INFECTIOUS DISEASES - PART 2 pptx

higher risk of being hospitalized because of RSV and LRTIs. Respiratory syncytial virus prophylaxis should be considered for AI/AN infants born at 32 to 35 weeks' gestation who will be younger than 6 months of age at the start of the RSV season (if 2 or more risk factors are present [see Respiratory Syncytial Virus, p 560]). Influenza. Hospitalization rates for all LRTIs are higher in AI/AN children. Like other US children, AI/AN children between 6 and 23 months of age should receive annual influenza vaccine, and household contacts of infants 0 to 23 months of age should receive annual influenza vaccine. Children in Residential Institutions Children housed in institutions pose special problems for control of certain infectious diseases. Ensuring appropriate immunization is important because of the risk of transmission within the facility and because conditions that led to institutionalization may increase the risk of complications from the disease. All children entering a residential institution should have received recommended immunizations for their age (see Fig 1.1, p 26, and Table 1.7, p 28). If they have not been immunized appropriately, arrangements should be made to administer these immunizations as soon as possible. Staff members should be familiar with standard precautions and procedures for handling contaminated blood and body fluids as well as trauma with bleeding. For residents who acquire potentially transmissible infectious agents while living in an institution, isolation precautions similar to those recommended for hospitalized patients should be followed (see Infection Control for Hospitalized Children, p 153). Specific diseases of concern include the following (see the disease-specific chapters in Section 3 for detailed recommendations). Measles. Epidemics can occur among susceptible children in institutional settings. Recommendations for managing children in an institutional setting when a case of measles is recognized are as follows: (1) within 72 hours of exposure, administer live measles virus vaccine (as MMR) to all susceptible children 1 year of age or older for whom immunization is not contraindicated; and (2) administer IG to immunocompromised children (see Measles, p 441) as soon as possible and within 6 days of exposure to all exposed susceptible children younger than 1 year of age. These IG recipients also will require live- virus vaccine (as MMR vaccine) at 12 months of age or thereafter, depending on the age and dose of IG administration (see Table 3.32, p 445, for the appropriate interval between IG administration and MMR immunization). Mumps. Epidemics can occur among susceptible unimmunized children in institutions. Major hazards are disruption of activities, the need for acute nursing care in difficult settings, and occasional serious complications (eg, in susceptible adult staff). If mumps is introduced, prophylaxis is not available to limit the spread or to attenuate the disease in a susceptible person. Immune Globulin is not effective, and Mumps Immune Globulin is not available. Although mumps virus vaccine may not be effective after exposure, the vaccine should be administered to susceptible people to protect against infection from future exposures. Influenza. Influenza can be unusually severe in a residential or custodial institutional setting. Rapid spread, intensive exposure, and underlying disease can result in a high risk of severe illness that may affect many residents simultaneously or in close sequence. Current measures for control of influenza in institutions include: (1) a program of annual influenza immunization of residents and staff; and (2) appropriate use of chemoprophylaxis during influenza epidemics (see Influenza, p 401). Pertussis. Because progressive developmental delay may have resulted in a deferral of pertussis immunization, many children in an institutional setting may not be appropriately immunized against pertussis. Because pertussis vaccine does not cause progressive neurologic disease and because pertussis disease poses a greater risk than does pertussis immunization, children who are not immunized fully and who are younger than 7 years of age or 11 years of age and older should be immunized against pertussis. If pertussis is recognized, infected people and their close contacts should receive chemoprophylaxis (see Pertussis, p 498). Hepatitis A. Outbreaks of hepatitis A affecting residents and staff can occur in institutions for custodial care by fecal-oral transmission. Infection usually is mild or asymptomatic in young children but can be severe in adults. Hepatitis A vaccine, in addition to IG, may be indicated for postexposure prophylaxis for staff and children 1 year of age or older in institutions in which a hepatitis A outbreak is occurring. If an outbreak occurs, susceptible residents and staff members in close personal contact with patients should receive IG (see Hepatitis A, p 326). Hepatitis B. Children living in residential institutions for children with developmental disabilities and their caregivers are assumed to be at increased risk of acquiring HBV infection. The high prevalence of markers of HBV infection among children living in these facilities indicates that HBV infections have the propensity for spread in an institutional setting, presumably by exposure to blood and body fluids containing HBV. Factors associated with high prevalence of HBV markers include crowding, high resident-to-staff ratios, and lack of in-service educational programs for staff. In the presence of such factors, the prevalence of HBV increases with the duration of time spent at the institution. Thus, susceptible residents entering or already residing and staff in institutions for children with developmental disabilities should be immunized against HBV; preimmunization serologic screening for HBV markers