F.A.S.N. annual conference 2009 Alix Casler, M.D., F.A.A.P. Orlando, FL

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1 F.A.S.N. annual conference 2009 Alix Casler, M.D., F.A.A.P. Orlando, FL

2 Immunization Update for School Nurses Overview of Vaccine Preventable Diseases FL Vaccine Requirements Medical Guidelines vs State School Requirements Where they differ Newer vaccines Clarification of Specific FL Guidelines What s News in Vaccine Preventable Disease

3 Vaccine Preventable Diseases DTaP Diphtheria: a bacterial illness with sore throat, fever, a membrane of pus in the throat, and neurologic and cardiac complications. Only 5 cases in the U.S. in There were 100, ,000 cases per year in the U.S. prior to immunization. (1925 serum run to Nome, AK) Tetanus: a condition caused by a bacterial toxin which paralyzes skeletal muscle in the tensed position. About 100 cases per year and 5 deaths per year in the U.S., almost all in unimmunized or those whose vaccine has lapsed. Pertussis (whooping cough): A bacterial respiratory infection causing prolonged cough. Highly contagious. Up to 3 million cases per year in the US with a 2% death rate and up to 50% compication rate in infected infants.

4 Clinical Presentation of Infant With Pertussis Video courtesy of the CDC.

5 Vaccine Preventable Diseases IPV Polio: A viral illness which can cause flaccid paralysis in about 1% of cases. The Americas were declared polio free as of As of 2006, the only areas where polio is still endemic are Nigeria, India, Pakistan, and Afghanistan. HIB Haemophilus Influenzae Type B: An invasive bacterium which can cause epiglotitis, meningitis, bone and joint infections, particularly in children under the age of 5 and those with immune problems. Hepatitis B: A blood and body fluid borne virus which can cause acute or chronic hepatitis and liver cancer.

6 Epiglottitis

7 Vaccine Preventable Diseases MMR Measles: A highly contagious (90% within a household) viral respiratory illness that causes the classic triad of cough, coryza, and conjunctivitis along with high fever and rash. Death rate of 3 per thousand in otherwise healthy people. U.S. cases are associated with imported disease and involve unimmunized hosts in most cases. Mumps: Another self limited viral illness that causes parotitis, rash and orchitis and may lead to sterility in pubertal males and other rare complications. Prior to the vaccine, mumps was the most common form of meningoencephalitis in the U.S. Rubella (German Measles): A minor respiratory viral illness with rash and low grade fever and often passes unnoticed. If contracted by a pregnant woman can cause severe fetal damage.

8 Measles

9 Mumps

10 Congenital Rubella Syndrome

11 Vaccine Preventable Diseases Varicella (chicken pox): A viral infection spread by respiratory route which causes a characteristic itchy rash. Prior to institution of vaccination there were about 100 deaths per year from complications of varicella such as pneumonia and skin infection. Huge socioeconomic burden in the U.S. Reactivation of varicella is shingles or zoster. Prevnar Pneumococcus: A Strep bacterium which can cause ear and sinus infections, pneumonia, meningitis, sepsis, bone and joint infections. Particularly infectious in children under 5 years of age and those with certain immune problems.

12 Vaccine Preventable Diseases: (Recommended but not required vaccines) Rotavirus: a viral illness spread by the fecal oral route which causes prolonged diarrhea with or without initial vomiting. A major cause of dehydration and hospitalization in the U.S. prior to immunization and a major infectious cause of death in children in the third world. Menactra: Meningococcus: A bacterium which causes very rapidly progressive meningitis and sepsis in all age groups, particularly the very young, the very old, and teens/young adults. 25% case fatality rate and 50% long term morbidity rate in teens and young adults. HPV: A very common sexually transmitted viral illness responsible for cervical dysplasia, cervical cancer, penile cancer, venereal warts, and newborn and childhood upper airway lesions. Hepatitis A: A common viral acute, self limited gastroenteritis with occasional incidence of acute hepatitis requiring hospitalization.

13 Meningococcemia Severe Late-Stage Meningococcal Infection in a 15-Year Year-Old Boy Reprinted with permission from Schoeller T, Schmutzhard E. N Engl J Med. 2001;34:1372.

