Basics
Description
- Immunization enhances or initiates resistance to infectious diseases.
- Protection from immunization occurs through several mechanisms:
- Passive immunization: Administration of purified antibodies or passive transfer of maternal antibodies through the placenta/breast milk.
- Active immunization: Stimulates immune system, producing IgM antibodies after 7-10 days followed by IgG antibodies, peaking between 2 and 6 wk.
- Oral and nasal vaccines induce mucosal secretory IgA antibodies while parenteral vaccines may not. Improper administration (route, dose, bad storage, etc.) may result in decreased immunity.
Etiology
- Several types of vaccines are available:
- Live attenuated (weakened) viruses (e.g., varicella [VZV]; measles, mumps, rubella [MMR]; rotavirus) replicate in the host and induce an immune response:
- May cause serious infections in the immunocompromised.
- Inactivated (or killed) vaccines (e.g., polio [IPV], hepatitis A [HepA], some influenza, pertussis) are safe in patients with compromised immune system.
- Toxoid, subunit, or conjugate vaccines (e.g., diphtheria, tetanus, Haemophilus influenzae b [Hib], Human papilloma virus [HPV], Pneumococcus, Meningococcus) use antigenic portions of toxins, proteins, or carbohydrates from viruses or bacteria to induce immune response
- Hepatitis B (HepB) vaccine uses recombinant DNA technology
- Several combination vaccines are also available but have an increased cost:
- Pediarix (diphtheria and tetanus toxoids and acellular pertussis adsorbed [DTaP], HepB, and inactivated poliovirus vaccine [IPV] combined)
- Comvax (HepB and Hib).
- Pentacel (DTaP, IPV, and Hib).
- Twinrix (HepA and HepB).
- MMRV (MMR and varicella).
Epidemiology
- The incidence of several life-threatening illnesses has been markedly reduced with widespread immunization use:
- Polio caused by wild-type viruses has been eliminated from the Western Hemisphere.
- Hib, diphtheria, and tetanus vaccines have nearly eliminated these invasive diseases among children in North America.
- The incidence of measles, rubella, and varicella has also declined; sporadic in unimmunized communities and foreign travelers to US.
- 7-valent and 13-valent conjugate pneumococcal vaccines (Prevnar 7 and Prevnar 13) have reduced invasive disease from 100-21 cases/100,000 for all types of pneumococcal infection and from 80-0.2/100,000 for vaccine serotypes (99% reduction).
- Rotavirus is a live oral vaccine
- Respiratory syncytial virus immune globulin given to high-risk patients
- Global surveillance of influenza activity allows for annual production of vaccines against seasonal influenza. Inactivated vaccines are available for IM administration and live attenuated virus vaccines can be given via the nasal route.
- Immunization recommendations and schedules are based on epidemiology, individual risks for disease and exposure, as well as vaccine safety and efficacy:
- Infants and young children are vaccinated against common childhood diseases, but some vaccines are not immunogenic (e.g., pneumococcal capsular polysaccharide antigen vaccine) or may be dangerous (e.g., MMR, VZV) in infants.
- Pregnant women are recommended to receive Tdap and inactivated influenza, but should not receive other live virus vaccines.
- Specific recommendations exist for other at-risk groups including international travelers, the elderly, health care workers, and immunocom-promised individuals.
Diagnosis
Signs and Symptoms
- Concern for vaccine-associated adverse events: The most common events associated with vaccination are mild and include local reactions (pain, swelling, erythema) and/or fever (usually within 7-10 days):
- Local reactions can occur with almost any injected vaccine, but are particularly common with tetanus, diphtheria, and pertussis (particularly after repeat doses), Hib (can cause sterile abscesses in young infants), VZV, HPV, and pneumococcus.
- Fever may follow immunization with rotavirus (40-43%), conjugate pneumococcus (24-35%), HPV (10-13%), MMR or MMRV (more common in the latter), and meningococcal vaccine. Influenza vaccine may cause fever 6-24 hr after administration.
- Rash may be seen as a rare side effect of VZV and MMRV, MMR may cause transient rash or fever 6-12 days after immunization.
- Neurologic symptoms are rare but most commonly seen after DTP vaccines (fussiness, inconsolable crying, drowsiness, brief seizures without fever, hypotonic-hyporesponsive episodes, encephalopathy, and Guillain-Barr © syndrome). Headache may follow vaccination with HepB or meningococcus; and MMR and MMRV are associated with febrile seizures in children and rare reports of encephalopathy. Guillain-Barr © has also been linked to influenza vaccine in adults.
- Vomiting and diarrhea are rare adverse effects of rotavirus vaccine in infants.
- MMR has been associated with arthralgias in adult women, and rare hematologic adverse events such as thrombocytopenia.
- Live attenuated influenza (nasal) has been associated with mild respiratory symptoms in adults and asthma exacerbations in children with a history of asthma.
Essential Workup
- ED visits for any reason present an opportunity to review immunization status and provide appropriate follow-up. Take a history of status of immunizations:
- If incomplete, take a good history as to the reason why immunizations have not been administered.
- True contraindications to vaccination:
- Anaphylactic reaction to a previous dose of the vaccine or:
- Anaphylaxis to bakers yeast is a contraindication to HepB vaccine.
- Anaphylaxis to chicken or egg protein is a contraindication to influenza vaccine (but not MMR).
- Anaphylaxis to neomycin or gelatin is a contraindication to MMR vaccine.
- Anaphylaxis to neomycin, streptomycin, or polymyxin is a contraindication to IPV vaccine.