probably is not cost-effective. After parenteral or sexual exposure to an institutionalized patient recognized to be an HBsAg carrier, patients or staff members who are unimmunized and susceptible should receive active and passive immunoprophylaxis (see Hepatitis B, p 335, for recommendations for previously immunized individuals). Pneumococcal Infections. Children with severe physical or mental disabilities, particularly children who are bedridden, who suffer from a compromised respiratory status, or who are capable of only limited physical activity, may benefit from influenza vaccine and pneumococcal conjugate or polysaccharide vaccine (see Pneumococcal Infections, p 525). Varicella. Because varicella is highly contagious, disease can occur in a large proportion of susceptible people in an institutional setting. All healthy individuals 1 year of age or older who lack a reliable history of varicella disease or immunization should be immunized. In addition, during a varicella outbreak, a second dose of varicella vaccine is recommended for people who have received 1 dose of varicella vaccine, resources permitting, provided the appropriate interval has elapsed since the first dose (3 months for people 12 months through 12 years of age and at least 4 weeks for people 13 years of age and older). Passive immunization during outbreaks currently is recommended only for immunocompromised, susceptible children at risk of serious complications or death from varicella (see Varicella-Zoster Infections, p 711). Other Infections. Other organisms causing diseases that spread in institutions and for which no immunizations are available include Shigella species, E coli O157:H7, other enteric pathogens, Streptococcus pyogenes, S aureus, respiratory tract viruses, cytomegalovirus, scabies, and lice. Children Living Outside the United States In general, children of active-duty military personnel require the same immunizations as their civilian counterparts. If delay in pertussis immunization is recommended for any reason, parents should be warned that the risk of contracting the disease in countries where pertussis immunization is not administered routinely is significantly higher than that in countries where effective vaccine is used. For military dependents traveling internationally, the risk of exposure to HAV, HBV, measles, pertussis, diphtheria, poliovirus, yellow fever, Japanese encephalitis, and other infections may be increased and may necessitate additional immunizations (see International Travel, p 98). In these instances, the choice of immunizations will be dictated by the country of proposed residence, expected travel, and the age and health of the child. For information on the risk of specific diseases in different countries and preventive measures, see International Travel (p 98) or consult the CDC Web site (www.cdc.gov/travel) or the WHO Web site (www.WHO.int/ith). Adolescent* and College Populations * Centers for Disease Control and Prevention. Vaccine-preventable diseases: improving vaccination coverage in children, adolescents, and adults. A report on recommendations from the Task Force on Community Preventive Services. MMWR Recomm Rep. 1999;48(RR-8):1-15 Adolescents and young adults may not be protected against all vaccine- preventable diseases. This age group may include people who escaped natural infection and who (1) were not immunized with all recommended vaccines; (2) received appropriate vaccines but at too young an age (eg, measles vaccine before 12 months of age); (3) received incomplete immunization regimens (eg, only 1 or 2 doses of HBV vaccine); (4) failed to respond to vaccines administered at appropriate ages; or (5) have waned immunity despite appropriate immunization. To ensure age-appropriate immunization, all children should have a routine appointment at 11 to 12 years of age for the following purposes: (1) to immunize people who previously have not received 2 doses of MMR vaccine; (2) to give varicella and/or hepatitis B vaccine and meningococcal conjugate vaccine as indicated; (3) to provide a dose of Tdap vaccine; and (4) to provide other immunizations and preventive services that are indicated. Additional vaccines that may be indicated at this preadolescent visit include influenza, pneumococcal, and hepatitis A vaccines. Specific indications for each of these vaccines are given in the respective disease-specific chapters in Section 3. Appointments for needed doses of vaccines that are not administered during the aforementioned visit should be scheduled. During all subsequent adolescent visits, immunization status should be reviewed and deficiencies should be corrected, including completion of the 3-dose HBV vaccine series and administration of meningococcal conjugate vaccine and Tdap vaccine as recommended. School immunization laws encourage "catch-up" programs for older adolescents. Accordingly, school and college health services should establish a system to ensure that all students are protected against vaccine- preventable diseases. Many colleges are implementing the American College Health Association (ACHA) recommendations for prematriculation immunization requirements, mandating protection against measles, mumps, rubella, tetanus, diphtheria, polio, varicella, and HBV (www.acha.org). In addition, N meningitidis vaccine is required by some colleges and universities; many states have laws requiring prematriculation immunization (www.immunize.org/laws). Meningococcal conjugate vaccine is preferred, but meningococcal polysaccharide vaccine also is acceptable. Measles. In the 1990s, many colleges and universities experienced measles outbreaks; such outbreaks could recur if the proportion of susceptible people increases. Additionally, students traveling internationally have been victims of measles and sources of importation into the United States. To prevent measles outbreaks