Immunizations in the United States: Combined Vaccines and Special Considerations

00:00 That was a lot of vaccines and I didn’t even cover all of them. There’s more, for example, yellow fever, when you’re going to go to endemic area or small pox which might be given to the military. These have different side effect profiles but parents often worry, “That’s a lot of vaccines. Do you have to put so many needles in my child?” Well, one way we can prevent so many needles is by combining the vaccines. For example, Pentacel is a marketed vaccine that is a combination of DTAP, IPV, and HIB altogether in one shot. So, these combination vaccines are very effective and are good because they reduce the amount of pain that a child has to go through to receive vaccines. One thing is that combination vaccines may happen at different age limits and may change the schedule somewhat, so you have to look into the CDC website very carefully if you’re going to use a combination vaccine because it may alter the schedule.

01:04 Alter the scheduling in general to reduce needles is not recommended. Also, one concern that some people have is that multiple vaccines might overwhelm the immune system. “Oh, that’s too many things for my immune system to worry about.” We could literally accommodate thousands more vaccines and our immune systems could totally handle it. We encounter countless number of viruses every year and we effectively fight them off ____ immune responses. Our immune system is ready to go and can easily handle these vaccines. Let’s talk a little bit about another vaccine that’s given every single year. This is the influenza vaccine.

01:49 It’s recommended for all children after 6 months of age and every year they formulate the vaccine a little bit differently based on what they expect will be flu strains that will be coming around the following winter. It is moderately effective. It’s not completely effective. You can totally get the flu but remember, flu is a killer especially of the elderly and the very young, so vaccination is important to prevent community spread. It’s generally safe but rarely can cause Guillain-Barre syndrome, and it’s mandated for healthcare workers and others, so I have to get it every year. If I don’t, I have to wear a mask, it can be unfortunate. So, let’s switch gears now and talk a little bit about adverse reactions to vaccines. Which vaccines and what adverse reactions we need to look out for. So, for all vaccines, there can be local pain, swelling, redness, a low-grade fever, some fussiness in the child, or maybe even if there’s a fever, a febrile seizure. Perhaps febrile seizures are where some of the myth that vaccines can cause brain damage. It’s just not true. Hepatitis A does sometimes cause headache after administration.

03:09 For the DTAP vaccine, rarely patients can get some limb swelling, high fever, or they could have a hypotonic, hyporesponsive episode. This resolves and is benign. The MMR can cause joint pain or rash. The meningococcal and flu vaccines both are known to potentially cause Guillain-Barre syndrome. So, in a patient with progressive weakness or pain in the extremities, that’s something you should think about and the rotavirus can cause a mild diarrhea. Occasionally, patients will have certain clinical features that means we have a precaution. That means we should think about it prior to using a vaccine. For the pertussis vaccine, we worry about changes in neurologic status or Guillain-Barre after a previous dose. If that’s happened, you might not give that pertussis vaccine. For the influenza, we worry about Guillain-Barre after a previous dose. If a patient had thrombocytopenia after a previous dose, we might not do the MMR. For all live attenuated vaccines, we wouldn't do them perhaps if the patient had close contact with someone who has a significant immunodeficiency, say, AIDS or severe combined immune deficiency.

04:27 Remember, live attenuated vaccines tend to get shed to other people as well. For varicella, we might not do it especially if there was a previous administration of high-dose steroids or IVIg.

04:42 it might not be effective. For patients with influenza who have gotten an intramuscular injection, we might not do that if they recently had high-dose steroids or recent chemotherapy and if a patient has a history of GI illness or history of intussusception, we might avoid rotavirus. There are also strict contraindications to vaccines under certain circumstances and this is in a comprehensive list but this is what you’ll need to know. So, if a child is moderately or severely ill, they may not respond to the following vaccines: MMR, varicella, the pneumococcal conjugate vaccine, influenza, rotavirus, or meningococcus. So, if they’re very sick, we’re not going to give these vaccines right now, we’ll put it off and give a catch up later. There are also specific contraindications to specific vaccines. Certainly, if a patient has previously been allergic to vaccine, we should not give it again. If a patient has a history of yeast intolerance, we should not give the hepatitis B vaccine. If they have a history of latex intolerance, some DTAP formulations and rotavirus should be avoided. If a patient has a history of allergy to gelatin or neomycin, we should avoid the MMR. If a patient is allergic to eggs or chicken, we should avoid the intramuscular influenza vaccine. It’s important to know which vaccines are live attenuated vaccines. This is because live attenuated vaccines are contraindicated in both pregnant women and children with immunodeficiency. This is because if you’re immunodeficient that attenuated vaccine may still be able to cause infection. The live attenuated vaccines are the MMR, the varicella, and the rotavirus vaccines. That’s my summary of immunizations and the immunization schedule in children in the United States. Thanks for paying attention.