Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
IMMUNIZATION 20 Common Questions and Answers Richard D. Krugman To cite this article: Richard D. Krugman (1976) IMMUNIZATION 20 Common Questions and Answers, Postgraduate Medicine, 59:4, 216-220, DOI: 10.1080/00325481.1976.11714342 To link to this article: http://dx.doi.org/10.1080/00325481.1976.11714342
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 11 August 2017, At: 20:00
pediatries IMMUNIZATION 20 Common Questions and Answers
Downloaded by [Australian Catholic University] at 20:00 11 August 2017
Richard D. Krugman, MD University of Colorado School of Medicine Denver
Who should receive DTP vaccine? Trivalent oral poliovirus vaccine? Measles? Rubella? Mumps? Influenza? Which vaccines can be safely given simultaneously? What causes immunization failures? These are a few of the questions that primary care physicians must be able to answer.
• The following questions are among those commonly asked at postgraduate education sessions for family practitioners and pediatricians. The answers are by no means inclusive guides to immunization practice. Further data may be found in the Red Book (the report of the Committee on lnfectious Diseases of the American Academy of Pediatries)* and in the Morbidity and
Morta/ity Weekly Reports. t 1. What is the usual schedule for immunizations? The routine immunizations currently recommended are: combined diphtheria-tetanus-pertussis (DTP) vaccine and trivalent oral poliovirus vaccine at 2, 4, and 6 months of age; tuberculin test at 9 months; measles, mumps, and rubella vaccines at 12 to 15 months; an additional dose each of DTP and trivalent oral poliovirus vaccine at 18 months and at 4 to 6 years; and adult-type diphtheria-tetanus toxoid every ten years thereafter. 2. If the DTP series is interrupted, should it be restarted? Adequate protection against diphtheria, tetanus, and pertussis requires three doses of DTP initially and two doses later. Even when several years intervene between administration of the doses, no more than five doses are necessary.
3. If a severe reaction to DTP vaccine injection occurs, should the series be continued? A severe local reaction (pain, erythema, induration, or a combination of these) is probably the result of subcutaneous Injection of the vaccine and does not contraindicate future immunizations. Care should be taken to insure that DTP vaccine is injected intramuscularly rather than subcutaneously. If a severe generalized reaction, such as a convulsion, should occur, further use of pertussis vaccine is contraindieated. Adult-type diphtheria-tetanus toxoid should be substituted for the DTP vaccine, and the series should be continued.
4. Who should receive pertussis vaccine? The infant should receive pertussis vaccine in the combined DTP form as part of the routine immunization series. The vaccine should not be given routinely to children after 6 years of age. Monovalent pertussis vaccine may be useful in epidemies, when even adults may be reimmunized, because greater morbidity occurs with the disease than with the immunization. *Available for $3 from the American Academy ofPediatrics. PO Box 1034. Evanston. IL 60204. tPublished by the Center for Disease Control, 1600 Clifton Rd NE, Atlanta, GA 30333. One of a series of anicles prepared by physicians on the staff of the University of Colorado Medical Center, Denver. Coordinator of the series is Banon Schmitt, MD, associate professor of pediatries and medical director of the pediatrie outpatient de· partment.
216
POSTGAADUATE MEDICINE • April 1976 • Vol. 59 • No. 4
Downloaded by [Australian Catholic University] at 20:00 11 August 2017
5. What are the indications for low doses of DTP (0.1 to 0.25 ml)? If a prior full-dose injection (0.5 ml) of DTP has caused a severe febrile response, reduced doses (0.1 to 0.25 ml) may be indicated. Reducing the DTP inoculum does not significantly affect the immunogenicity of the diphtheria and tetanus components of the vaccine, but it does reduce the likelihood of response to the pertussis component. Compensating for reduced DTP dosage by increasing the number of injections, eg, to six 0.25-ml doses, is not recommended; it may have the undesirab1e effect of hyperimmunizing the child to diphtheria and tetanus toxoids. In the child with a severe febrile response (short of a convulsion), the choiee is either to administer the recommended 0.5-m1 dose and after two hours begin vigorous antipyretie therapy or to reduce the dose and )essen the likelihood of response to the pertussis component.
