Burchum & Rosenthal: Lehnes Pharmacology for Nursing Care, 9th Edition

Chapter 68: Childhood Immunization

Key Points
Chapter 68 reviews childhood immunizations. The chapter begins with a review of the
definitions of the various types of vaccines and then discusses vaccination-preventable
diseases, immunizations, and the adverse effects of immunization.

The purpose of immunization is to protect against infectious diseases.

Of all the advances in medicine, none has reduced sickness and death more than
immunization.
Experience has shown that the most effective way to reduce vaccine-preventable diseases
(VPDs) is to create a highly immune population.
A vaccine is a preparation that contains whole or fractionated microorganisms.
Administration of a vaccine causes the recipients immune system to manufacture
antibodies directed against the microbe from which the vaccine was made. The two major
classes of vaccines are killed vaccines and live (attenuated) vaccines. Killed vaccines are
composed of whole, killed microbes or isolated microbial components. Live (attenuated)
vaccines are composed of live microbes that have been weakened or rendered completely
avirulent.
A toxoid is a bacterial toxin that has been changed to a nontoxic form. Administration
causes the recipients immune system to manufacture antitoxins, which protect against
injury from toxins but do not kill the bacteria that produce them.
Vaccination is defined as the administration of any vaccine or toxoid.
Immunization is a more inclusive term than vaccination, in that immunization refers to the
production of both active immunity and passive immunity, whereas vaccination refers to
the production of active immunity only.
Active immunity develops in response to infection or to administration of a vaccine or
toxoid. In either case, the result is endogenous production of antibodies. Active immunity
takes weeks or months to develop but is long lasting.
Passive immunity is conferred by administering preformed antibodies (immune
globulins). Protection is immediate but lasts only as long as the antibodies remain in the
body.
Specific immune globulins contain a high concentration of antibodies directed against a
specific antigen. Administration provides immediate passive immunity.
In the United States, vaccination has greatly reduced the incidence of some infectious
diseases (e.g., pertussis, mumps, tetanus) and virtually eliminated five others: diphtheria,
smallpox, poliomyelitis, rubella, and measles. With two diseases, results have been even
more dramatic: wild-type polio is gone from the Western hemisphere, and smallpox is
gone from the planet.
The goal of the Childhood Immunization Initiative is to eliminate all indigenous cases of
diphtheria, measles, rubella, tetanus, and Haemophilus influenzae type b infection from
the United States.
Public health officials rely on healthcare providers to report cases of VPDs.
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The information is used to (1) determine whether an outbreak is occurring, (2) evaluate
prevention and control strategies, and (3) evaluate the impact of national immunization
policies and practices.
Vaccines generally are very safe. Mild reactions are common, and serious events are rare.
Vaccinations can hurt. This pain, in turn, can lead to needle fears, procedural anxiety, and
avoidance of additional immunizations. Accordingly, minimizing pain is a primary goal.
Immunocompromised children are at special risk from live vaccines and should not
receive them.
Several large, high-quality studies conducted in Denmark, Britain, and the United States
have failed to show a causal link between childhood immunization using thimerosalcontaining vaccines and the development of autism.
The risk of serious adverse reactions can be minimized by observing appropriate
precautions and contraindications.
Absolute contraindications to vaccine administration in children include history of
anaphylactic reaction to a specific vaccine or vaccine component, as well as presence of
moderate or severe illnesses with or without a fever.
Practitioners are required to report certain adverse events to the Vaccine Adverse Event
Reporting System (VAERS). The information is used to help determine whether (1) a
particular event that occurs after vaccination is actually caused by the vaccine, and (2)
what the risk factors might be.

The chapter then provides a review of the target diseases.

