Chapter 17: VACCINES, IMMUNIZATIONS AND CONTRAINDICATIONS

PEARLY NOTES: Since the pediatric vaccination recommendations tend to change frequently, it’s difficult for the American Board of Pediatrics (ABP) to include board questions on the most current guidelines. Your focus in studying this section should be the information that is not going to be controversial or rapidly changing (like schedules!). Also, be sure to keep a strong focus on when vaccinations should NOT be given. Lastly, some information overlaps between the Infectious Diseases chapter and this chapter. Make sure you go through them in order.

PERTINENT CDC LINKS

These links are here for your reference in case you get stuck and have questions. You do NOT need to go through them to pass the exam. If going through them will overwhelm you, don’t. Some links in particular are more daunting than others.

• IMMUNIZATION/VACCINATION SCHEDULE (0–18 YEARS OF AGE)
  • (GOOD) www.pbrlinks.com/CDC1
  • (OVERWHELMING) www.pbrlinks.com/CDC2
• IMMUNIZATION/VACCINATION CATCH-UP SCHEDULE (0–18 YEARS): www.pbrlinks.com/CDC3
• REGULAR AND CATCH-UP SCHEDULE IN ONE PDF: www.pbrlinks.com/CDC4
• COMPLETE CDC RECOMMENDATION ON VACCINES (OVERWHELMING): www.pbrlinks.com/CDC5
• CONTRAINDICATIONS TO VACCINES (GOOD): www.pbrlinks.com/CDC6

STEROIDS AND IMMUNIZATIONS

In general, the types of steroid regimens commonly prescribed are not a contraindication to immunizations. If a course of steroids is given for less than 14 days, then REGARDLESS OF THE DOSE given, ANY vacci­na­tion is allowed (including all live vaccines). If > 20 mg/day, or > 2 mg/kg/day of prednisone is prescribed for > 14 days, then live vaccines should be held for one month after the course is over.

MNEMONIC: If > 20 mg/day or > 2 mg/kg/day is given for > 2 weeks, then HOLD the live vaccines for at least 1 month after the steroids have been stopped. For anything else, go ahead and give.

PREMATURITY AND VACCINATIONS

Except for Hepatitis B and Rotavirus, vaccinations in premature babies are very similar to full-term babies. For Hepatitis B, if born to a Hepatitis B negative mom, the baby’s first Hepatitis B vaccination can be delayed until 1 month of age or until hospital discharge. For the Rotavirus vaccine, since it is shed in the stool and is a risk to others it cannot be given while a preemie is in the hospital. Regarding safely administering the rest of the immunizations, a premature baby may receive ALL scheduled vaccinations at 2 months of chronological age whether the baby is in the hospital or out of the hospital.

LIVE VACCINES

The live vaccines have traditionally been Measles, Rubella, “Sabin” (AKA oral polio, OPV), Varicella/VZV, Adenovirus (for military only), Mumps, and Yellow Fever. Oral polio is not used in the U.S., so you’re unlikely to be tested on it. The newer live vaccines are the inhaled influenza virus vaccine and the rotavirus vaccine. So, the list includes MMR, OPV, VZV, Adenovirus, Yellow Fever, inhaled Influenza, and Rotavirus. Two different live vaccines can be given on the same day, but if they are being given on different days, then there should be a 4-week interval between vaccinations.

PEARL: For the purposes of the exam, do not give any of these vaccines to a pregnant teen (see below) or someone who is severely immunocompromised. This includes patients with HIV and a low CD4 count (< 200 cells/mL), as well as many of those patients with disorders reviewed in the Allergy & Immunology chapter.

PEARL: If an HIV patient is generally healthy, do NOT hold back any vaccines.

PEARL: For high dose steroid (> 20 mg/day) or chronic steroid use (> 14 days use) wait 1 month after stopping glucocorticoid therapy to give live virus vaccines (MMR or Varicella.

MNEMONIC: MR. SPAMY is ALIVE! This mnemonic includes the older live vaccines, including Measles, Rubella, Sabin (Polio if oral OPV), Pox viruses (Varicella/VZV), Adenovirus (for military only), Mumps, and Yellow Fever. This does not include the intranasal influenza (virus) vaccine or the rotavirus vaccine! Also, VZV is actually a herpes virus and not a pox virus.

MNEMONIC: MR. FARM-SPY is ALIVE includes all of the live vaccines. Creating a story around one or both of these mnemonics will help even more.

MNEMONIC: Here’s a mnemonic that covers some (not all) of the DEAD vaccinations. “RIP, Hepatitis A & B!” = Rest In Peace Hepatitis A & B = Rabies, Influenza, Polio (IPV), Hepatitis A, and Hepatitis B.