6. Should oral poliovirus vaccine be given to breast-fed babies? Recent data show that infant response to trivalent oral poliovirus vaccine is not affected by recently ingested breast milk. The amount of antibody secreted in breast milk does not appear to be sufficient to diminish the infection induced with live attenuated poliovirus. Sorne physicians prohibit mothers from feeding infants for an hour after administration of oral poliovirus vaccine, as a precaution against regurgitation of milk and vaccine. The excellent response of infants to the currently recommended five-dose series of oral poliovirus vaccine and the extraordinarily low risk of natural infection in the United States probably make this practiee unnecessary. 7. Should use of oral poliovirus vaccine
be deferred during minor acute illnesses? In general, administration of oral poliovirus vaccine need not be deferred for minor acute illnesses. This also applies to ali live virus vaccine and to DTP. Minor illnesses characterized by fever are relative contraindications to immunization, and gastrointestinal ill ness (eg, diarrhea), with or without fe ver, is a relative contraindieation to administration of trivalent oral poliovirus vaccine. Any routine immunization should be deferred only if the chance that the child will return for the vaccine exceeds th at of the intercurrent min or illness interfering with the response.
Vol. 59 • No. 4 • April1976 • POSTGRADUATE MEDICINE
8. Can a tuberculin tine test be given concurrent/y with measles vaccine? Recent data show that the tuberculin response is not diminished by simultaneous administration of measles vaccine.
9. Who should receive measles vaccine? In general, live attenuated measles vaccine should be given to ali children at 1 year of age. In epidemies, infants 6 to 11 months old should also be immunized. However, infants immunized for any reason before age 1 should be reimmunized at 12 to 15 months of age. To assure protection, children who received measles vaccine before the introduction of further attenuated live virus vaccine in 1969 should also be reimmunized. The use of measles vaccine is contraindicated during immunosuppressive therapy, in the presence of leukemia or other neoplastie disease, or within three months after the administration of whole blood or gamma globulin. Clinieally, administration of live attenuated measles vaccine (grown on chiek embryo fibroblast cell cultures) poses no problems in c hildren with egg allergy. JO. What causes measles immunization
failures in epidemies? Many physicians have reported cases of natural measles that have occurred in children known to have received measles vaccine. These findings have raised questions about long-term protection afforded by measles vaccine. The most likely reasons for failure are: ( 1) use of vaccine inactivated by heat or light because of improper handling, (2) administration of vaccine to infants before 1 year of age, in whom residual maternai antibody may have interfered with immunization, and (3) administration of vaccine either simultaneously with or within three months of a gamma globulin injection or a whole-blood transfusion. However, even if none of these reasons apply and if immunization is done under the best of circumstances, measles vaccine may still not be 100% effective. The reasons for this are not clear, but interference by subclinical infection present at the ti me of vaccination may be a factor. If, for example, measles vaccine is only 98% effective, 2% of the children who receive the vaccine will not be protected and in an epidemie will get measles.
11. What should be done to protect the unimmunized infant or child who has been exposed to meas/es? ..,.
217
pediatries----------------------Richard O. Krugman
Downloaded by [Australian Catholic University] at 20:00 11 August 2017
Dr. Krugman is assistant professor of pediatries, University of Colorado School of Medicine, Denver. He is director of pediatrie group practice and the child health associate internship year.
Although it has been shown that measles vaccine given within 48 hours of exposure protects against the disease, this approach is impractical because the exact time of exposure is often difficult to pinpoint. Furthermore, excretion of the measles virus peaks during the catarrhal stage, so that exposure in the family often precedes diagnosis ofnatural disease by severa) days. Protection may be provided by intramuscular administration of immune serum globulin either in a dosage of 0.04 ml/kg of body weight, which modifies the infection and leads to active immunity, or in a dosage of0.25 ml/kg, which prevents infection and should be followed after at least three months by immunization with live attenuated measles vaccine. Children who are receiving immunosuppressive therapy should be given 20 to 30 ml of immune serum globulin to prevent disease. The measles vaccine is, of course, contraindicated.