Routine childhood vaccination currently is recommended for protection against 16

infectious diseases: diphtheria, tetanus (lockjaw), pertussis (whooping cough), measles,
mumps, rubella, invasive H. influenzae type b, hepatitis A, hepatitis B, polio, varicella
(chickenpox), influenza, invasive pneumococcal disease, meningococcal disease
(meningitis), rotavirus gastroenteritis, and genital human papillomavirus infection.
Measles is a highly contagious viral disease characterized by rash and high fever (103F
to 105F). Infection is spread by inhalation of aerosolized sputum or by direct contact
with nasal or throat secretions. Initial symptoms include fever, cough, headache, sore
throat, and conjunctivitis. Three days later, rash develops.
Mumps is a viral disease that primarily affects the parotid glands (the largest of the three
pairs of salivary glands). Although mumps can occur in adults, it usually occurs in
children ages 5 to 15. As a rule, the first symptom is swelling in one of the parotid glands,
often accompanied by local pain and tenderness.
Rubella, also known as German measles, is a generally mild viral infection. However, if
it occurs during pregnancy, the consequences can be severe. Initial symptoms include
sore throat, mild fever, and swelling in lymph nodes behind the ears and in the back of
the neck. Shortly afterward, a rash develops on the face and scalp, spreads rapidly to the
torso and arms, and then fades in 2 or 3 days.
Diphtheria is a potentially fatal infection caused by Corynebacterium diphtheriae, a
gram-positive bacillus. The bacterium colonizes the throat and nasal passages and
produces a toxin that spreads throughout the body. The toxin can damage the heart and
nerves, resulting in heart failure and paralysis.
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Tetanus, also known as lockjaw, is a frequently fatal disease characterized by painful

spasm of all skeletal muscles. The cause is a potent endotoxin elaborated by Clostridium
tetani, a gram-positive bacillus. The first symptom often is stiffness of the jaw (hence the
name lockjaw). As infection progresses, the patient may experience stiff neck, difficulty
swallowing, restlessness, irritability, headache, chills, fever, and convulsions.
Pertussis, also known as whooping cough or the 100-day cough, occurs primarily in
infants and young children. The cause is Bordetella pertussis, a gram-negative bacillus.
Initial symptoms include rhinorrhea, mild fever, and persistent cough. As infection
worsens, coughing becomes more intense.
Poliomyelitis, also known as polio or infantile paralysis, is a serious disease in which the
poliovirus attacks neurons of the central nervous system that control muscle movement.
The result is skeletal muscle paralysis, usually in the legs, although muscles of respiration
and muscles of the arms also may be affected.
Haemophilus influenzae type b is a gram-negative bacterium that can cause meningitis,
pneumonia, and serious throat and ear infections. The bacterium is the leading cause of
serious illness in children under the age of 5 years and the most common cause of
bacterial meningitis, which has a mortality rate of 5%.
Varicella (chickenpox) is a common, highly contagious, and potentially serious disease of
childhood. The causative organism is the varicella-zoster virus, a member of the
herpesvirus group. Patients typically develop 250 to 500 maculopapular or vesicular
lesions, usually on the face, scalp, or trunk. Other symptoms include fever, malaise, and
loss of appetite. Among children, the most common complications are bacterial
suprainfection and acute cerebellar ataxia.
Herpes zoster, also known as shingles or simply zoster, develops in 15% of patients years
after childhood chickenpox has resolved. The cause is reactivation of varicella-zoster
viruses that had been dormant in sensory nerve roots. Episodes of zoster begin with
neurologic pain in the area of skin supplied by the affected nerve roots. In about 14% of
patients, neurologic pain persists for a month or longer, and in a few cases, the pain lasts
for years.
Hepatitis B is a serious liver infection caused by the hepatitis B virus. Acute infection can
cause anorexia, malaise, diarrhea, vomiting, jaundice, pain (in muscles, joints, and the
stomach), and death. Chronic infection can result in cirrhosis, liver cancer, and death.
Hepatitis A is a serious liver infection caused by the hepatitis A virus. Symptoms of
hepatitis A include fever, malaise, nausea, jaundice, anorexia, diarrhea, and stomach pain.
In the United States, Streptococcus pneumoniae (pneumococcus) is the leading bacterial
cause of childhood meningitis, sepsis, pneumonia, and otitis media. Among children with
pneumococcal meningitis, up to 50% suffer permanent brain damage or hearing loss, and
about 10% die.
Meningococcal infection is a serious disease caused by Neisseria meningitidis, also
known as the meningococcus. Invasive meningococcal disease is a leading cause of
meningitis in American children. Outbreaks can occur in day care centers, schools, and
colleges.
Influenza is a serious infection of the respiratory tract and a major cause of morbidity and
mortality worldwide.
Rotavirus, which infects the intestinal mucosa, is the most common diarrheal pathogen
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worldwide. Infection presents initially as upset stomach and vomiting, usually with fever,
and progresses to several days of diarrhea, which can be mild to severe. The combination
of vomiting and severe diarrhea can result in life-threatening dehydration. Virtually all
children become infected repeatedly within the first 5 years of life.
Human papillomavirus (HPV) infection is the cause of virtually all anogenital warts and
cervical cancers. Transmission occurs most often by direct genital contact during vaginal
or anal intercourse. The types of HPV that infect the anogenital region can also cause
cancers of the vulva, vagina, urethra, tongue, tonsils, penis, and anus.
Genital HPV is the most common sexually transmitted infection. In the United States,
about 6.2 million people become infected each year. Among sexually active males and
females, about 50% will be infected at some time during their life.

