Running head: NSG 6435 CASE STUDIES 1

Case Studies for Pediatric Vaccinations

NSG 6435-Practicum III-Family Health -Pediatrics

Hephzibah Tranquilan

South University, Tampa Campus

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Case 1:

You are rotating in the newborn nursery. Your next admission is a term newborn born at
3.5 kg, and all maternal labs are negative.

The infant's exam is normal. What vaccine(s) should she get? What information could
change your standard recommendation and how would it change?

The hepatitis B (Hep B) vaccine is recommended for all newborn infants and should be
given within 24 hours of birth, even when you anticipate that they will receive
combination vaccines in the future that would result in more than 3 total doses of the Hep
B vaccine. The CDC believes it is important to provide protection from birth for all
infants who have potential for in-utero exposure to hepatitis B, which are potentially all
infants.

If the mother is Hep B positive, the baby should receive Hep B #1 and hepatitis B
immune globulin (HBIG) within 12 hours of delivery. Infants born to mothers who are
Hep B surface antigen (HBsAg) positive should be tested for the HBsAg between 9 and
19 months of age (generally the visit after they complete their series, but not before 9
months of age to make sure the test does not reflect effects of HBIG given at birth).

If the mother's hepatitis B status is unknown, Hep B #1 is to be given within 12 hours of

delivery. The next step is to test the mother's Hep B status. If she is negative, there is no
need for further treatment at this point. If you are unable to confirm that she is Hep B
negative, the baby should be given HBIG within one week of delivery. The effectiveness
of the HBIG is greatest when given as soon as possible after exposure. HBIG has little
effect after 7 days.

Case 2:

1.What vaccines does she get? What combinations are available at your clinic?
Hep B #2, Oral rotavirus #1, DTaP #1, Hib #1, PCV13 #1, IPV #1

The CDC recommends giving combination vaccines when possible to minimize the number of
needle sticks that the child will receive. The recommendations are to continue with the same
combination when possible, but also not to delay vaccination if the same combination is not
immediately available. Essentially this means to give them whatever combination you have in
clinic. Always check with nursing staff on availability before promising parents this limited
number of actual shots.
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Of note, there are two rotavirus (RV) vaccines. RV5 is a three-dose oral vaccine series given at
2, 4, and 6 months of age. RV1 is a two-dose series, given at 2 months and 4 months of age. The
baby must be at least 6 weeks old before getting the first dose of RV, and the series cannot be
started after 14 weeks and 6 days of age. The final dose must be given before the baby is 8
months old.

2.What if she were here early at 5 weeks and 5 days for her 2-month visit?

She will need to come back for all vaccines. Six weeks is the earliest you can start the primary
series. It is fine (and encouraged) to schedule this as a nurse visit in a week if you have
completed the rest of their routine care at this visit.

3.What if she presented at 4 months for her 2-month visit? What is different about the
vaccines she can receive?

She cannot receive her rotavirus vaccine. Rotavirus vaccine is a live attenuated virus to protect
against rotavirus diarrhea. It has a very specific window in which it can be given. Outside this
window, safety and efficacy have not been confirmed, and the vaccine should not be given.

This child comes back at 12 months after completing her primary series of vaccines at 2, 4,
and 6 months of age. She received the same vaccines at each visit and was right on
schedule. Parents have no concerns, she is developing normally, and her exam is normal.

4. What vaccines can she get today?

MMR #1 (must be at least 12 months), Varicella #1 (must be at least 12 months), PCV 13 #4,
Hep A #1, Flu vaccine (for any child older than 6 months)

5. Which vaccines should she get at the 15-month visit?

DTaP #4, Hib #4

For both MMR and Varicella, which are live attenuated vaccines, fever and mild flu-like
symptoms can be seen up to 10 days post vaccination. There can be viral shedding with these
vaccines, and the Varicella vaccine can even produce red spots or small vesicles in the skin
adjacent to where the vaccine is given. There is an increased risk of febrile seizure with any
measles-containing vaccine.2 Children who are immunosuppressed should not be given either of
these vaccines. Children who are HIV infected but have functionally normal CD4 counts should
be vaccinated (see the American Academy of Pediatrics Red Book3 for specific guidelines for
children who are infected with HIV).
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There is a small increased risk of febrile seizure when the MMR and varicella vaccines are given
as a combination vaccine at 12 months.4 Based on this risk, the Advisory Committee on
Immunization Practices (ACIP) favors separate dosing for the first dose. However, for the
booster dose at 4 years, they recommend the combination (as they do with all other
combinations) if it is available since there is no increased risk at that age.4,5

The first year that a child receives the flu vaccine, they should receive 2 doses spaced 4 weeks
apart. After the first year, they can get one dose per year. Note: The live attenuated influenza
vaccine (LAIV) will be available for the 2019-20 flu season and can be given to children older
than 24 months.