12. Who should receive mumps vaccine? The public health priority for immunization with mumps vaccine is lower than that for DTP, oral poliovirus, measles, and ru bella vaccines, but mumps vaccine is recommended for ali children 1 to 12 years old. Susceptible men are also candidates for immunization. However, since 40% of cases of mumps are subclinical and 80% to 85% of persons have the disease during childhood or adolescence, routine immunization of adults is unwarranted. Immune serum globulin and mumps immune globulin have not been shown to be consistent) y effective in preventing the infection.
13. Who should receive rubella vaccine? Advisory groups currently recommend routine immunization against rubella for children 1 to 12 years old and for susceptible women of childbearing age. Precautions against pregnancy should be taken in the three
218
months following immunization. Although sorne experts disagree with this approach, it seems to have succeeded in preventing the expected rubella epidemie that was predicted for 1970 to 1973.
14. Should rubella vaccine be given to children of pregnant women? No documented cases of transmission of rubella vaccine virus from children to others in their environment have been reported. Two factors have been involved: ( 1) Rubella vaccine virus apparently is present only in small amounts in the throat of immunized children, as only low titers have been found, and (2) attenuation of the live rubella virus causes it to Jose most of its ability to infect by the nasopharyngeal route. Thus, the likelihood of transmission of vaccine viruses from child to mother is extremely low. However, because susceptible pregnant women should not be immunized but may be exposed to rubella by their children, it can be argued that their children should be immunized.
15. What are the uses of adult-type diphtheria-tetanus toxoid? Adult-type diphtheria-tetanus toxoid should be used for routine immunization (every ten years). It may also be substituted for tetanus toxoid when both tetanus prophylaxis and additional protection against diphtheria are needed, and it is used instead of DTP for primary immunization of children more than 6 years old.
16. Who should receive influenza vaccine? Public health officiais are distressed that only 15% of the target population who need influenza vaccine (the elderly and chronically ill adults or children) actually get it. Furthermore, adults in high-risk orcritical vocations, such as hospital personnel, transit workers, and schoolteachers, are also candidates for immunization.
17. Who should receive smallpox vaccine? Smallpox vaccine is no longer recommended for routine use in the United States, because the incidence of adverse reactions far exceeds th at of the disease. This recommendation includes the stipulation that persons at high risk for contact with imported cases, such as immigration authorities and medical and hospital personnel, maintain their immunization status. Persons traveling to areas of the world
POSTGRADUATE MEDIC..E • April1!!76 • Vol. 59 • No. 4
Downloaded by [Australian Catholic University] at 20:00 11 August 2017
pediatries-----------------------
where smallpox is endemie must, of course, be immunized. 18. Which vaccines can be given simultaneously? Abundant data show that measles, mumps, and rubella vaccines can be given simultaneously and at the same time as trivalent oral poliovirus vaccine, either as a combined product or singly at separate sites. Other data, obtained by the Center for Disease Control, confirm th at as many as nine antigens (DTP, measles, mumps, rubella, and trivalent oral poliomyelitis vaccine) can be given simultaneously without altering seroconversion rates or increasing side effects. This approach is recommended wh en it is administratively or medically preferable to give many antigens at once, eg, to subjects of poorly funded health programs or to migrant children who are not likely to return for regularly scheduled appointments. 19. How weil are vaccines handled? A recent survey of vaccines used in offices and clinics showed th at nearly 30% of those tested had lost sorne potency, which indicates improper handling at sorne point in the distribution chain. The standards for proper
handling of vaccines should be as high as those for handling donor blood. The insert in packaged vaccine contains proper storage information. 20. What is '' immunization dyspractice''? "Immunization dyspractice" is a term coined to cali attention to the expected and unavoidable adverse consequences of immunization. The probability of oral poliovirus vaccine leading to paralysis is 0.06/million doses; the probability of measles vaccine being associated with encephalitis is 1/million doses. However, because the incidence of paralysis and encephalitis associated with the natural occurrence of poliomyelitis and measles, respectively, far exceeds th at associated with the immunization, society benefits from the use of these vaccines. When an adverse reaction does occur, it is not usually a malpractice situation; thus, lawsuits do not seem to be indicated. Society should develop the means for adequate compensation of victims of dyspractice. •
Address reprint requests to Richard D~ Krugman. MD, Box C 219, Department of Pediatries, University of Colorado Medical Center, 4200 E Ninth Ave, Denver, CO 80220.