and ensure high levels of immunity among young adults on college and university campuses, the ACHA has recommended that colleges and universities require 2 doses of measles vaccine as a condition for matriculation. The first dose must have been given on or after the first birthday; the interval between the first and second dose must have been at least 1 month. Similarly, in postsecondary school educational settings, the AAP recommends a 2-dose measles immunization schedule, given as MMR vaccine, for people born in 1957 or after. Rubella. Adolescents and adults should be considered susceptible to rubella if documentation of receipt of one dose of vaccine or serologic evidence of antibody is lacking. Immunizing susceptible adolescents and adults in college decreases the chance of outbreaks and helps to prevent congenital rubella syndrome. Varicella. Varicella immunity is desirable in adolescents and adults, especially adults in colleges and universities and women of childbearing age. Adults, adolescents, and children with a reliable history of varicella disease can be assumed to be immune, and immunization is not necessary. Because approximately 70% to 90% of people 18 years of age or older without a reliable history of varicella disease also will be immune and because 2 doses of vaccine are needed for people 13 years of age and older, serologic testing of people 13 years of age or older and immunization of people who are seronegative may be cost-effective. If serologic testing is performed, a tracking system to access seronegative people should be in place to ensure that susceptible people are immunized. However, serologic testing is not required, because varicella vaccine is well tolerated in people who are immune from immunization or previous disease. In many situations, especially for young adolescents, universal immunization rather than serologic testing and tracking may be easier to implement. People older than 12 years of age will require 2 doses of vaccine separated by 4 to 8 weeks. Hepatitis B. Hepatitis B virus vaccine is recommended for administration to all susceptible adolescents, especially adolescents who have one or more risk factors for HBV infection. Risk factors include multiple sexual partners (defined as more than 1 partner within the previous 6 months), a sexually transmitted disease, sexually active homosexual or bisexual behavior, injection drug use, institutionalization or incarceration, and occupation or training involving contact with blood or body fluids. In 2005, the ACIP recommended that unimmunized adults at high risk and all adults seeking protection from hepatitis B should be immunized. Diphtheria, Tetanus, and Pertussis. Adolescents 11 to 18 years of age should receive a single dose of Tdap instead of Td vaccine for booster immunization. For complete recommendations, see Pertussis, p 498. Influenza. Epidemic influenza can affect any closed population. Physicians responsible for health care in schools and colleges should consider annual influenza immunization of students, particularly students residing in dormitories or students who are members of athletic teams, to decrease morbidity and to minimize disruption of routine activities during epidemics. Students with chronic medical conditions should be immunized annually (see Influenza, p 401). Neisseria meningitidis. Immunization of college freshmen living in dormitories is recommended by the AAP and the ACIP. Because of the feasibility constraints of targeting freshmen in dormitories, colleges may elect to target all matriculating freshmen. Use of meningococcal conjugate vaccine (MCV4) is preferred; but if MCV4 is unavailable, meningococcal polysaccharide vaccine is an acceptable alternative (see Meningococcal Infections, p 452). Other recommendations. Because adolescents and young adults commonly travel internationally, their immunization status and travel plans should be reviewed 2 or more months before departure to allow time to administer any needed vaccines (see International Travel, p 98). Some physicians are unaware that adolescents and young adults have risks of vaccine-preventable diseases and do not give priority to immunization. Pediatricians should assist in providing information on benefits and risks of immunization. People with religious or philosophic exemptions have been victims and sources of vaccine-preventable diseases. Therefore, reasons for and risks of administering recommended vaccines should be reviewed, refusal should be documented, and the importance of immunization should be emphasized. The possible occurrence of diseases such as measles, mumps, rubella, hepatitis A, hepatitis B, pertussis, influenza, and N meningitidis infections in a school or college should be reported promptly to local health officials according to individual state guidelines. Health Care Personnel* * Centers for Disease Control and Prevention. Immunization of health-care workers: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR. 1997;46(RR-18):1-42 Adults whose occupations place them in contact with patients with contagious diseases are at increased risk of contracting vaccine-preventable diseases and, if infected, transmitting them to their patients. All health care personnel should protect themselves and susceptible patients by receiving appropriate immunizations. Physicians, health care facilities, and schools for health care professionals should play an active role in implementing these policies. Vaccine-preventable infections of special concern to people involved in the health care of children are as follows (see the disease-specific chapters in Section 3 for further recommendations). Rubella. Outbreaks of rubella among health care personnel have been reported. Although the disease is mild in adults, the risk to a fetus necessitates documentation of rubella immunity in health care personnel of both