DTaP #4 and Hib #4 may be given as early as 12 months of age; it just needs to be at least 6
months between the third and fourth doses of these vaccines. These two vaccines come in a
combination vaccine for the 15-month visit, so they are preferentially given together. In truth, the
order of how you split the vaccines between the 12- and 15-month visit is somewhat arbitrary.

6. What vaccines are needed at 18 months?

Hep A #2, because she got her first dose Hep A at the 12-month visit, she should get her second
dose of Hep A at the 18-month visit. The two doses of Hep A must be 6 months apart. This visit
is also a great time to catch up on other vaccines that the child may have missed.

She comes back at her 2-year well-child visit after completing her series on time as above.
Parents report that they experienced a car accident last month from which she suffered a
splenic laceration resulting in emergent splenectomy. She has no other injuries and is
recovering well.

7. Which vaccines does she need today?

Normally, she would not need any immunizations at her 2-year visit (except the flu shot during
flu season) but, given her splenectomy, she is at risk for infection by encapsulated organisms.
She should have increased protection against the following bacteria:

Pneumococcus, Meningococcus

She has completed her series of PCV 13) (4 doses through 12-15 months). For high-risk children,
the PPSV23 is a polysaccharide vaccine that is recommended at 2 years old, and at least 8 weeks
after her last dose of PCV13. As she gets older, the more expanded 23-valent polysaccharide
vaccine is preferred. In high-risk children, the current recommendation is for a single
revaccination with PPSV23 five years after the initial dose. For clarity, she gets one dose of
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PPSV23 at this visit, one in 5 years, and she needs one more again at 65 years old, so three
lifetime PPSV23 vaccinations for this population.

For meningococcal coverage, the recommendation is a dose of MenACWY for high-risk

individuals at 19 months or older and a booster dose 8 weeks later. After this initial vaccination,
repeat every 5 years for anyone at risk. (For travelers to endemic areas, MenACWY may be
given as young as 9 months.)

Today she should receive:

PPSV23 (repeat in 5 years once), MenACWY (booster in 8 weeks, then repeat every 5 years)

8. In addition to the patient above, which groups of patients are at higher risk for
pneumococcal disease, and need PPSV23 early (starting at 2 years old)?1
There are three groups of patients:

1) Immunocompetent children with chronic disease: Congenital heart disease, Chronic

lung disease, Diabetes mellitus, Cerebrospinal fluid (CSF) leak, Cochlear implants

2) Children with anatomic or functional asplenia (such as in sickle cell disease)

3) Immunocompromised children: HIV (at any CD4 level), End-stage renal disease

(ESRD), Nephrotic syndrome (loss of protein, leading to loss of antibodies),
Immunosuppressive drugs or radiation therapy, Solid organ transplant, Congenital
immunodeficiencies

Case 3:

A healthy 5-year-old comes in with his mother for a well-child check in November. Her
routine vaccines are up to date through 2 years old, but she has never received a flu
vaccine.

1. Which vaccines do you recommend at this visit?1

DTaP #5, IPV #4, MMR #2, Varicella #2, Influenza

DTaP and IPV come in a combination, as do MMR and Varicella, and these combinations can be
used if available.
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In terms of flu vaccine, all children vaccinated for the first time between the ages of 6 months
and 8 years need 2 doses separated by 4 weeks. This child needs two vaccines separated by one
month.

All children must receive an IPV booster on or after their fourth birthday. If this child had
received a fourth IPV prior to her fourth birthday, she should receive a fifth booster dose at
today's visit.

Case 4:

A 12-year-old girl who has not seen a doctor in several years comes in for a routine well-
child check. Mom asks about whether she really needs the "cancer vaccine" and if it really
works. She wants to know what other vaccines are recommended.

1. How do you counsel mom and patient and what do you recommend?

Tdap booster, MenACWY, HPV9 (preferred)

The efficacy of the HPV vaccine is nearly 100% in clinical trials in preventing cervical cancer.
The prevalence of HPV is about 20 million Americans, or 15% of our population is infected. The
HPV vaccine is recommended for both girls and boys.6 The ACIP currently recommends a two-
dose schedule (0, 6 months) when initiating HPV vaccination before age 15 years. If starting the
HPV series after age 15, the three-dose schedule should be used (0, 1-2 months, 6 months). If
available, you should use HPV9 to complete the HPV series, even if prior vaccinations were
HPV4. The ACIP at this time has not recommended re-vaccination of persons already vaccinated
with the HPV4 vaccine.

2. What if she got a Td booster last year at another clinic? Does that change what you give
her today?

No. There used to be a recommendation to wait at least 2 years after Td prior to giving a Tdap
vaccination. Tdap can now be administered to someone who has not yet received it, regardless of
the interval since their last standard Td vaccination. She should still get Tdap today. This
recommendation applies to adults as well.
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Case 5: Your next patient is the twin brother of the 12-year-old girl above.

1. Which vaccines do you recommend for him?1,6

Tdap booster, MenACWY, HPV9 (preferred)

He should receive the same vaccines as his sister. Since October 2011, the ACIP recommends
HPV vaccination for all boys at the 11- to 12-year-old visit and catch up vaccination up to age
21. Men ages 22 to 26 may also be vaccinated. Both HPV4 and HPV9 are approved for both
males and females, although the HPV9 vaccine is recommended in all.

2. When do both children need a MenACWY booster?1

They should receive a second dose of MenACWY at 16 years old.

3.Who should get the MenACWY vaccine before they are 12 years old?7
The MenACWY should be given to children with the following conditions8:

Functional asplenia (including sickle cell disease), HIV infection, Persistent complement
deficiency.

Note: Look carefully at dosing schedule before initiating.

4. Who should get the MenB vaccine and what is the dosing schedule? 1
The CDC recommends a dose for adolescents not at increased risk at ages 16-23 (preferably 16-
18) based on shared decision-making discussion

Children 10 years or older at high risk for serogroup B meningococcal disease: Functional
asplenia (including sickle cell disease), HIV infection, Persistent complement deficiency

 Note: The 2 brands (Trumenba and Bexsero) are not interchangeable and you must use
the same vaccine to complete the series.

References:
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American Academy of Pediatrics, Committee on Infectious Diseases; Pickering  LK, Baker  CJ,
Long  SS, McMillan  JA, eds. Red Book: 2006 Report of the Committee on Infectious
Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006.

Centers for Disease Control and Prevention (CDC); Advisory Committee on Immunization
Practices (ACIP). Update: recommendations from the Advisory Committee on
Immunization Practices (ACIP) regarding administration of combination MMRV
vaccine. MMWR Morb Mortal Wkly Rep. 2008;57(10):258–260. Pubmed ID: 18340332.

Klein  NP, Fireman  B, Yih  WK,  et al; Vaccine Safety Datalink. Measles-mumps-rubella-
varicella
combination vaccine and the risk of febrile seizures. Pediatrics. 2010;126(1):e1–e8.
Pubmed ID: 20587679.

MacNeil  JR, Rubin  L, McNamara  L, Briere  EC, Clark  TA, Cohn  AC; Meningitis and Vaccine
Preventable Diseases Branch, Division of Bacterial Diseases, National Center for
Immunization and Respiratory Diseases, CDC. Use of MenACWY-CRM vaccine in
children aged 2 through 23 months at increased risk for meningococcal disease:
recommendations of the Advisory Committee on Immunization Practices, 2013. MMWR
Morb Mortal Wkly Rep. 2014;63(24):527–
530. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6324a2.htm#Tab. Accessed
March 26, 2020.

Marin  M, Broder  KR, Temte  JL, Snider  DE, Seward  JF; Centers for Disease Control and
Prevention (CDC). Use of combination measles, mumps, rubella, and varicella vaccine:
recommendations of the Advisory Committee on Immunization Practices
(ACIP). MMWR Recomm Rep. 2010;59(RR-3):1–12. Pubmed ID: 20448530.