CME Designation The American Academy of Pediatrics (AAP) is accredited by the Accreditation

Council for Continuing Medical Education (ACCME) to provide continuing medical

education for physicians.

The AAP designates this live activity for a maximum of 1.00 AMA PRA Category 1

Credit(s)™. Physicians should claim only the credit commensurate with the extent of

their participation in the activity.

This activity is acceptable for a maximum of 1.00 AAP credits. These credits can be

applied toward the AAP CME/CPD Award available to Fellows and Candidate

Members of the American Academy of Pediatrics.

The American Academy of Physician Assistants (AAPA) accepts certificates of

participation for educational activities certified for AMA PRA Category 1 Credit™

from organizations accredited by ACCME. Physician assistants may receive a

maximum of 1.00 hours of Category 1 credit for completing this program.

This program is accredited for 1.00 NAPNAP CE contact hours of which 0.25

contain pharmacology (Rx) content per the National Association of Pediatric Nurse

Practitioners (NAPNAP) Continuing Education Guidelines.

1

Reminder: Requirements for Team

Members to Receive CME

Within 1-2 days of the webinar, please submit a

spreadsheet containing the following information

about the webinar participants from your practice:

Please send this spreadsheet to Liz Rice-Conboy at

ericeconboy@aap.org. An evaluation survey will be

sent out via REDCap. Liz will email a PDF of the CME

Certificate directly to each participant.

2

Full name (as it

will appear on

your CME

Certificate)

Email address (you

will be sent a

webinar evaluation

after the webinar)

Designation (as

it will appear on

your CME

Certificate)

Full Address (only if this

differs from the

address of the Project

leader’s address)

Introducing Dr. Meg Fisher

Dr. Fisher received her undergraduate education at Susquehanna University,

Selinsgrove, PA, and her medical degree from the University of California at

Los Angeles School of Medicine. She completed her Pediatric Residency and

Fellowship Training in Pediatric Infectious Diseases from St. Christopher’s

Hospital for Children, Philadelphia. Her current appointment is Medical

Director, The Children’s Hospital at Monmouth Medical Center and Professor

of Pediatrics, Drexel University College of Medicine.

Dr. Fisher's academic achievements include the following: frequent CME

speaker locally, regionally, nationally, and internationally; Journal reviewer,

Editorial Board, PREP Audio, member of the AAP Committee on Infectious

Diseases (Red Book) from 1996 to 2002 and 2006 to 2011; member of the

AAP Committee on Continuing Medical Education from 2003 to 2009; elected

to Executive Committee of the AAP Section on Infectious Diseases 2003,

elected Chair 2006; elected Secretary/Editor of the AAP New Jersey Chapter

2004, Treasurer 2006; Vice President Elect 2008; Vice President 2010; and

President 2012; over 30 articles published in peer-reviewed journals,

numerous invited articles, book chapters, audiotapes and one book.

Her special interests include medical education, pediatric infectious diseases,

infection control, and microbrews.

3

Immunization Schedule

Tricks & Tips

Meg Fisher, MD Medical Director, The Children’s Hospital

Monmouth Medical Center

An affiliate of the Saint Barnabas Health Care System

Long Branch, NJ

Disclosures

I have no disclosures.

I may be mentioning off label uses of vaccines.

Learning Gap

• Gap: Not all physicians are aware of the

processes used to develop the vaccine schedule

Observations during CIzQIDS baseline

assessment indicate issues to address:

• Immunization against diseases that are

currently rare in the US: Why bother?

• The right age to give immunizations

• Minimum intervals between doses

• Medical contraindications: Valid or not?

• Simultaneous administration of multiple

vaccines

• Complexity of schedule: How to remember

all of that?

Learning Objectives

1. Discuss the rational of the vaccine schedule

2. Implement strategies to ensure you and your

patients are following the immunization

schedule

Immunization

• Public health success story

• Rates of all vaccine preventable illnesses have

plummeted:

• Smallpox, diphtheria, tetanus, polio, measles,

mumps, rubella, Haemophilus influenzae type b

almost gone in the US

Immunizations Work!

10

CDC images: http://www.cdc.gov/vaccines/vpd-vac/photo-all-vpd.htm

Seen any cases of smallpox?