The chapter then presents information about the specific vaccines and toxoids, beginning with
measles, mumps, and rubella virus vaccine.

Measles, mumps, and rubella vaccine (MMR) is a combination product composed of

three live virus vaccines. Administration induces synthesis of antibodies directed against
the measles, mumps, and rubella viruses.
Mild adverse effects, such as local soreness, erythema, swelling, and a transient rash and
fever may occur in 5% to 15% of children. Fever, soreness, and pain can be reduced with
acetaminophen or a nonaspirin, nonsteroidal antiinflammatory drug, such as ibuprofen.
In rare cases, MMR causes thrombocytopenia and anaphylactic reactions. The leading
suspect in anaphylactic reactions is a hydrolysis product of gelatin. Until more is known,
authorities recommend that MMR be used with extreme caution in children with a known
allergy to gelatin. No causal link has been shown between MMR and development of
autism, Crohns disease, or any other serious long-term illness.
MMR is contraindicated during pregnancy and should be used with caution in children
with a history of (1) thrombocytopenia or thrombocytopenic purpura or (2) anaphylacticlike reactions to gelatin, eggs, or neomycin (MMR contains a small amount of this
antibiotic).

The chapter then discusses the diphtheria and tetanus toxoids and acellular
pertussis vaccines, followed by a discussion of the poliovirus vaccine.

Primary vaccination against diphtheria, tetanus, and pertussis usually is done

simultaneously with a combination product composed of diphtheria toxoid, tetanus
toxoid, and acellular pertussis vaccine (DTaP). Vaccination with DTaP produces
antibodies against diphtheria toxin, tetanus toxin, and B. pertussis.
After children have received a full series of DTaP shots, they will need subsequent
booster shots.
The reactions seen most often are low fever, fretfulness, drowsiness, anorexia, and local
reactions (pain, swelling, and redness).
Very rarely, DTaP causes acute encephalopathy.
Two vaccines against polioviruses have been developedoral poliovirus vaccine (OPV)
and inactivated poliovirus vaccine (IPV). OPV contains live, attenuated viruses, whereas

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IPV contains inactivated polioviruses.

OPV has caused polio in a few children, whereas IPV has not and cannot. Because the
benefit/risk ratio for IPV is clearly superior, OPV has been withdrawn from the U.S.
market.
IPV is devoid of serious adverse effects. As with other injected drugs, local soreness may
occur.

The chapter then provides information on the H. influenzae type b vaccine and the varicella
vaccine.

Vaccines directed against H. influenzae type b (Hib) are prepared by conjugating

(covalently binding) a purified capsular polysaccharide (PRP) from H. influenzae to
either (1) tetanus toxoid or (2) an outer membrane protein isolated from Neisseria
meningitidis. The reason for conjugating PRP to these other compounds is to enhance
antigenicity.
The Hib vaccine is among the safest of all vaccines. Serious adverse effects have not
been reported. The few adverse effects that do occur generally are transient and mild.
The varicella virus vaccine is composed of live, attenuated varicella viruses.
Varicella vaccine, given as a two-dose series, confers full protection in about 99% of
those vaccinated. Furthermore, in those who get chickenpox despite vaccination, the
symptoms are always mild; these children develop fewer lesions, experience less fever,
and recover more quickly. The varicella vaccine is very safe; no serious adverse events
have been reported.
The varicella vaccine is contraindicated in pregnant women, in individuals with certain
cancers, and in individuals hypersensitive to neomycin or gelatin. The vaccine generally
should be avoided by immunocompromised individuals. Children who are vaccinated
should avoid aspirin and other salicylates for 6 weeks. This precaution is based on the
theoretical risk of Reyes syndrome.
Because of misconceptions, although rates of varicella vaccination have increased, many
eligible children still do not get vaccinated.

The chapter then discusses the hepatitis vaccines.