- Specific reactions within 48 hr of vaccine of a previous vaccine:
- Severe, inconsolable screaming for 3 hr
- Distinctive high-pitched cry
- Hyporesponsive episode
- Temperature >40.5 °C unexplained by other cause
- Severe local reaction involving the circumference of the injected limb unless owing to inadvertent SC injection
- Encephalopathy within 7 days of vaccine:
- Severe acute neurologic illness with prolonged seizures and/or unconsciousness and/or focal signs
- Progressive neurologic disease excluding epilepsy
- Reasons to defer vaccine administration:
- Moderate or severe acute disease regardless of fever.
- Congenital or acquired immunodeficiency (e.g., HIV, malignancy/chemotherapy associated): Possible risk from live attenuated vaccines such as VZV, MMR, and influenza. Caution should be used when considering these vaccines for healthy individuals in close contact with the immunocompromised.
- Pregnancy is a contraindication to live attenuated virus vaccines including VZV and HPV; inactivated virus (influenza) and conjugate vaccines (DTaP) are thought to be safe.
- Recent convulsion is a relative contraindication to pertussis.
- Recent administration of immune globulin may lessen the efficacy of vaccinations
- Vaccines may be given with the following:
- Mild acute illness with or without fever
- Mild to moderate local reaction (i.e., swelling, redness, soreness), low-grade or moderate fever after previous dose
- Current antimicrobial therapy
- Convalescent phase of illness
- Premature birth (HepB vaccine is an exception)
- Recent exposure to an infectious disease
- History of penicillin allergy, other nonvaccine allergies, relative with allergies, receiving allergen extract immunotherapy
- HIV-infected children who are either asymptomatic or not severely immunocompromised should be vaccinated.
Treatment
Pre-Hospital
Attention should be focused on the airway, breathing, and circulation.
Initial Stabilization/Therapy
Initial medications for anaphylactic reaction to vaccines include IM or IV epinephrine, diphenhydramine, albuterol for wheezing, and IV fluids for hypotension.
Ed Treatment/Procedures
- Treat anaphylaxis with epinephrine, antihistamines, albuterol and IV fluids as indicated.
- Treatment of potential exposure to infectious disease or contaminated wounds follows specific guidelines for active or passive immunization.
- Treatment of adverse reactions depend on symptoms:
- Local reactions at the injection site can be treated with cold compresses, analgesics, or antipruritics. Control bleeding with a pressure dressing.
- Treat fever, headaches, myalgias, and arthralgias with acetaminophen or ibuprofen.
- Treat ongoing seizures with benzodiazepines
- Consider prophylaxis with acetaminophen at the time of injection of vaccines and again 4-8 hr later:
- Children who receive varicella vaccine should avoid salicylates for 6 wk post vaccination because of the association of varicella infection and salicylates to Reye syndrome.
- Specific discussion with the parents is required to review the risks and benefits of tetanus vaccination, particularly given the frequent occurrence of trauma and the need to provide both passive and active immunity at that time:
- Document in the chart that the risks and benefits have been thoroughly discussed. A formal informed consent is used in some settings.
- The National Childhood Vaccine Injury Act requires that a copy of the Vaccine Information Statements be provided before administering each dose of the vaccine.
Medication
- Acetaminophen 15 mg/kg/dose q4-6h PO
- Ibuprofen 10 mg/kg/dose q6-8h PO
Follow-Up
Disposition
Admission Criteria
- Patients with serious adverse reactions following immunization should be admitted.
- Patients with anaphylaxis and encephalopathy may require admission to a pediatric ICU.
- Unexpected adverse events should be reported to the Vaccine Adverse Event Reporting System.
Discharge Criteria
Patients may be discharged home after routine immunizations unless an immediate adverse reaction occurs. It is essential that follow-up with the primary care physician be arranged to complete immunizations.
Pearls and Pitfalls
- Failure to continue diphenhydramine for 48 hr following an allergic reaction. Steroids may also be considered.
- Failure to recognize egg allergy as a contraindication to influenza vaccine.
Additional Reading
- Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention. Recommended Guidelines. Available at: http://www.cdc.gov/vaccines/recs/acip/
- American Academy of Pediatrics: Report of the Committee on Infectious Diseases. 29th ed. Elk Grove, CA: ILL; 2012.
- CDC Travelers Health: Vaccinations. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. Available at: wwwnc.cdc.gov/travel/
- Cohn AC, Mac Neil JR, Clark TA, et al. Prevention and control of meningococcal disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013;62(2):1-28.
- National Immunization Hotline. Phone 800-232-2522.
- Park SY, Van Beneden CA, Pilishvili T, et al. Invasive pneumococcal infections among vaccinated children in the United States. J Pediatr. 2010;156(3):478-483.
- Payne DC, Boom JA, Staat MA, et al. Effectiveness of pentavalent and monovalent rotavirus vaccines in concurrent use among US children <5 years of age, 2009-2011. Clin Infect Dis. 2013;57(1):13-20.
- Swamy GK, Garcia-Putnam R. Vaccine-preventable diseases in pregnancy. Am J Perinatol. 2013;30(2):89-97.
See Also (Topic, Algorithm, Electronic Media Element)
- Anaphylaxis
- Encephalitis
- Hepatitis
- Influenza
- Measles
- Mumps
- Pertussis
- Polio
- Rabies
- Rubella
- Seizure, Adult
- Seizure, Pediatric
- Tetanus
- Varicella
Codes
ICD9
- V07.2 Need for prophylactic immunotherapy
- V15.83 Personal history of underimmunization status
ICD10
- Z23 Encounter for immunization
- Z28.3 Underimmunization status
SNOMED
- 127785005 Administration of substance to produce immunity either active or passive (procedure)
- 51116004 Passive immunization (procedure)
- 33879002 administration of vaccine to produce active immunity (procedure)