Vaccines

For decades, our country's health care system and its government have struggled with the challenge of providing immunization coverage for all children. Starting with the Section 317 legislation of 1962, numerous policy initiatives have been passed in an effort to ensure that sufficient supplies of vaccines are available, that the cost of vaccines for low–income children is covered-and that these vaccines are actually administered to the children that need them.

The expansion of the immunization schedule for 2009 has resulted in several success stories. Two rotavirus vaccines are now available. Following the introduction of immunization against rotavirus, a sharp decline in cases of rotavirus gastroenteritis was seen.

Children with asthma who had received influenza vaccination had fewer asthma exacerbations, according to a recent study conducted in the pediatric clinics of Brooke Army Medical Center, Fort Sam Houston and Wilford Hall Medical Center, Lackland Air Force Base in Texas.

A 17-month-old girl awoke with drooling, cough, respiratory distress, and a muffled cry and was brought to the emergency department. She had no nausea, vomiting, or diarrhea and no history of choking, aspiration, or airway problems.

Vaccines are perhaps the single most important contribution the 20th century made to civilization. They have been responsible for saving untold numbers of lives and for vastly improving the quality of many more. Although vaccines have had some bad press of late, they are still strongly recommended by the medical community. However, financial issues, difficulties with managed care organizations (MCOs) and other parts of our health care system, and problems with the manufacture and delivery of vaccines prevent optimal use of this crucial preventive service. Here I discuss the problems associated with vaccine delivery and administration and suggest several practical solutions.

Vaccines may represent the greatest advance in children’s health of the past 50 years, but they also, sadly, can frequently be a source of stress for today’s pediatricians. There is the issue of potential difficulty in recouping the cost of the vaccines from managed care organizations.

According to one Web site, pediatric health care providers should be arrested and prosecuted because of their involvement in the “chemical holocaust” of children.1 This chemical holocaust refers to vaccination- one of the greatest public health successes in the history of modern medicine.

Parents are understandably concerned about vaccines and autism, a relationship publicized by lawsuits, alternative therapies, and claims of government cover-up.

The approval of Gardasil (Merck)-a recombinant vaccine providing protection against human papillomavirus (HPV)-in 2006 sparked instant controversy.1,2 Because HPV infection is a sexually transmitted disease, the use of a vaccine for such a disease brought the following political, medical, and moral questions to the forefront:

Pertussis has long been known to cause severedisease and death in infants, especially in thosewho are unvaccinated or who are too young tobe immunized. With the number of pertussiscases in the United States increasing,1 those ofus who care for susceptible infants are looking for solutionsto this dangerous problem.

A 23-month-old girl presented with an erythematous papular rash on her torso that extended in a linear pattern around to the back. The mother first noticed the rash while bathing the child 3 days earlier. The child had no associated itching, irritability, or fever, but she had mild rhinorrhea preceding the rash that resolved without treatment. The patient and her older sibling were cared for at home by their mother.

By the pre-middle school visit, the child should have already received 3 or 4 doses of IPV (only 3 are required if the last dose was given after the age of 4 years); 3 doses of hepatitis B vaccine; 2 doses of MMR vaccine; 2 doses of varicella vaccine; and 2 doses of hepatitis A vaccine.

ABSTRACT: The pre-middle school well child visit is now an important landmark on the vaccine schedule. The pre-kindergarten visit no longer has the distinction of being the last of the visits for "school shots." Pediatricians should emphasize this point at the 4- to 6-year-old well child visit so that parents are aware of the need for another series of vaccines in about 5 years.

Widespread vaccination has led many parents to underappreciate the severity of vaccine-preventable diseases. Many new parents have never seen anyone with such infections as diphtheria, mumps, or measles--or their potential clinical consequences. Some parents wonder why their child needs to be vaccinated against seemingly nonexistent diseases and worry about vaccine safety. The images on the following pages and on page S18 serve as a small dose of reality for those who may have been lulled into a false sense of security.

A 5-year-old boy with seizure disorder and developmental delay presented to our allergy and immunology clinic for a severe reaction that developed after he had received multiple vaccines. One month before our evaluation, the patient had been vaccinated against varicella, hepatitis A, and influenza at his pediatrician's office. Latex gloves were not used for vaccine administration.