Blbllography Arbeter AM, Arthur JH, Blakeman GI, et al: Measles immunity: Reimmunization of children who previously received live measles vaccine and gamma globulin. J Pediatr 81:737, 1972 Barkin SZ: Measles, mumps, rubella vaccine: Advance in immunization. Rocky Mt Med J 72:247, 1975 Berg JM: Neurologie complications of pertussis immunization. Br Med J 2:24, 1958 Bloom JL, Graubarth H, Lipp RW Jr, et al: Evaluation of a trivalent measles, mumps, rubella vaccine in children. J Pediatr 87:85, 1975 Brickman HF, Beaudry PH, Marks Ml: The timing oftuberculin tests in relation to immunization with live viral vaccines. Pediatries 55:392, 1975 Deforest A, Parker PB, DiLiberti JH, et al: The effect of breast-feeding on the antibody response of infants to trivalent oral polio virus vaccine. J Pediatr 83:93, 1973 Eickhoff TC: lmmunization against influenza: Rationale and recommendations. J Infect Dis 123:446, 1971 Fleet WF Jr, Benz EW Jr, Karzon DT, et al: Fetal consequences of maternai rubella immunization. JAMA 227:621, 1974 Goldstein JA, Neff JM, Lane JM, et al: Smallpox vaccination reactions, prophylaxis, and therapy of complications. Pediatries 55:342, 1975 John TJ: The effect of breast feeding on the antibody response of infants to trivalent oral poliovirus vaccine. (Letter) J Pediatr 84:307, 1974 Krugman RD, Meyer BC, Enterline JC, et al: Impotency of live virus vaccines as a result of improper handling in clinical practice. J Pediatr 85:512, 1974
220
Krugman S: Present status of measles and rubella immunization in the United States: A medical progress report. J Pediatr 78:1, 1971 Krugman S, Katz SL: Ru bella immunization, a five-year progress report. N Engl J Med 290:1375, 1974 Landrigan PJ, Witte JJ: Neurologie disorders following live measles virus vaccination. JAMA 223:1459-1462, 26 Mar 1973 Me liman WJ, Wetton R: Depression of the tuberculin reaction by attenuated measles virus vaccine. J Lab Clin Med 61:3, 1963 Rasmussen CM, Thomas CW, Mulrooney RJ, et al: Inadequate poliovirus immunity Ievels in irnmunized lllinois children. Am J Dis Child 126:465, 1973 Rousseau WE, Noble GR, Tegtmeier GE, et al: Persistence of poliovirus neutralizing antibodies eight years after immunization with live attenuated virus vaccine. N Engl J Med 289: 1357' 1973 Sanders DY, Cramblett HG: Antibody titers to polioviruses in patients ten years after immunization with Sabin vaccine. J Pediatr 84:406, 1974 Weibel RE, Buynak EB, Stokes J Jr, et al: Persistence of immunity following monovalent and combined live measles, mumps, and rubella virus vaccines. Pediatries 51:467, 1973 - - : Measurement of immunity following live mumps (5 years), measles (3 years), and rubella (2lh years) virus vaccines. Pediatries 49:334, 1972 White WG, Barnes GM, Griffith AH, et al: Duration of immunity after active immunization against tetanus. Lancet 2:95, 1969
POSTGRADUATE MEDICINE o April1976 o Vol. 59 o No. 4
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
IMMUNIZATION 20 Common Questions and Answers Richard D. Krugman To cite this article: Richard D. Krugman (1976) IMMUNIZATION 20 Common Questions and Answers, Postgraduate Medicine, 59:4, 216-220, DOI: 10.1080/00325481.1976.11714342 To link to this article: http://dx.doi.org/10.1080/00325481.1976.11714342
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 11 August 2017, At: 20:00
pediatries IMMUNIZATION 20 Common Questions and Answers
Downloaded by [Australian Catholic University] at 20:00 11 August 2017
Richard D. Krugman, MD University of Colorado School of Medicine Denver
Who should receive DTP vaccine? Trivalent oral poliovirus vaccine? Measles? Rubella? Mumps? Influenza? Which vaccines can be safely given simultaneously? What causes immunization failures? These are a few of the questions that primary care physicians must be able to answer.