Hepatitis B vaccine (HepB) contains hepatitis B surface antigen (HBsAg), the primary
antigenic protein in the viral envelope. Administration of HepB promotes synthesis of
specific antibodies directed against hepatitis B virus.
HepB is one of the safest vaccines. The most common reactions are soreness at the
injection site and mild to moderate fever. Acetaminophen or ibuprofen may be used to
relieve discomfort, but aspirin should be avoided.
The only contraindication is a previous anaphylactic reaction either to HepB itself or to
bakers yeast.
All infants should receive monovalent HepB within 12 hours of birth. Infants whose
mothers are HBsAg positive should also receive hepatitis B immune globulin.
The hepatitis A vaccine is composed of inactivated hepatitis A viruses.

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HepA is extremely safe; mild adverse effects include soreness at the injection site and
headache.

The chapter then discusses the pneumococcal conjugate vaccine and meningococcal
conjugate vaccine.

In 2010, the U.S. Food and Drug Administration approved a 13-valent pneumococcal
conjugate vaccine (PCV13) for the prevention of invasive pneumococcal disease in
infants and children. An unconjugated vaccinepneumococcal polysaccharide vaccine
(PPV)also is available. However, PPV is approved only for adults and high-risk
children over the age of 2 years.
PCV13 appears very safe. No serious adverse effects have been reported. About 50% of
those vaccinated become drowsy after the shot, lose their appetite, or develop erythema
or tenderness at the injection site.
In the United States, two meningococcal conjugate polysaccharide vaccines (MCVs) are
usedMenactra, which was approved in 2005, and Menveo, which was approved in
2010. Both vaccines protect against the same four meningococcal serotypes (hence their
abbreviation, MCV4). The most common reactions are local pain, headache, and fatigue.
Local redness, swelling, and induration are also common.
Concerns that MCV4 might cause Guillain-Barr syndrome (GBS) appear to be
unfounded, as shown by two large studies. In one study, there were 99 confirmed cases of
GBS among 12,589,910 people vaccinated. In the other study, there were 5 cases among
889,684 people vaccinated. In both studies, the incidence of GBS was no higher than
would be expected in the absence of vaccination.

The chapter then discusses the influenza vaccine, the rotavirus vaccine, and the vaccine for
human papillomavirus.

Annual vaccination against influenza, including the H1N1 subtype, now is recommended
for all children between 6 months and 18 years of age.
In the United States, two rotavirus vaccines are availableRotaTeq, approved in 2006,
and Rotarix, approved in 2008. Both contain live, attenuated viruses. No serious adverse
effects were observed with RotaTeq. The safety of Rotarix appears comparable to that of
RotaTeq but with one important exception: postmarketing data show a small risk of
intussusception.
Rotarix (but not RotaTeq) is contraindicated for infants with any uncorrected congenital
malformation of the gastrointestinal (GI) tract that could predispose to intussusception.
Two HPV vaccines are available: Gardasil and Cervarix. These vaccines differ in
composition, indications, and immunogenicity. Gardasil protects against cervical, vulvar,
and vaginal cancer in females, as well as anal cancer and genital warts in females and
males. By contrast, Cervarix protects only against cervical cancer, but the protection may
last longer than with Gardasil.
Gardasil is used to prevent cancers, precancerous lesions, and genital warts in females
and males.
A Papanicolaou test (Pap test) still is needed, because Gardasil protects against only four

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types of HPV, leaving those vaccinated at risk of cervical cancer caused by other types of
HPV. Additionally, because Gardasil does not eliminate preexisting HPV infection, those
vaccinated remain at risk of cancer from an infection that was present before the vaccine
was given.
Gardasil appears to be very safe. Injection-site reactionspain, erythema, swelling, and
itchingalthough common, are mild and short lived. Fainting has occurred in teenage
girls, sometimes resulting in hospitalization.
Cervarix is designed to stimulate the production of neutralizing antibodies against two
types of HPVspecifically, types 16 and 18, which cause 70% of cervical cancers.
Cervarix is indicated only for the prevention of cervical cancers and precancerous lesions
caused by HPV types 16 and 18.
Because Cervarix does not confer 100% protection, vaccinated women should still have
routine Pap screening to allow early detection and treatment of precancerous lesions.
The most common local reactions with Cervarix are pain, redness, and swelling. The
most common systemic reactions are fatigue, headache, myalgia, GI symptoms,
arthralgia, fever, and rash.

Copyright 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc.