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Vaccine Preventable Diseases Vaccines Typically Given in the United States Disease and Organism Acelluar pertusis (Whooping Cough) (Bordetella pertussis)4 Vaccines Available1 Pediarix (combination – DTaP/IPV/HepB) TriHIBit (combination – DTaP/Hib) Daptacel (combination – DTaP) Infanrix (combination – DTaP) Tripedia (combination – DTaP) Boostrix (combination – Tdap) Adacel (combination – Tdap) Signs/ Symptoms2 Treatment Supportive care Erythromycin, Clarithromycin x 7 days, Azithromycin x 5 days (effective as 10 -14 day course of erythromycin) Trimethoprim/sulfamethoxazole X 7 days Click here to hear whooping cough Catarrhal stage: runny nose, sneezing, low-grade fever, occasional, mild cough Paraoxysmal stage: “whooping cough”, cyanosis, vomiting, exhaustion may follow fit of coughing, Convalescent stage: gradual recovery Transmission Human to human (adolescents and adults may serve a reservoirs), airborne transmission Reportable to CDC?3 Yes Antibiotics do not usually alter the course of the disease, unless given very early on in disease progression. Antibiotics are usually prescribed to eradicate organisms from secretions to minimize the risk of transmission. All those in close contact with infected patient should be treated with antibiotic effective against pertusiss. Close contacts of age < 7 should complete four-dose series with minimum intervals Combination vaccines are preferred over the other available forms for childhood immunizations because they offer a combination of vaccines to be given at once, minimizing the number of injections as well as opportunities for missing a dose. However, some combinations may only be licensed for a certain age group. 2 All images are hyperlinked to original web pages. 3 May change yearly. Check with CDC website to confirm. (http://www.cdc.gov/epo/dphsi/phs/infdis.htm) 4 Different manufacturer’s formulations may not be used interchangeably; no data exists on the effect of interchanging vaccines on the protection offered. Use of the same manufacturer’s vaccine is preferred for at least the first three doses. 1 Diptheria (Corynebacterium diphtheriae - symptoms caused by exotoxin of bacteria) Pediarix (combination – DTaP/IPV/HepB) TriHIBit (combination – DTaP/Hib) Daptacel (combination – DTaP) Infanrix (combination – DTaP) Tripedia (combination – DTaP) Boostrix (combination – Tdap) Adacel (combination – Tdap) Decavac (combination –Td) Generic (combination – Td) Anterior nasal diphtheria: mucopurulent nasal discharge, may be blood-tinged Pharyngeal and Tonsillar diphtheria: malaise, sore throat, anorexia, lowgrade fever, bluish-white membrane on tonsils, may extend to soft palate; may progress to lymphadenopahy Laryngeal diphtheria: fever, hoarseness, barking cough Cutaneous diphtheria: scaling rash, ulcers with demarcated edges and membranes Haemophilus influenzae type B disease (Haemophilus influenzae type B)6 Hepatitis A6 5 6 Pediarix (combination – DTaP/IPV/HepB) TriHIBit (combination – DTaP/Hib) Comvax (combination – HepB/Hib) HibTITER PedvaxHIB ActHIB Twinrix (combination – Hep A/Hep B) Havrix Vaqta Meningitis: fever, decreased mental status, stiff neck Epiglottitis: swelling of epiglottis Septic arthritis Cellulitis Pneumonia Diptheria antitoxin5 (in horse serum) Only available from CDC through IND Prior to giving, must do skin test for horse serum May need to follow desensitization protocol Dosage dependent on area of infection • Pharyngeal/ laryngeal x 48 hours: 20,000 – 40,000 units • Nasopharyngeal: 40,000 – 60,000 units • Systemic disease > 3 days or diffuse neck swelling: 80,000 – 100,000 units • Skin lesions only: 20,000 – 40,000 units Must also receive antibiotics x 14 days: Erythromycin 40 mg/kg/day, max 2 g/day OR Procaine pen G IM < 10 kg: 300,000 Units/day; > 10 kg: 600,000 Units/day Broad-spectrum cephalosporin until culture and sensitivity return Acute hepatitis: dark urine, jaundice, fever, malaise, N/V, abdominal pain, arthralgia, increased LFTs Antitoxin will not treat the disease itself; however, it will bind free toxin to avoid further complications. Various formulations from different manufacturers may be used interchangeably without any decrease in protection. Supportive care Human to human (some human may be carriers and asymptomatic); respiratory tract, occasionally skin contact Yes Human to human, with asymptomatic carriers; respiratory droplet spread Invasive disease, i.e. associated with meningitis, bacteremia, epiglotittis, pneumonia Human to human, fecal-oral transmission, either person-toperson contact or contaminated food or water Acute cases Hepatitis B6 7 Pediarix (combination – DTaP/IPV/HepB) Twinrix (combination – Hep A/Hep B) Comvax (combination – HepB/Hib) Engerix-B Recombivax HB Prodrome: malaise, anorexia, N/V, RUQ pain, fever, headache, myalgia, skin rashes, arthralgia, dark urine Icteric phase: jaundice, light or gray stools, hepatic tenderness, hepatomegaly May lead to chronic infection: chronic hepatitis, cirrhosis, liver failure, hepatocellular carcinoma Human Papillomavirus (HPV 6, 11, 16, 18) Gardasil (Cervarix7) Influenza (orthomyxovirus family, may be type A, B, or C) Fluarix Fluvirin Fluzone FluLaval FluMist (intranasal, live virus) Mostly asymptomatic Manifestations may include anogenital warts, recurrent respiratory papillomatosis, cervical cancer precursors, cancers Abrupt onset of fever, myalgia, sore throat, nonproductive cough, headache Developed by GSK; awaiting FDA approval Supportive treatment for acute infection Human to human, parenteral or mucosal exposure to Hepatitis B positive body fluids from person with acute or chronic infection Main modes: sexual contact, injection drug use Yes Dependent of manifestation of HPV Human to human, direct contact, usually sexual contact No Supportive care If diagnosed within 48 hours of onset, antiviral medications may be used Influenza A – human to human, animal to human Influenza B and C – human to human; Airborne virusladen droplets, direct/indirect contact with respiratory secretions Novel influenza A isolates Chronic infection (must meet certain critieria): Interferon 5 million units SC qday x 16 weeks Lamivudine 100 mg PO qday (for life or antibody conversion) Oseltamivir 75 mg PO qday (types A and B) Zanamivir 10 mg inhaled qday (types A and B) Influenza-associated mortality < 18 years of age Measles (paramyxovirus, Morbillivirus genus) Meningococcal disease (Neisseria meningitidis) M-M-R-II (combination -MMR) ProQuad (combination - MMRV) Attenuax Menomune Menactra Mainly supportive care Human to human, respiratory droplets Yes Broad-spectrum cephalosporins for intial treatment, with streamlining after culture and sensitivities return Human to human, with some humans as asymptomatic carriers; respiratory droplet or direct contact Yes Supportive care Human, to human, airborne or direct contact with infected droplet nuclei or saliva Yes In children, may consider Vitamin A 200,000IU PO x 2 days, especially if hospitalized and ocular complications Prodrome: fever, cough, runny nose, conjunctivitis Rash, Koplik spots (rash on mucous membranes) Meningitis: sudden onset of fever, headache, stiff neck, N/V, photophobia, altered mental status In adults, some may choose to use ribavirin (20-35 mg/kg/day x 7days) Sepsis: abrupt onset of fever, petechial or purpuric rash, associated with hypotension, shock, acute adrenal hemorrhage, multiorgan failure May also see pneumonia, arthritis, otitis media, epiglottitis Mumps (paramyxovirus) M-M-R-II (combination -MMR) ProQuad (combination - MMRV) Mumpsvax Until diagnosis is confirmed, patient may receive empiric coverage for S. aureus, another major cause of parotitis Prodrome: myalgia, anorexia, malaise, headache, low-grade fever Parotitis (unilateral or bilateral) Pneumococcal disease (Streptococcus pneumoniae) Poliomyelitis (enterovirus, Picornaviridae family) Pneumovax 23 Prevnar Pneumonia: abrupt onset of fever and chills, pleuritic chest pain, productive cough with rusty sputum, dyspnea, tachypnea, hypoxia, malaise, weakness Meningitis: may present also with pneumonia, headache, lethargy, fever, cranial nerve signs, seizures, coma Bacteremia: 25-30% development in those with pneumonia Pediarix (combination – DTaP/IPV/HepB) Ipol Rotavirus (Reoviridae family) RotaTeq Rubella (German Measles) (togavirus, Rubivirus genus) M-M-R-II (combination -MMR) ProQuad (combination - MMRV) Meruvax II Prodrome: upper respiratory tract infection, gastrointestinal diseases, influenza-like illness Nonparalytic aseptic meningitis, flaccid paralysis (less than 1%) Can range from asymptomatic, selflimited watery diarrhea, to severe dehydrating diarrhea with fever and vomiting; may be accompanied by fever Initial infections are worse than recurrent infections Broad-spectrum treatment with cephalosporin or fluroquinolone, depending on PCN resistance rates in area; consider using vancomycin if suspect meningitis Human to human with asymptomatic carriers; direct contact with respiratory droplets Only in children less than five years of age Supportive care Human to human, fecal-oral transmission Yes Supportive care, with emphasis on rehydration Human to human, fecal-oral transmission No Supportive care Human to human, Airborne transmission, droplets from respiratory secretions May be shed by infants with congenital rubella syndrome for up to 1 year Soil, human and animal intestinal tracts; Yes Streamline treatment to appropriate antibiotic once culture and sensitivity has returned (Congenital Rubella Syndrome) Prodrome: low-grade fever, malaise, lymphadenopathy, upper respiratory symptoms Maculopapular rash Tetanus (Clostridium tetani – symptoms caused by Pediarix (combination – DTaP/IPV/HepB) TriHIBit (combination – DTaP/Hib) Local: persistant contraction in same area of injury Cephalic: otitis media, iN/Volvement Tetanus immune globulin5 (TIG) 3,000 to 5,000 units, with part infiltrated at site of wound Yes exotoxin of bacteria) Varicella (Chicken pox) Varicella zoster virus (herpesvirus family) Daptacel (combination – DTaP) Infanrix (combination – DTaP) Tripedia (combination – DTaP) Boostrix (combination – Tdap) Adacel (combination – Tdap) Decavac (combination –Td) Generic (combination – Td) Generic (TT) of cranial nerves Intravenous immune globulin (IVIG) may be used if TIG not available Wounds should be cleaned with necrotic, foreign tissue removed. Generalized tetanus: lockjaw, neck stiffness, difficulty in swallowing, rigidity of abdominal muscles, spasms Supportive therapy may be necessary during spasms Antibiotics play no role in treatment of active tetanus ** Tetanus disease does not result in immunity. Once stable, patient should received tetanus toxoid8.** Supportive care ProQuad (combination – MMRV) Varivax Avoid using aspirin in pediatrics to treat fever to avoid Reye’s syndrome Prodrome: mild, if any Generalized, pruritic rash that progresses to vesicular lesions accompanied with malaise, pruritis, fever Zoster (Herpes Zoster, Shingles) Varicella zoster virus (herpesvirus family) Zostavax Supportive care Prodrome: mild, if any Pruritic rash, present only on one side of the body, following a dermatome, that progresses to vesicular lesions accompanied with malaise, pruritis, fever In immunocompromised hosts, rash can be disseminated contaminated wounds (not contagious from person to person) Human to human, infected respiratory tract secretions as well as airborne droplet, direct contact or inhalation of aerosols from vesicular fluid of lesions Yes Human to human, infected respiratory tract secretions as well as airborne droplet, direct contact or inhalation of aerosols from vesicular fluid of lesions No Other Vaccines That May Be Encountered in the United States 8 Immunity does not result because of the potency of the toxin. The lethal dose of toxin is so small that the immune system cannot adequately respond to make appropriate antibodies. Vaccinia (Smallpox) (variola virus) Dryvax Prodrome: high fever, malaise, prostration, severe headache and backache Maculopapular rash papules pustules; spreads from oral mucosa to face, forearms, trunks, legs High fever, weakness, abdominal pain, headache, loss of appetite, rose-colored rash Typhoid9 Typhim Vi Vivotif Berna (oral, live) Rabies7,10 BioRab Imovax Rabies RabAvert Hallucinations, confusion, anxiety, biting, hydrophobia, autonomic dysfunction, SIADH, arrhythmias, myocarditis, CHF, bleeding, N/V, ileus Yellow fever7 YF-Vax Japanese Encephalitis7 (flavavirus family) JE-Vax Acute phase: fever, muscle pain, headache, shivers, anorexia, N/V Toxic phase: (only 15%) fever, jaundice, abdominal pain, vomiting, bleeding from multiple orifices, kidney failure Mild infections – fever, headache Severe infections – quick onset, headache, high fever, neck stiffness, stupor, disorientation, coma, tremors, occasional convulsions 9 Only 10 Supportive treatment Human to human; respiratory droplets Yes Ciprofloxacin 500 mg BID x 10 days Bactrim DS BID x 15 days Chloramphenicol 1 g q6h x 14 days Pediatrics: Ceftriaxone 10-15 mg/kg BID x 10 – 14 days If from wild animals: If previously vaccinated, one IM dose of vaccine day 0, 3 If not previous vaccinated, rabies immunoglobulin 20 IUnits/kg5 (all at wound site if possible, otherwise IM and vaccine (IM) day 0,3,7,14,28 If from family pet: Observe animal for 10 days for signs of rabies Supportive therapy Human to human, some humans may serve as carriers; fecal-tooral contact Animal (primarily raccoons, skunks, bats) to human contact; animal bite Yes Mosquito to human (nonhuman primates serve as hosts); transmission by insect bite Mosquito to human (animals serve as hosts); transmission by insect bite Yes Supportive therapy recommended for those persons traveling to endemic areas. Consult the Yellow Book (http://wwwn.cdc.gov/travel/contentYellowBook.aspx) for more specific recommendations. Recommended for certain persons with high risks of exposure to rabies. Yes Yes Tuberculosis (Mycobaterium tuberculosis, Mycobacterium bovis) bacilli Calmette-Guérin11 (circle highlights caviation from TB) Pulmonary TB: cough > 2 weeks, fever, night sweats, weight loss, hemoptysis, SOB Disseminated TB: fever, weight loss, organ involvement 11 Not available in the United States. Once cultures confirm TB, patients will receive at least a combination of four drugs(depending on sensitivities), most likely including isoniazid 5 mg/kg max 300 mg, rifampin 10 mg/kg max 600 mg, pyrazinamide 15 – 30 mg/kg max 2 g, ethambutol 15 – 25 mg/kg max 1.6g –frequency depends upon schedule determined by physician and patient but total length of treatment will be for at least 6 – 9 months Patient should be isolated until AFB negative x 3 Human to human; respiratory droplets Yes