• The following questions are among those commonly asked at postgraduate education sessions for family practitioners and pediatricians. The answers are by no means inclusive guides to immunization practice. Further data may be found in the Red Book (the report of the Committee on lnfectious Diseases of the American Academy of Pediatries)* and in the Morbidity and
Morta/ity Weekly Reports. t 1. What is the usual schedule for immunizations? The routine immunizations currently recommended are: combined diphtheria-tetanus-pertussis (DTP) vaccine and trivalent oral poliovirus vaccine at 2, 4, and 6 months of age; tuberculin test at 9 months; measles, mumps, and rubella vaccines at 12 to 15 months; an additional dose each of DTP and trivalent oral poliovirus vaccine at 18 months and at 4 to 6 years; and adult-type diphtheria-tetanus toxoid every ten years thereafter. 2. If the DTP series is interrupted, should it be restarted? Adequate protection against diphtheria, tetanus, and pertussis requires three doses of DTP initially and two doses later. Even when several years intervene between administration of the doses, no more than five doses are necessary.
3. If a severe reaction to DTP vaccine injection occurs, should the series be continued? A severe local reaction (pain, erythema, induration, or a combination of these) is probably the result of subcutaneous Injection of the vaccine and does not contraindicate future immunizations. Care should be taken to insure that DTP vaccine is injected intramuscularly rather than subcutaneously. If a severe generalized reaction, such as a convulsion, should occur, further use of pertussis vaccine is contraindieated. Adult-type diphtheria-tetanus toxoid should be substituted for the DTP vaccine, and the series should be continued.
4. Who should receive pertussis vaccine? The infant should receive pertussis vaccine in the combined DTP form as part of the routine immunization series. The vaccine should not be given routinely to children after 6 years of age. Monovalent pertussis vaccine may be useful in epidemies, when even adults may be reimmunized, because greater morbidity occurs with the disease than with the immunization. *Available for $3 from the American Academy ofPediatrics. PO Box 1034. Evanston. IL 60204. tPublished by the Center for Disease Control, 1600 Clifton Rd NE, Atlanta, GA 30333. One of a series of anicles prepared by physicians on the staff of the University of Colorado Medical Center, Denver. Coordinator of the series is Banon Schmitt, MD, associate professor of pediatries and medical director of the pediatrie outpatient de· partment.
216
POSTGAADUATE MEDICINE • April 1976 • Vol. 59 • No. 4
Downloaded by [Australian Catholic University] at 20:00 11 August 2017
5. What are the indications for low doses of DTP (0.1 to 0.25 ml)? If a prior full-dose injection (0.5 ml) of DTP has caused a severe febrile response, reduced doses (0.1 to 0.25 ml) may be indicated. Reducing the DTP inoculum does not significantly affect the immunogenicity of the diphtheria and tetanus components of the vaccine, but it does reduce the likelihood of response to the pertussis component. Compensating for reduced DTP dosage by increasing the number of injections, eg, to six 0.25-ml doses, is not recommended; it may have the undesirab1e effect of hyperimmunizing the child to diphtheria and tetanus toxoids. In the child with a severe febrile response (short of a convulsion), the choiee is either to administer the recommended 0.5-m1 dose and after two hours begin vigorous antipyretie therapy or to reduce the dose and )essen the likelihood of response to the pertussis component.