sexes. People should be considered immune on the basis of serologic tests or documented proof of rubella immunization on or after the first birthday. A history of rubella disease is unreliable and should not be used in determining immune status. All susceptible people should be immunized with MMR vaccine (or monocomponent rubella vaccine if immunity to measles and mumps has been documented) before initial or continuing contact with pregnant patients. Measles. Because measles in health care personnel has contributed to spread of this disease during outbreaks, evidence of immunity to measles should be required for health care personnel born after 1957. Proof of immunity is established by physician-documented measles, a positive serologic test for measles antibody, or documented receipt of 2 doses of live- virus measles vaccine, the first of which is given on or after the first birthday. Health care personnel born before 1957 generally have been considered immune to measles. However, because measles cases have occurred in health care personnel in this age group, health care facilities should consider offering at least 1 dose of measles-containing vaccine to workers who lack proof of immunity to measles, particularly in communities with documented measles outbreaks. Mumps. Transmission of mumps in health care facilities can be disruptive and costly. Adults born before 1957 generally have been considered immune to mumps; adults born in 1957 or after are considered immune if they have documentation of a single dose of mumps vaccine received on or after their first birthday or laboratory evidence of immunity. Hepatitis B. Vaccine is recommended for all health care personnel who are likely to be exposed to blood or blood-containing body fluids. The Occupational Safety and Health Administration of the US Department of Labor has issued a regulation requiring employers of workers at risk of occupational exposure to HBV to offer HBV immunization to employees at the employer's expense. Employees who refuse recommended immunizations should sign a refusal document. In some cases, susceptible health care personnel immunized appropriately with HBV vaccines fail to develop serologic evidence of immunity against HBsAg (anti-HBs). Serologic evidence of immunity is defined as serum anti-HBs concentration 10 mIU/mL. People who do not respond to the primary immunization series should complete a second 3-dose vaccine series with reevaluation of anti-HBs titers 1 to 2 months after the series is completed. People who do not respond to the second series and are HBsAg negative should be considered susceptible to HBV infection and need to receive HBIG prophylaxis for any known or probable exposure to blood or body fluids infected with HBV.* Influenza. Certain groups of patients, such as people with chronic cardiovascular or pulmonary disease, are at increased risk of serious or complicated influenza infection. Because health care personnel can transmit influenza to their patients and nosocomial outbreaks can occur, influenza immunization should be recommended and encouraged for all hospital personnel and other health care professionals with direct patient contact each autumn. Influenza vaccine should be available to personnel on all shifts in a convenient manner and location, such as through use of mobile immunization carts. Varicella. Proof of varicella immunity is recommended for all health care personnel. In health care institutions, serologic screening of personnel who have an uncorroborated negative or uncertain history of varicella before immunization is likely to be cost-effective but need not be done. Varicella immunization is recommended for all immunocompetent people. Tuberculosis.* Early detection and treatment of patients (or visitors) with communicable tuberculosis is recommended to prevent tuberculosis infection in health care personnel. The risk of transmission of tuberculosis in hospitals varies greatly and is determined by local epidemiologic data. Policies for tuberculin skin testing for health care personnel should conform to CDC guidelines. According to current CDC recommendations, BCG immunization should be considered on an individual basis in settings with a high prevalence of multidrug-resistant Mycobacterium tuberculosis infection, in situations in which transmission of resistant organisms is likely, and in facilities where comprehensive infection-control precautions against M tuberculosis transmission have been implemented and have failed. a * Hepatitis B virus infection: a comprehensive immunization strategy to eliminate transmission in the US. Part II: immunization of adults. MMWR, 2006; in press (see http://www.cdc.gov/mmwr) * Centers for Disease Control and Prevention. Controlling tuberculosis in the United States: recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America. MMWR Recomm Rep. 2005;54(RR-12):1-81 a Centers for Disease Control and Prevention. The role of BCG vaccine in the prevention and control of tuberculosis in the United States: a joint statement by the Advisory Council for the Elimination of Tuberculosis and the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 1996;45(RR- 4):1-18 Refugees and Immigrants Prevention of infectious diseases in refugee and immigrant children presents special challenges because of the diseases to which these children may have been exposed and the different immunization practices in their native countries. In addition, other aspects of providing care to immigrant, refugee, homeless, and immigrant children should be considered. b Since 1996, people seeking an immigrant visa for permanent residency must show proof of receipt of at least the first dose of all vaccines in the recommended immunization series. Although these regulations apply to most immigrant children entering the United States, internationally adopted children who are younger than 10 years of age are exempt from these requirements. Adoptive parents are required to sign a waiver indicating their intention to comply with the ACIP immunization requirements after the child's arrival in the United States. Refugees are not required to meet immunization requirements of the Immigration and Nationality Act at the time of initial entry into the United States but must show proof of immunization when they apply for permanent residency, typically within 3 years of arrival. b American Academy of Pediatrics, Committee on Community Health Services. Providing care for immigrant, homeless, and migrant children. Pediatrics. 