14 Florida Vaccine Requirements Public/Non Public Schools K 12 (children entering, attending, or transferring to FL schools) Four or five doses of diphtheria, tetanus, and pertussis vaccine Three or four doses of polio vaccine Two doses of measles, mumps, and rubella vaccine Two or three doses of hepatitis B vaccine One dose of varicella vaccine (kindergarten effective school year 2001/2002, then each year an additional grade) Two doses of varicella vaccine (kindergarten effective school year 2008/2009, then each year an additional grade) IMMUNIZATION GUIDELINES Effective July 2008 Rule 64D 3.046, Florida Administrative Code

15 Florida Vaccine Requirements Public/Non Public Pre K3 (age appropriate doses) Diphtheria, tetanus, and pertussis vaccine Polio vaccine Measles vaccine Mumps vaccine Rubella vaccine Hepatitis B vaccine Varicella vaccine (effective school year 2001/2002) Haemophilus influenzae type b (Hib) vaccine IMMUNIZATION GUIDELINES Effective July 2008 Rule 64D 3.046, Florida Administrative Code

16 Florida Vaccine Requirements Public/Non Public Schools Seventh Grade: Effective with the 2009/2010 school year, in addition to all other compulsory school immunizations, children entering, attending, or transferring to the seventh grade in Florida schools are required to complete the following: One dose of tetanus diphtheria pertussis vaccine (Tdap) IMMUNIZATION GUIDELINES Effective July 2008 Rule 64D 3.046, Florida Administrative Code

17 Florida Vaccine Requirements Licensed childcare facilities and family daycare homes: Children entering or attending licensed childcare facilities and family daycare homes shall have received as many of the following ageappropriate immunizations as are medically indicated in accordance with the current Recommended Childhood Immunization Schedule: Diphtheria, tetanus, and pertussis vaccine Polio vaccine Measles vaccine Mumps vaccine Rubella vaccine Varicella vaccine (Effective July 1, 2001) Haemophilus influenzae type b (Hib) vaccine Pneumococcal Conjugate vaccine (Effective January 1, 2008 for children 2 to 24 months of age) IMMUNIZATION GUIDELINES Effective July 2008 Rule 64D 3.046, Florida Administrative Code

18 Clarification of Confusing Guidelines Temporary Exemptions (treat all exemptions with caution) Religious Exemptions Permanent Exemptions Specific Clarifications: DTaP How many doses depends on age at administration HIB How many doses depends on age at administration and type given Polio How many doses also depends on age doses were given very confusing. MMR Two doses at least one month apart, with final dose on or after the 4 th birthday HBV Three dose series for those under age 11 with minimum intervals Two dose adolescent series also with minimum interval Varicella Two dose recommendation as of children having entered Kg in school year

19 2008 US Recommended Immunization Schedule for Children 0 6 Years of Age 1 Range of recommended ages Certain high risk groups Vaccine Hepatitis B Rotavirus Diphtheria, Tetanus, Pertussis Age Birth HepB 1 month HepB 2 months Rota DTaP 4 months Rota DTaP 6 months HepB Rota DTaP 12 months 15 months DTaP 18 months months 2-3 years 4-6 years DTaP Haemophilus influenzae type b Hib Hib Hib Hib Pneumococcal PCV PCV PCV PCV PPV Inactivated Poliovirus IPV IPV IPV IPV Influenza Influenza (Yearly) Measles, Mumps, Rubella MMR MMR Varicella Varicella Varicella Hepatitis A Meningococcal HepA (2 doses) HepA Series MCV4 Reference: 1. CDC. MMWR. 2008;57(1):Q1 Q4. Additional information is available at

20 2008 US Recommended Immunization Schedule for Children 7 18 Years of Age 1 1. CDC, MMWR, January 2, 2009 / 57(51);Q 1 Q 4

21 Where Medical Guidelines and FL Requirements Differ and Why??? Medical Practice: These guidelines are intended to serve the purposes outlined in Section I.A. of this document and are not intended to supplant relevant immunization medical practice as set forth by the referenced authorities cited below. The manner and frequency of administration of immunizations shall conform to recognized standards of medical practice in accordance with U.S. Department of Health and Human Services, Public Health Service s Recommendations of the Advisory Committee on Immunization Practices (ACIP), and the latest Report of the Committee of Infectious Diseases of the American Academy of Pediatrics (Red Book). IMMUNIZATION GUIDELINES Effective July 2008 Rule 64D 3.046, Florida Administrative Code

22 Where Medical Guidelines and FL Requirements Differ and Why??? Rotavirus Hepatitis A Menactra HPV Other variations

23 Vaccine News, Feb 2009 Gardasil stir The Texas fiasco National Conference of State Legislatures, Nov 18, 2008 VAERS Implications regarding sexuality HIB vaccine shortage Merck product unavailable Resulting guidelines HIB disease outbreak in Minnesota CDC, MMWR, January 23, 2009 / 58 (Early Release);1 3

24 Vaccine News, Feb 2009 Measles disease in the U.S. January 1 April 25, 2008, a total of 64 confirmed measles cases were preliminarily reported to CDC 54 were associated with importation of disease 63 were unvaccinated or had unknown status CDC, MMWR, May 1, 2008 / 57 (Early Release);1 4 Mumps outbreak in the U.S cases reported in 2006 in Midwest states NEJM, Volume 358: April 10, 2008 Number 15

25 References For general information on infectious diseases prevented by immunization I strongly recommend the CDC website at I also like Wikipedia. Their summaries are quite nice and very understandable For U.S. National Guidelines: For Florida Statutes: For vaccine information I recommend the following sites:

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