ordered prior to starting a statin medication and need to be rechecked every 3-6 months.

Needle lengths for vaccine injections depending on age

In order to minimize local reactions, needles used for intramuscular injection must be long enough to reach an appropriate amount of muscle mass in order to prevent seepage of vaccine into surrounding subcutaneous tissue. The recommended needle length for infants 2-12 months of age is 1"; the anterolateral thigh is the recommended injection site for this age group. The recommended needle length for preterm and term newborns is 5/8"; the anterolateral thigh is the recommended injection site for this age group. The recommended needle length for toddlers and children is 5/8-1" (for injection into the deltoid muscle) or 1-1 1/4" (for injection into the anterolateral thigh). The recommended injection site for all adolescents is the deltoid muscle; the recommended needle length for adolescent males and females weighing < 60 kg is 5/8-1"; for females 60-90 kg 1"; for females > 90 kg 1 1/2"; for males weighing 60-118 kg 1"; for males > 118 kg 1 ½".

Steroids and varicella vaccine

Individuals who are receiving systemic corticosteroids (≥ 2 mg/kg/day of prednisone or ≥ 20 mg/day of prednisone) for ≥ 2 weeks should not receive the varicella vaccine for at least 1 month after discontinuation of treatment.

route of vaccination

It is recommended that the measles, mumps, and rubella (MMR); monovalent varicella; and measles, mumps, rubella, and varicella (MMRV) vaccines be administered subcutaneously. Both the inactivated polio virus (IPV) and pneumococcal polysaccharide (PPSV23) vaccines are approved for administration by either the subcutaneous or intramuscular route.

live oral human-bovine reassortant pentavalent vaccine (RotaTeq) recommend rather than the live oral human attenuated monovalent rotavirus vaccine (Rotarix)?

Latex allergy

Recommendations for children with persistent complement component deficiency

MenACWY-CRM (Menveo®) - licensed for 2 months to 55 years of age Children who receive initial vaccination at 8 weeks to 6 months of age: administer doses at 2, 4, 6, and 12-15 months of age. Unvaccinated children 7-23 months of age: administer 2 doses—2nd dose at least 12 weeks after the 1st dose and 12 months of age. Children ≥ 24 months of age who have not received a complete series: administer 2 primary doses—2nd dose at least 8 weeks after the 1st dose. Hib-MenCY (MenHibrix®) - licensed for 6 weeks to 18 months: Children 6 weeks to 18 months of age: administer doses at 2, 4, 6, and 12-15 months of age. If the 1st dose of Hib-MenCY is given at or after 12 months of age, a total of 2 doses should be given (2nd dose at least 8 weeks after the 1st dose) to ensure protection against serogroups C and Y meningococcal disease. MenACWY-D (Menactra®) - licensed for 9 month to 55 year olds: Children 9-23 months of age: administer 2 primary doses—2nd dose at least 12 weeks after the 1st dose. Children ≥ 24 months of age who have not received a complete series: administer 2 primary doses—2nd dose at least 8 weeks after the 1st dose. If the primary series is administered at 9 months to 6 years of age, a booster dose is recommended 3 years after primary immunization; boosters should then be repeated every 5 years. If the primary series is administered at ≥ 7 years of age, a booster dose is recommended 5 years after the primary immunization; repeated 5 years thereafter. Men B-4C (Bexsero®): High-risk children 10 years of age and older: administer 2 doses separated by at least 1 month Men B-FHbp (Trumenba®): High-risk children 10 years of age and older: flexible 2- or 3-dose regimen (administer at 0 months, 2 months, and 6 months or 0 months and 6 months), though it is recommended that high-risk children receive the 3-dose regimen. In general give MCV4 vaccine 2 doses 8-12 weeks apart with a booster dose 3 years after primary immunisation repeated every 5 years after

Is myopia common in children?

Myopia is nearsightedness and is rare in early term infants; it is more common in preterm infants and among infants with retinopathy of prematurity. The prevalence of myopia increases throughout childhood, particularly during and after puberty

IS THERE UPPer limit to # of vaccines that can be given in 1 visit?

No upper limit to # of vaccines per visit. But, if both PCV13 and PPSV23 are indicated, doses of PCV13 should be given first, followed by PPSV23 at least 8 weeks after the final dose of PCV13. If menactra brand MCV4 is used, all PCV13 doses should be given first then menactra 4 weeks later.

Should all children receive PPSV23 or is it only for high-risk children?

No, it is only for high risk children, like in children with sickle cell anaemia.

For A 10-month-old who received hepatitis B vaccine at birth and hepatitis B, IPV, DTaP, Hib, rotavirus, and conjugate pneumococcal vaccines at 2 months of age and has been lost to follow-up until today, do any vaccines require reinstitution of the entire vaccine series because of the 8-month lapse in the immunization schedule?

No. Explanation For DTaP, IPV, Hib, pneumococcal conjugate, hepatitis A or hepatitis B vaccines, a lapse in the immunization schedule does not require reinstitution of the entire series or additional doses of the vaccine. Administer subsequent vaccine doses as if the usual recommended interval has elapsed since the last visit. Therefore, because doses of all listed vaccines were missed at 4 and (for some) at 6 months of age, administer the 2nd (3rd for hepatitis B) dose of each vaccine during the current visit. The exception is the rotavirus vaccine, which is not indicated after 8 months, 0 days of age.

catch-up" immunization schedule for children of various ages who start late or who are > 1 month behind: 7 yo girl who only received polio vaccine and has had varicella infxn

Of the choices provided, MMR would be the most appropriate vaccine to recommend, followed by a 2nd dose after an interval of at least 28 days. Completion of the polio series (with IPV) and institution of hepatitis A and B immunization should also be strongly considered. Vaccine recommendations include variations related to age and natural history. DTaP is administered only to children < 7 years of age. Children between 7 and 10 years of age who have not completed their primary immunization schedule should receive a single dose of Tdap; if additional tetanus and diphtheria toxoid doses are required, Td should be used (at 2 months and then again 6-12 months after Tdap). Hib is not recommended for healthy children > 60 months of age; however, 1 dose of Hib vaccine should be administered to unimmunized children ≥ 60 months of age with anatomic or functional asplenia or HIV infection. HPV vaccine is not recommended < 9 years of age or > 26 years of age. A 2-dose schedule is recommended for children < 15 years of age who are starting vaccination, with the 2nd dose administered 6-12 months after the 1st dose. Those starting vaccination at 15-26 years of age should receive 3 doses on a schedule of 0, 1-2, and 6 months. Routine vaccination is recommended at 11-12 years of age. In children who have been sexually abused, the vaccine can be given as early as 9 years of age. Varicella is not required for a child with a natural history of the disease.

Facts about HPV vaccine.

Of the response choices, the statement you are most likely to include in your discussion is that the vaccine provides protection against noncervical HPV-associated cancers. Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. In a study conducted before HPV vaccine licensure, 25% of persons aged 14 to 19 years and 45% of those aged 20 to 24 years were infected. It is estimated that more than 80% of men and women in the United States will be infected with HPV during their lifetime. Most HPV infections are asymptomatic and resolve spontaneously. Infection with low-risk HPV types (eg, 6 and 11) may cause anogenital warts or mild forms of intraepithelial neoplasia affecting the vulva, vagina, cervix, anus, or penis. Persistent infection with 1 of the 13 oncogenic (high-risk) types may lead to precancerous or cancerous lesions. In the United States, types 16 and 18 are responsible for 63% of HPV-associated cancers (70% of cervical cancers); types 31, 33, 45, 52 and 58 cause an additional 10%. In addition to cervical carcinoma, HPV is associated with other malignancies. In 1 study, HPV DNA was found in 90% of cervical, 75% of vaginal, 69% of vulvar, 63% of penile, and 91% of anal cancers. Approximately 70% of oropharyngeal cancers are believed to result from HPV infection, especially type 16. Currently, 2 HPV vaccines are licensed and available in the United States: 4-valent (types 6, 11, 16, 18) and 9-valent (types 6, 11, 16, 18, 31, 33, 45, 52, 58). Each of the vaccines is approved for the prevention of HPV-associated cervical, vaginal, vulvar, and anal cancers, and precancerous lesions. The additional coverage provided by the 9-valent vaccine could increase protection against invasive cervical cancer from 70% to 90%. The 4- and 9-valent vaccines are approved for the prevention of anogenital warts, 90% of which are caused by types 6 and 11. Both vaccines are approved for use in both girls and boys. The Advisory Committee on Immunization Practices offers the following recommendations regarding HPV immunization: Vaccination of girls and boys should begin routinely at 11 or 12 years, but may be initiated as early as 9 years. The vaccine is also recommended for females of ages 13 to 26 years and males of ages 13 to 21 years who were not previously immunized. For men who have sex with men and for persons who are immunocompromised, vaccination is recommended through age 26 years. The vaccines are administered with 1 of 2 schedules: For those 9 to 14 years of age, a 2-dose schedule is recommended: the second dose is given 6 or 12 months after the first (if the series is initiated before the 15th birthday, 2 doses are administered) For those 15 to 26 years of age, a 3-dose schedule is recommended: the second dose is administered 1 to 2 months after the first; the third dose is given at least 6 months after the first. If the vaccine series is interrupted it may be resumed (ie, the series does not need to be restarted). If possible, the same vaccine form should be used to complete the immunization series. However, if this is not possible, another vaccine may be substituted. The most common adverse effects of HPV vaccination are injection site pain, erythema, and/or edema. Headache, dizziness, fever, nausea, fatigue, or syncope may occur. The vaccine is not associated with an increased risk of developing central nervous system demyelinating disease. Although it is a concern expressed by some parents, studies indicate that girls who receive the vaccine are not more likely than those who do not to be sexually active or to have an increased number of sexual partners. In the United States, only 39.7% of girls and 21.6% of boys aged 13 to 17 years receive 3 or more doses of HPV vaccine (ie, complete the series). The rate of immunization with 1 or more doses of HPV has increased, but remains lower than for 1 or more doses of tetanus, diphtheria, and pertussis (Tdap) or meningococcal bacteria A, C, W and Y (MenACWY). Although the reasons for this are not fully understood, the lack of a strong provider recommendation is 1 factor. In 1 study, 55% of parents who received a physician's recommendation for HPV immunization had their sons vaccinated compared with only 1% of parents who received no such recommendation. Similarly, in a study published in 2014, the most common reason parents did not vaccinate their daughters against HPV was the lack of a physician recommendation. Resources that may assist clinicians in communicating the importance of HPV vaccine to parents and patients are available at: http://www.cdc.gov/hpv/index.html.