6. Should oral poliovirus vaccine be given to breast-fed babies? Recent data show that infant response to trivalent oral poliovirus vaccine is not affected by recently ingested breast milk. The amount of antibody secreted in breast milk does not appear to be sufficient to diminish the infection induced with live attenuated poliovirus. Sorne physicians prohibit mothers from feeding infants for an hour after administration of oral poliovirus vaccine, as a precaution against regurgitation of milk and vaccine. The excellent response of infants to the currently recommended five-dose series of oral poliovirus vaccine and the extraordinarily low risk of natural infection in the United States probably make this practiee unnecessary. 7. Should use of oral poliovirus vaccine
be deferred during minor acute illnesses? In general, administration of oral poliovirus vaccine need not be deferred for minor acute illnesses. This also applies to ali live virus vaccine and to DTP. Minor illnesses characterized by fever are relative contraindications to immunization, and gastrointestinal ill ness (eg, diarrhea), with or without fe ver, is a relative contraindieation to administration of trivalent oral poliovirus vaccine. Any routine immunization should be deferred only if the chance that the child will return for the vaccine exceeds th at of the intercurrent min or illness interfering with the response.
Vol. 59 • No. 4 • April1976 • POSTGRADUATE MEDICINE
8. Can a tuberculin tine test be given concurrent/y with measles vaccine? Recent data show that the tuberculin response is not diminished by simultaneous administration of measles vaccine.
9. Who should receive measles vaccine? In general, live attenuated measles vaccine should be given to ali children at 1 year of age. In epidemies, infants 6 to 11 months old should also be immunized. However, infants immunized for any reason before age 1 should be reimmunized at 12 to 15 months of age. To assure protection, children who received measles vaccine before the introduction of further attenuated live virus vaccine in 1969 should also be reimmunized. The use of measles vaccine is contraindicated during immunosuppressive therapy, in the presence of leukemia or other neoplastie disease, or within three months after the administration of whole blood or gamma globulin. Clinieally, administration of live attenuated measles vaccine (grown on chiek embryo fibroblast cell cultures) poses no problems in c hildren with egg allergy. JO. What causes measles immunization
failures in epidemies? Many physicians have reported cases of natural measles that have occurred in children known to have received measles vaccine. These findings have raised questions about long-term protection afforded by measles vaccine. The most likely reasons for failure are: ( 1) use of vaccine inactivated by heat or light because of improper handling, (2) administration of vaccine to infants before 1 year of age, in whom residual maternai antibody may have interfered with immunization, and (3) administration of vaccine either simultaneously with or within three months of a gamma globulin injection or a whole-blood transfusion. However, even if none of these reasons apply and if immunization is done under the best of circumstances, measles vaccine may still not be 100% effective. The reasons for this are not clear, but interference by subclinical infection present at the ti me of vaccination may be a factor. If, for example, measles vaccine is only 98% effective, 2% of the children who receive the vaccine will not be protected and in an epidemie will get measles.
11. What should be done to protect the unimmunized infant or child who has been exposed to meas/es? ..,.
217
pediatries----------------------Richard O. Krugman
Downloaded by [Australian Catholic University] at 20:00 11 August 2017
Dr. Krugman is assistant professor of pediatries, University of Colorado School of Medicine, Denver. He is director of pediatrie group practice and the child health associate internship year.
Although it has been shown that measles vaccine given within 48 hours of exposure protects against the disease, this approach is impractical because the exact time of exposure is often difficult to pinpoint. Furthermore, excretion of the measles virus peaks during the catarrhal stage, so that exposure in the family often precedes diagnosis ofnatural disease by severa) days. Protection may be provided by intramuscular administration of immune serum globulin either in a dosage of 0.04 ml/kg of body weight, which modifies the infection and leads to active immunity, or in a dosage of0.25 ml/kg, which prevents infection and should be followed after at least three months by immunization with live attenuated measles vaccine. Children who are receiving immunosuppressive therapy should be given 20 to 30 ml of immune serum globulin to prevent disease. The measles vaccine is, of course, contraindicated.