As a clinical immunologist with a special interest in vaccines, it is a pleasure to present this special issue of Consultant For Pediatricians. Vaccines are among the major achievements of modern medicine. Once common serious childhood illnesses, including tetanus, diphtheria, polio, mumps, and measles, are now rarely seen in this country. It is ironic, therefore, that with the precipitous decline in the incidence of many infectious diseases brought about by widespread vaccination--and the very recent availability of several new vaccines--many parents have been lulled into a false sense of security about the risk posed by the diseases these vaccines have been designed to prevent.

With the introduction of Gardasil--the vaccine that protects against infection with human papillomavirus (HPV) types 6, 11, 16, and 18--pediatricians are fielding an increasing number of questions from parents about this disease. Parents want to know how prevalent HPV infection actually is and how much of an impact the vaccine will have.

Consultations & Comments: "Focus on Vaccines" Correction: MMR Never Contained Thimerosal

ABSTRACT: Because the clinical diagnosis of influenza can be difficult, pediatricians often turn to rapid antigen tests to confirm a clinical suspicion of influenza. However, keep in mind that the predictive values of such tests vary with disease prevalence; despite the favorable sensitivity and specificity of most such tests, their positive predictive value is relatively low early and late in the influenza season. In addition, to gauge the predictive accuracy of a test in a particular setting, consider the degree of clinical suspicion as well as the frequency of influenza in the community at that time. Rapid influenza tests are most often helpful when the likelihood of influenza is intermediate (ie, in the early phase of influenza season when there is very strong clinical suspicion or during the peak of the season when there is moderate clinical suspicion).

The July 2006 issue, which featured an update on STDs, included a case on primary syphilis in a teenager (page 427). Therapy with intramuscular penicillin G (weekly for 3 weeks) or ceftriaxone (daily for 2 weeks) was recommended. However, the CDC's newly published guidelines on STD treatment recommend therapy with a single intramuscular dose of 2.4 million units of penicillin G.1 If the patient is allergic to penicillin, the alternative is therapy with doxycycline (100 mg orally bid for 14 days) or tetracycline (500 mg qid for 14 days). Ceftriaxone is not a recommended treatment for syphilis.

Staphylococcal pneumonia can be a rapidly progressive illness that is commonly associated with pneumothorax and pleural effusion. Affected patients require close monitoring. Consider staphylococcal infection in any infant with pneumonia whose health deteriorates clinically or radiographically.

Your doctor has just told you that you have an infection with human papillomavirus (HPV). Most teens have a lot of questions about warts and HPV. This guide will help answer some of those questions.

The patient, a 14-year-old boy, comes to see you the same day he was bitten by a dog. In the examination room, you find him seated comfortably in the chair with his right hand and arm bandaged.

Key words: type 2 diabetes melllitus, childhood obesity

Pediatricians around the countryare being bombardedwith questions about avianflu. This brief review of thecurrent status of the avian fluoutbreak and its treatment and preventionprovides the informationyou will need to answer the mostpressing patient questions.

This 12-month-old girl presented with a diffuse rash that was first noticed by the child's day-care provider a day earlier. A fever (temperature of 39.4°C [103°F]) subsequently developed.

In the Photoclinic item titled "Vaccine-Induced Herpes Zoster," by Julie L. Cantatore-Francis, MD, and Yelva Lynfield, MD (Consultant For Pediatricians, June 2005, pages 290 and 291), the dosage of acyclovir was incorrectly printed as 80 mg/d divided into 4 doses. The correct dosage is 80 mg/kg/d divided into 4 doses. We apologize for the error.

An otherwise healthy 22-month-old was referred for evaluation of a pruritic rash on her buttocks and right leg of 5 days' duration. Her mother reported that the rash had begun as red bumps and blisters on the buttocks that subsequently spread to the right leg.

With the significant decline in disease caused by Haemophilus influenzae type b and Streptococcus pneumoniae achieved through vaccination, Neisseria meningitidis has moved to the forefront. Its emergence as the most important cause of bacterial meningitis challenges the pediatrician to prevent and control this terrible disease. Meningococcal disease can be easily misdiagnosed. It may present with different clinical manifestations, and its signs and symptoms may mimic those of common viral illnesses, such as influenza. The onset and progression of meningococcal disease are rapid. Although the rate of disease is highest in infants, morbidity and mortality rates for this disease are highest in adolescents and young adults, despite the existence of effective therapies.1