Rosen & Barkin's 5-Minute Emergency Medicine Consult (389 page)

• ED visits for any reason present an opportunity to review immunization status and provide appropriate follow-up. Take a history of status of immunizations:
  
  • If incomplete, take a good history as to the reason why immunizations have not been administered.
    
• True contraindications to vaccination:
  
  • Anaphylactic reaction to a previous dose of the vaccine or:
    
    • Anaphylaxis to baker’s yeast is a contraindication to HepB vaccine.
      
    • Anaphylaxis to chicken or egg protein is a contraindication to influenza vaccine (but not MMR).
      
    • Anaphylaxis to neomycin or gelatin is a contraindication to MMR vaccine.
      
    • Anaphylaxis to neomycin, streptomycin, or polymyxin is a contraindication to IPV vaccine.
      
  • Specific reactions within 48 hr of vaccine of a previous vaccine:
    
    • Severe, inconsolable screaming for 3 hr
      
    • Distinctive high-pitched cry
      
    • Hyporesponsive episode
      
    • Temperature >40.5°C unexplained by other cause
      
    • Severe local reaction involving the circumference of the injected limb unless owing to inadvertent SC injection
      
  • Encephalopathy within 7 days of vaccine:
    
    • Severe acute neurologic illness with prolonged seizures and/or unconsciousness and/or focal signs
      
  • Progressive neurologic disease excluding epilepsy
    
• Reasons to defer vaccine administration:
  
  • Moderate or severe acute disease regardless of fever.
    
  • Congenital or acquired immunodeficiency (e.g., HIV, malignancy/chemotherapy associated): Possible risk from live attenuated vaccines such as VZV, MMR, and influenza. Caution should be used when considering these vaccines for healthy individuals in close contact with the immunocompromised.
    
  • Pregnancy is a contraindication to live attenuated virus vaccines including VZV and HPV; inactivated virus (influenza) and conjugate vaccines (DTaP) are thought to be safe.
    
  • Recent convulsion is a relative contraindication to pertussis.
    
  • Recent administration of immune globulin may lessen the efficacy of vaccinations
    
• Vaccines may be given with the following:
  
  • Mild acute illness with or without fever
    
  • Mild to moderate local reaction (i.e., swelling, redness, soreness), low-grade or moderate fever after previous dose
    
  • Current antimicrobial therapy
    
  • Convalescent phase of illness
    
  • Premature birth (HepB vaccine is an exception)
    
  • Recent exposure to an infectious disease
    
  • History of penicillin allergy, other nonvaccine allergies, relative with allergies, receiving allergen extract immunotherapy
    
  • HIV-infected children who are either asymptomatic or not severely immunocompromised should be vaccinated.
    

TREATMENT

Attention should be focused on the airway, breathing, and circulation.

Initial medications for anaphylactic reaction to vaccines include IM or IV epinephrine, diphenhydramine, albuterol for wheezing, and IV fluids for hypotension.

• Treat anaphylaxis with epinephrine, antihistamines, albuterol and IV fluids as indicated.
  
• Treatment of potential exposure to infectious disease or contaminated wounds follows specific guidelines for active or passive immunization.
  
• Treatment of adverse reactions depend on symptoms:
  
  • Local reactions at the injection site can be treated with cold compresses, analgesics, or antipruritics. Control bleeding with a pressure dressing.
    
  • Treat fever, headaches, myalgias, and arthralgias with acetaminophen or ibuprofen.
    
  • Treat ongoing seizures with benzodiazepines
    
• Consider prophylaxis with acetaminophen at the time of injection of vaccines and again 4–8 hr later:
  
  • Children who receive varicella vaccine should avoid salicylates for 6 wk post vaccination because of the association of varicella infection and salicylates to Reye syndrome.
    
• Specific discussion with the parents is required to review the risks and benefits of tetanus vaccination, particularly given the frequent occurrence of trauma and the need to provide both passive and active immunity at that time:
  
  • Document in the chart that the risks and benefits have been thoroughly discussed. A formal informed consent is used in some settings.
    
  • The National Childhood Vaccine Injury Act requires that a copy of the Vaccine Information Statements be provided before administering each dose of the vaccine.
    

• Acetaminophen 15 mg/kg/dose q4–6h PO
  
• Ibuprofen 10 mg/kg/dose q6–8h PO
  

FOLLOW-UP

• Patients with serious adverse reactions following immunization should be admitted.
  