12. Who should receive mumps vaccine? The public health priority for immunization with mumps vaccine is lower than that for DTP, oral poliovirus, measles, and ru bella vaccines, but mumps vaccine is recommended for ali children 1 to 12 years old. Susceptible men are also candidates for immunization. However, since 40% of cases of mumps are subclinical and 80% to 85% of persons have the disease during childhood or adolescence, routine immunization of adults is unwarranted. Immune serum globulin and mumps immune globulin have not been shown to be consistent) y effective in preventing the infection.
13. Who should receive rubella vaccine? Advisory groups currently recommend routine immunization against rubella for children 1 to 12 years old and for susceptible women of childbearing age. Precautions against pregnancy should be taken in the three
218
months following immunization. Although sorne experts disagree with this approach, it seems to have succeeded in preventing the expected rubella epidemie that was predicted for 1970 to 1973.
14. Should rubella vaccine be given to children of pregnant women? No documented cases of transmission of rubella vaccine virus from children to others in their environment have been reported. Two factors have been involved: ( 1) Rubella vaccine virus apparently is present only in small amounts in the throat of immunized children, as only low titers have been found, and (2) attenuation of the live rubella virus causes it to Jose most of its ability to infect by the nasopharyngeal route. Thus, the likelihood of transmission of vaccine viruses from child to mother is extremely low. However, because susceptible pregnant women should not be immunized but may be exposed to rubella by their children, it can be argued that their children should be immunized.
15. What are the uses of adult-type diphtheria-tetanus toxoid? Adult-type diphtheria-tetanus toxoid should be used for routine immunization (every ten years). It may also be substituted for tetanus toxoid when both tetanus prophylaxis and additional protection against diphtheria are needed, and it is used instead of DTP for primary immunization of children more than 6 years old.
16. Who should receive influenza vaccine? Public health officiais are distressed that only 15% of the target population who need influenza vaccine (the elderly and chronically ill adults or children) actually get it. Furthermore, adults in high-risk orcritical vocations, such as hospital personnel, transit workers, and schoolteachers, are also candidates for immunization.
17. Who should receive smallpox vaccine? Smallpox vaccine is no longer recommended for routine use in the United States, because the incidence of adverse reactions far exceeds th at of the disease. This recommendation includes the stipulation that persons at high risk for contact with imported cases, such as immigration authorities and medical and hospital personnel, maintain their immunization status. Persons traveling to areas of the world
POSTGRADUATE MEDIC..E • April1!!76 • Vol. 59 • No. 4
Downloaded by [Australian Catholic University] at 20:00 11 August 2017
pediatries-----------------------
where smallpox is endemie must, of course, be immunized. 18. Which vaccines can be given simultaneously? Abundant data show that measles, mumps, and rubella vaccines can be given simultaneously and at the same time as trivalent oral poliovirus vaccine, either as a combined product or singly at separate sites. Other data, obtained by the Center for Disease Control, confirm th at as many as nine antigens (DTP, measles, mumps, rubella, and trivalent oral poliomyelitis vaccine) can be given simultaneously without altering seroconversion rates or increasing side effects. This approach is recommended wh en it is administratively or medically preferable to give many antigens at once, eg, to subjects of poorly funded health programs or to migrant children who are not likely to return for regularly scheduled appointments. 19. How weil are vaccines handled? A recent survey of vaccines used in offices and clinics showed th at nearly 30% of those tested had lost sorne potency, which indicates improper handling at sorne point in the distribution chain. The standards for proper
handling of vaccines should be as high as those for handling donor blood. The insert in packaged vaccine contains proper storage information. 20. What is '' immunization dyspractice''? "Immunization dyspractice" is a term coined to cali attention to the expected and unavoidable adverse consequences of immunization. The probability of oral poliovirus vaccine leading to paralysis is 0.06/million doses; the probability of measles vaccine being associated with encephalitis is 1/million doses. However, because the incidence of paralysis and encephalitis associated with the natural occurrence of poliomyelitis and measles, respectively, far exceeds th at associated with the immunization, society benefits from the use of these vaccines. When an adverse reaction does occur, it is not usually a malpractice situation; thus, lawsuits do not seem to be indicated. Society should develop the means for adequate compensation of victims of dyspractice. •
Address reprint requests to Richard D~ Krugman. MD, Box C 219, Department of Pediatries, University of Colorado Medical Center, 4200 E Ninth Ave, Denver, CO 80220.