Diphtheria 175,885 0 100

Measles 503,282 55 99.9

Mumps 152,209 6,584 95.7

Pertussis 147,271 15,632 89.4

Polio (paralytic) 16,316 0 100

Rubella 47,745 11 99.9

Congenital Rubella Syn. 823 1 99.9

Tetanus 1,314 41 96.9

H. influenzae type b 20,000+ 208 99.0

and unknown (<5 yrs)

Disease Pre-vaccine Era* 2006** % decrease

* Baseline 20th century annual morbidity

+ Estimated because no national reporting existed in the pre-vaccine era

** Source: MMWR 2007;56(33):851-64

Comparison of Pre-Vaccine and Current Reported Morbidity of Vaccine-Preventable Diseases

Total 1,064,854 22,532 97.9

Vaccine Preventable Diseases

hepatitis B

rotavirus

diphtheria

tetanus

pertussis

polio

Haemophilus influenzae type b

Streptococcus pneumoniae

influenza

measles

mumps

rubella

varicella

hepatitis A

Neisseria meningitidis

human papillomavirus

Anthrax, rabies, yellow fever, typhoid fever, monkeypox, Japanese

encephalitis

Advisory Committee on

Immunization Practices (ACIP) • Comprised of:

• 15 experts, selected by the Secretary of

DHHS

• 8 ex-officio members – government

agencies

• 26 liaisons, including members from

Canada, Mexico and the United Kingdom

• Make recommendations for vaccine use

• www.cdc.gov/vaccines/acip/index.html

Immunization Schedules

• Developed by the ACIP

• Schedules revised yearly

• Childhood and Adolescent Schedules approved

by the AAP and AAFP

• Adult Schedules approved by the AAFP, ACOG

and ACP

ACIP Recommended Immunization Schedule for

persons age 0 through 18 years—U.S. 2013

Available at:

http://www.cdc.gov/mm

wr/preview/mmwrhtml/s

u6201a2.htm

Get the code to embed

this in your practice’s

website and it will be

updated whenever CDC

updates

recommendations!

http://www.cdc.gov/vacc

ines/schedules/syndicat

e.html

Vaccine Schedule

• Goal: protect children as soon as possible

• Maternal antibody is a gift but it doesn’t keep on

giving; protection wanes by 6 mo

• Many vaccines require multiple doses

• Boost protection when needed

Why so soon?

• Early infection often more dangerous

• Maternal antibody half life is a month

• Delaying doesn’t decrease adverse events

• Delaying leaves children unprotected

Why so many?

• Prevention is better than trying to cure

• More in this case is better

• Multiple doses needed to initiate and maintain

protective antibody

• The immune system is designed to handle

multiple antigens at once

Is Natural

Disease Better ?

• Very risky approach

• An ounce of prevention makes more sense

• Not true for many of the diseases

• Not an approach that protects children

National Vaccine Injury

Compensation Program

Established by National Childhood Vaccine Injury

Act

No fault compensation program

http://www.hrsa.gov/vaccinecompensation/

Report suspected adverse events to VAERS

Rationale for Schedule

Recommendations are based on evidence

What has been TESTED and shown to be both

SAFE and EFFECTIVE

Minimum and maximum ages

Minimum intervals

Number of doses

Varying recommendations for different products

High-risk groups and special circumstances

HIB: Invasive

Haemophilus

Influenzae disease

is bad Pneumonia, bacteremia, meningitis, epiglottitis, septic arthritis,

cellulitis, otitis media, purulent pericarditis, endocarditis,

osteomyelitis

• 3-6% of children with invasive H.flu disease die

• 20% of children who survive H.flu meningitis have permanent

neurological sequellae

• In post-vaccine era, most cases are among under-immunized

or those too young to have completed primary series http://www.cdc.gov/hi-disease/clinicians.html

Photo courtesy of Children’s Immunization Project St. Paul

HIB vaccine schedule is tricky

• Primary series between 6 wks and 6 mos

• 2 and 4 months if both PRP-OMP (PedvaxHIB

or Comvax; Merck)

• 2, 4, and 6 months if other or unknown

• Minimum interval between doses 4 weeks

• Booster dose between 12 and 15 months

• Not routinely indicated for children > 5 years

except those with leukemia, malignant

neoplasms or functional asplenia

Why Age Matters • HIB vaccine given at < 6 wks can induce immunologic

tolerance to HIB antigen

• Response to different antigens varies with age

• Especially true regarding polysaccharides in coat of H.flu

• Why youngest are most likely to succumb to invasive disease

• Why conjugated vaccines were developed to protect the most

vulnerable

• Why kids with delayed immunizations need fewer shots for

coverage

• If first dose is given at 7-11 months, give second dose 4 weeks later

and booster 8 weeks after second dose (all brands)

• If first dose is given at 12-14 months, give second (and final) dose 8

weeks later

• After 15 months, only one dose is needed

Causes of confusion

• Many different choices of vaccines

• Different antigens in different products

• Different schedules for different products

• Similar names or similar packaging

• HIB and HepB (BEWARE at 1 mo!)

• Pentacel and Pediarix

What is a Valid Dose?

Was it given after the minimum age?

Was it given after the minimum interval?

When you can’t count on effectiveness, don’t count the dose.

Measles, mumps, rubella & varicella

• Live viruses have to reproduce to stimulate

adequate immunity

• Passive immunity (Maternal antibody, blood

products, immune globulin) can interfere with

virus replication

• Viruses can interfere with each other

• Immunosuppression requires thoughtful

consideration of risks and benefits

• CDC provides recommendations based on

relative risks

Measles, mumps, rubella & varicella

• When given on or after first birthday, maternal antibody

levels are low enough to allow replication

• If given all together, all 4 viruses can replicate enough to

stimulate immunity

• If MMR and varicella are not given on the same day,

give at least 4 weeks apart

• Second dose is to immunize those who might not have

responded to the first dose

• Routinely given at 4-6 years

• Must be at least 4 weeks after first dose

Special circumstances

• For international travelers or during an outbreak:

• Give MMR to 6-11 month olds

• Dose given before 12 months doesn’t “count”: repeat

after birthday

• Give second dose if they haven’t had it already

and it is >4wks after 1st dose

• If patient has had blood products, immune globulin

or IVIG, antibody interferes with replication

• Must wait for antibody to wane; interval varies

What is a valid contraindication? (See Vaccinator Toolkit, Chapter 3)

Contraindications to MMR:

• Severe allergic reaction

(anaphylaxis) after a previous

dose or to a vaccine component

• Known severe immunodeficiency

• Pregnancy

Precautions

• Moderate or severe acute illness

• Recent receipt of antibody-

containing blood product

• History of thrombocytopenia

• Need for tuberculin skin testing

http://www.immunize.org/catg.d/p3072a.pdf

Conditions commonly

misperceived as contraindications

to MMR

• Positive tuberculin skin test

• Simultaneous tuberculin skin test

• Breastfeeding

• Pregnancy of mother or close

household contact

• Recipient is female of child-

bearing age

• Immunodeficient member of

household

• Asymptomatic or mildly

symptomatic HIV infection

• Allergy to eggs http://www.cdc.gov/vaccines/recs/vac-

admin/contraindications-misconceptions.htm

Optimizing Safety and

Effectiveness of vaccines requires

adherence to the schedule

Appropriate ages

Minimum intervals

Special circumstances

Contraindications

Precautions

Yes, it’s complicated.

Use your back-up brains!

• Post schedule where you can consult it frequently

• Remember to read the footnotes

• Use clinical decision tools from EMR or state registry

• Encourage staff to double check each other

• If you see something, say something.

• For uncommon circumstances, don’t guess. Look it up.

• Train staff to assess immunization status using posted

schedule and contraindications checklist

• Train all staff to check minimum ages and intervals

Post and regularly consult the

2013 ACIP immunization schedule

Found on page 56 of the CIzQIDS vaccinator

toolkit!

Disseminate the information

• Empower parents with up-to-date

recommendations and appropriate digital

resources

• Use posted schedule as visual aid when

talking with parents about what’s due

Give parents a written reminder of when

their child is due for the next set of shots

Bookmark the CDC’s

“Instant Childhood

Immunization

Scheduler”:

http://www2a.cdc.gov/n

ip/kidstuff/newschedule

r_le/

Avoid missed

opportunities

1. Assess and immunize at both

well child checks and sick visits

There is no evidence that minor acute illness

reduces vaccine efficacy or increases vaccine

adverse reactions

36

Avoid Missed Opportunities

2. Post and regularly

consult the “Guide to

Contraindications and

Precautions to

Commonly Used

Vaccines”

Found on page 112-113 in the

CIzQIDS Vaccinator Toolkit!

Mild illness, such as otitis media or an upper

respiratory infection, is NOT a contraindication to

vaccination

Avoid missed

opportunities

Tip for when patients come a bit early . . . Although it is not recommended to schedule

vaccinations early, vaccinations given ≤4 days

before minimum recommended interval/age

are considered valid

Except MMR and varicella must be on the

same day or at least 28 days apart

Avoid missed opportunities 3. Immunize as soon as a child presents

within the due interval/age, even if the due

interval is several

months long

39

The CDC found that by age 2,

over twice as many (20% vs.

11%) children were missing 4th

DTaP (typically given at 15-18mo)

vs. varicella or MMR (typically

given at 12 mo) CDC, National, State, and Local Area Vaccination Coverage Among

Children Aged 19-35 Months - United States, 2009. MMWR.

2010;59:1171-1177

New Mexico

recommends

immunization at

the beginning of

the

recommended

intervals

Immunizing as

soon as

possible

protects the

most vulnerable.

http://www.immu

nizenm.org/doc

uments/DBO20

12Complete.pdf

Ben Franklin

“In 1736 I lost one of my sons, a fine boy of four years old, by the smallpox taken in the common way. I long regretted bitterly and still regret that I had not given it to him by inoculation. This I mention for the sake of the parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it; my example showing that the regret may be the same either way, and that, therefore, the safer should be chosen.”

Tell the stories: Tetanus in 2012

http://www.abc.net.au/local/stori

es/2013/06/06/3776327.htm

“Auckland parents Ian and

Linda Williams thought they

had made an informed choice

not to vaccinate their children,

but after their son ended up in

intensive care with a tetanus

infection they realised they

had made a terrible mistake.”

Diphtheria, Tetanus & Pertussis

43

Diphtheria skin lesion on leg, neonatal tetanus, and conjunctival hemorrhages and bruising from coughing from pertussis

Pertussis

Immunity wanes:

• 76% of cases in

adolescents & adults

• May be mild and

undiagnosed in older

ages

• 91% of deaths < 6 mos.

of age

44

30 yrs+

20-29 yrs

10-19 yrs

5-9 yrs

0-4 yrs

3 of 4 cases of infant pertussis contracted from family member

Bisgard KM et al. Infant pertussis: who was the source? Ped Inf Dis J 2004;23(11):985-9.

DTaP Vaccine

• Routine: 4 doses • at 2, 4, 6, and 15-18 months

• Dose #1: as early as 6 weeks

• Dose #4: as early as 12 mos. if 6 months since

dose #3 and child unlikely to return at 15-18

months

Do NOT give DTaP or DT to > 7 yrs

Dose #4 on or after 4th birthday then dose #5

not needed

45

Tdap Vaccine

Routine: 1 dose Tdap at 11-12 yo then Td every 10 years

Pregnant women: 1 dose during each pregnancy

Catch up: 1 dose Tdap from 13-18 yo NEW: Catch up: By 7-10 yo, if not fully

immunized against pertussis, should receive 1 dose TdaP, NOT Td (. Then no Tdap at 11-12 yo

NEW: No minimal interval between Td & Tdap for children 7 to 18 yo

46

47

Influenza disease

200,000 hospitalizations and 36,000 deaths each flu season

Highest rates of infection: children

Highest rates of serious illness and death: > 65 yrs. and < 2 yrs, and high-risk

Complications: pneumonia, AOM, worsening of reactive airway disease

Cartoon from the 1918 flu pandemic

48

Influenza vaccine

Annually for all children 6 mo – 18 yo

Annually for all contacts of children 5

18 yo at risk of influenza complications

(asthma, congenital heart disease, etc.)

Educational poster from the 1918 flu pandemic

Influenza vaccine continued

2 types of influenza vaccines:

•TIV, Trivalent inactivated: injection for ≥6mo

• No live virus, just antigens

• Quadrivalent inactivated vaccines are being

licensed

•LAIV, Live attenuated, quadrivalent: (FluMist)

intranasal for healthy, 2-49 yo

• Cold-adapted: survives and replicates only at

T<25°C (nose/throat). Warm temp of LRT

destroys virus, so cannot cause disease

49

Common Schedule Questions

Q. Can we use Pediarix at the 2, 4 and 6 month

visit if the child had a dose of Hep B in the

newborn nursery?

A. Yes, it is okay to give the birth HepB + 3 doses of

Pediarix (4 doses of HepB total)

Common Schedule Questions

Q. My patients often miss their 15 and 18

month well visits and the recommended

vaccines. How can we make sure these

kids are up to date?

A. Consider giving the 4th DTaP at the 12

month visit (valid per ACIP if ≥ 4 months

since dose #3)

Common Schedule Questions

Q. But we already give MMR and varicella at the 12 month

visit, isn’t that too many vaccines to give at once?

A. No. The ACIP recommends simultaneous vaccination

unless contraindicated. At the 12 month visit, you could give

MMR, Varicella, HepA, DTaP, Hib, PCV and influenza (in

season).

A 2007 study of Chinese immigrants to US receiving MMR varicella, HepA,

DTaP/Td, Hib, PCV7 and influenza found no allergic reactions/serious side effects (pain at injections site and fever most common)

Hua L. Hongtao H. Shunqin W. Jinping G. Jiandong C. Zhaoliang L. Xinwen F. Simultaneous vaccination of Chinese applicants for a United States immigrant visa. Travel Med Infect Dis. 2008

May;6(3):130-6

Common Schedule Questions

Q. Sometimes when kids come in for well visits, we find

out they also have an ear infection. Isn’t being sick or

having a fever a contraindication to vaccination?

A. No. A mild acute illness, such as otitis media or a URI

is NOT a contraindication, nor is a fever < 104.8.

Common Schedule Questions

Q. Why are some kids up-to-date at 18 months

with only 3 doses of Hib?

A. If a child receives Comvax or PedvaxHib for

the first and second dose of Hib (typically given

at 2 and 4 months), then then no 6 month dose

is needed, and 3rd dose can be given at age 12-

15 months to complete the series. If only one of

the doses was Comvax or PedvaxHib, or the

brand is unknown, a 4 dose series is indicated.

Questions and Comments

Smiling is a contagious condition!