• Patients with anaphylaxis and encephalopathy may require admission to a pediatric ICU.
  
• Unexpected adverse events should be reported to the Vaccine Adverse Event Reporting System.
  

Patients may be discharged home after routine immunizations unless an immediate adverse reaction occurs. It is essential that follow-up with the primary care physician be arranged to complete immunizations.

• Failure to continue diphenhydramine for 48 hr following an allergic reaction. Steroids may also be considered.
  
• Failure to recognize egg allergy as a contraindication to influenza vaccine.
  

• Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention. Recommended Guidelines. Available at:
  http://www.cdc.gov/vaccines/recs/acip/
  
• American Academy of Pediatrics: Report of the Committee on Infectious Diseases. 29th ed. Elk Grove, CA: ILL; 2012.
  
• CDC Traveler’s Health: Vaccinations
  . Atlanta, GA: US Department of Health and Human Services, CDC; 2012. Available at:
  wwwnc.cdc.gov/travel/
  
• Cohn AC, Mac Neil JR, Clark TA, et al. Prevention and control of meningococcal disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP).
  MMWR Recomm Rep
  . 2013;62(2):1–28.
  
• National Immunization Hotline. Phone 800-232-2522.
  
• Park SY, Van Beneden CA, Pilishvili T, et al. Invasive pneumococcal infections among vaccinated children in the United States.
  J Pediatr
  . 2010;156(3):478–483.
  
• Payne DC, Boom JA, Staat MA, et al. Effectiveness of pentavalent and monovalent rotavirus vaccines in concurrent use among US children <5 years of age, 2009–2011.
  Clin Infect Dis
  . 2013;57(1):13–20.
  
• Swamy GK, Garcia-Putnam R. Vaccine-preventable diseases in pregnancy.
  Am J Perinatol
  . 2013;30(2):89–97.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Anaphylaxis
  
• Encephalitis
  
• Hepatitis
  
• Influenza
  
• Measles
  
• Mumps
  
• Pertussis
  
• Polio
  
• Rabies
  
• Rubella
  
• Seizure, Adult
  
• Seizure, Pediatric
  
• Tetanus
  
• Varicella
  

CODES

• V07.2 Need for prophylactic immunotherapy
  
• V15.83 Personal history of underimmunization status
  

BASICS

Congenital or acquired deficiency in the ability to fight infection:

• Antibody production (B cell)
  
• Cellular immunity (T cell)
  
• Phagocytic dysfunction
  
• Complement deficiency
  
• Breach of skin/mucosal barriers
  

• Congenital disorders
  
• Immunosuppressive medications
  
• Aging:
  
  • Immunosenescence
    
  • Poor circulation and wound healing
    
• Chronic (lung, kidney, or heart) disease
  
• HIV infection:
  
  • CD4 count determines susceptibility to pathogens
    
• Diabetes:
  
  • Hyperglycemia impairs immune response
    
  • Vascular insufficiency
    
• Malnutrition:
  
  • Poverty
    
  • Alcoholism and drug abuse
    
  • Eating disorders
    
• Asplenia:
  
  • Functional asplenia (sickle cell disease) or surgical splenectomy increases risk of infection with encapsulated organisms
    
• Organ transplantation:
  
  • Antirejection medications suppress immune response
    
  • Infections may be donor derived, recipient derived, or nosocomial
    
  • Increased risk of viral pathogens, such as cytomegalovirus, Epstein–Barr virus, and human herpes viruses
    
  • Time elapsed since transplantation is crucial, as different patterns of infection arise in early, intermediate, and late posttransplantation periods
    
• Malignancy
  
• Chemotherapy:
  
  • Increased risk of infection with pyogenic bacteria and fungi
    
  • Infection risk related to length and severity of neutropenia
    
• Neutropenia:
  
  • Defined as absolute neutrophil count (ANC) <500/mm
    ³
    or <1,000/mm
    ³
    with an anticipated nadir of <500/mm
    ³
    
  • In US, gram-positive organisms are the leading etiology of infection
    
  • Gram-negative organisms are somewhat less common but often virulent
    
  • Polymicrobial infections are increasingly frequent
    
  • Anaerobic isolates remain relatively rare
    
  • The risk of fungal pathogens increases with prolonged neutropenia (>1 wk), prior use of broad-spectrum antibiotics, or intense chemotherapy