Blbllography Arbeter AM, Arthur JH, Blakeman GI, et al: Measles immunity: Reimmunization of children who previously received live measles vaccine and gamma globulin. J Pediatr 81:737, 1972 Barkin SZ: Measles, mumps, rubella vaccine: Advance in immunization. Rocky Mt Med J 72:247, 1975 Berg JM: Neurologie complications of pertussis immunization. Br Med J 2:24, 1958 Bloom JL, Graubarth H, Lipp RW Jr, et al: Evaluation of a trivalent measles, mumps, rubella vaccine in children. J Pediatr 87:85, 1975 Brickman HF, Beaudry PH, Marks Ml: The timing oftuberculin tests in relation to immunization with live viral vaccines. Pediatries 55:392, 1975 Deforest A, Parker PB, DiLiberti JH, et al: The effect of breast-feeding on the antibody response of infants to trivalent oral polio virus vaccine. J Pediatr 83:93, 1973 Eickhoff TC: lmmunization against influenza: Rationale and recommendations. J Infect Dis 123:446, 1971 Fleet WF Jr, Benz EW Jr, Karzon DT, et al: Fetal consequences of maternai rubella immunization. JAMA 227:621, 1974 Goldstein JA, Neff JM, Lane JM, et al: Smallpox vaccination reactions, prophylaxis, and therapy of complications. Pediatries 55:342, 1975 John TJ: The effect of breast feeding on the antibody response of infants to trivalent oral poliovirus vaccine. (Letter) J Pediatr 84:307, 1974 Krugman RD, Meyer BC, Enterline JC, et al: Impotency of live virus vaccines as a result of improper handling in clinical practice. J Pediatr 85:512, 1974
220
Krugman S: Present status of measles and rubella immunization in the United States: A medical progress report. J Pediatr 78:1, 1971 Krugman S, Katz SL: Ru bella immunization, a five-year progress report. N Engl J Med 290:1375, 1974 Landrigan PJ, Witte JJ: Neurologie disorders following live measles virus vaccination. JAMA 223:1459-1462, 26 Mar 1973 Me liman WJ, Wetton R: Depression of the tuberculin reaction by attenuated measles virus vaccine. J Lab Clin Med 61:3, 1963 Rasmussen CM, Thomas CW, Mulrooney RJ, et al: Inadequate poliovirus immunity Ievels in irnmunized lllinois children. Am J Dis Child 126:465, 1973 Rousseau WE, Noble GR, Tegtmeier GE, et al: Persistence of poliovirus neutralizing antibodies eight years after immunization with live attenuated virus vaccine. N Engl J Med 289: 1357' 1973 Sanders DY, Cramblett HG: Antibody titers to polioviruses in patients ten years after immunization with Sabin vaccine. J Pediatr 84:406, 1974 Weibel RE, Buynak EB, Stokes J Jr, et al: Persistence of immunity following monovalent and combined live measles, mumps, and rubella virus vaccines. Pediatries 51:467, 1973 - - : Measurement of immunity following live mumps (5 years), measles (3 years), and rubella (2lh years) virus vaccines. Pediatries 49:334, 1972 White WG, Barnes GM, Griffith AH, et al: Duration of immunity after active immunization against tetanus. Lancet 2:95, 1969
POSTGRADUATE MEDICINE o April1976 o Vol. 59 o No. 4