2005;115:1095-1100 Children who have resided in refugee processing camps for a few months often have had access to medical and treatment services, which may have included some immunizations. However, these children almost universally are incompletely immunized and often have no immunization records. For refugee children whose immunizations are not up-to-date, as documented by a written immunization record (see Immunizations Received Outside the United States, p 35), vaccines as recommended for their age should be administered (see Fig 1.1, p 26, and Table 1.7, p 28). For children without documentation of immunizations, a new vaccine schedule may be initiated. Alternatively, measurement of antibody concentrations to diphtheria, tetanus, measles, mumps, rubella, varicella, and poliovirus (each serotype) and anti-HBs as well as HBsAg and anti-HBc, if from an area with endemic hepatitis B infection, may be considered to determine whether the child needs additional immunizations or initiation of the immunization schedule appropriate for that child's age (see Table 2.18, Approaches to the Evaluation and Immunization of Internationally Adopted Children, p 189). Although many children will have received DTP, poliovirus, measles, and hepatitis B vaccines, most will not have received Hib, pneumococcal, hepatitis A, rubella, mumps, and varicella vaccines. Measles antibody may be measured to determine whether the child is immune; however, many children may need a dose of mumps and rubella vaccines, because these vaccines are not given routinely in developing countries. A clinical diagnosis of rubella without serologic testing should not be accepted as evidence of rubella immunity. Varicella vaccine is not administered in most countries, and history of varicella infection may be unavailable or unreliable in these populations; therefore, children should be immunized for varicella or have antibody testing performed. All refugees and immigrants from areas with endemic hepatitis B infection, particularly Asia and Africa, should be screened for hepatitis B with serologic tests for HBsAg, anti-HBs, and antibody to hepatitis B core antigen (anti-HBc). A child who tests positively for HBsAg has active infection and may be defined as a chronic carrier if the HBsAg persists for longer than 6 months. Most children who are HBsAg carriers are asymptomatic. Therefore, screening is important to identify children who need follow-up and management and to limit transmission of disease. Transmission risks should be minimal among children in the United States because of universal infant HBV immunization programs. However, adult caregivers may be unimmunized and should be given hepatitis B vaccine if they are susceptible and HBIG if they have had a significant exposure to blood of a carrier (see Hepatitis B, p 335). Serologic screening of all pregnant refugees and immigrants for HBsAg is imperative to identify women whose infants need passive as well as active immunoprophylaxis. Tuberculosis and HIV infection also are important public health concerns, because many refugees and immigrants come from countries with high prevalences of tuberculosis and HIV infection. Tuberculosis cases in foreign- born people now account for more than 50% of all tuberculosis cases in the United States. Although tuberculosis rates have decreased among children born in the United States in the last decade, rates remain high among children from developing countries. The risk of HIV infection among refugees and immigrants depends on the country of origin and on individual risk factors, especially among vulnerable refugee populations. The decision to screen children for HIV should depend on history and risk factors (eg, receipt of blood products, maternal drug use), physical examination findings, and prevalence of HIV infection in the child's country of origin. If there is a suspicion of HIV infection, testing should be performed before administration of live vaccines. International Travel Children and adolescents should be up-to-date on routinely recommended immunizations before international travel. In addition, travel requires consideration of additional vaccines to prevent hepatitis A, yellow fever, meningococcal disease, typhoid fever, cholera, rabies, and Japanese encephalitis. Vaccines may be required or recommended depending on the destination and type of international travel (see Table 1.15, p 21). Travelers to tropical and subtropical areas often risk exposure to malaria, dengue fever, other vectorborne pathogens, leptospirosis, diarrhea, and other diseases for which vaccines are not available. For travelers to areas with endemic malaria, antimalarial chemoprophylaxis and insect precautions are vitally important (see Malaria, p 435). Attention to hand hygiene and choosing safer foods and beverages for consumption also can reduce travelers' risk of acquiring other communicable diseases. Up-to-date information, including alerts about current disease outbreaks that may affect international travelers, is available on the CDC Travelers' Health Web site at www.cdc.gov/travel or the WHO Web site at www.who.intl/ith/. Health Information for International Travel (the "Yellow Book") is published every 2 years by the CDC and is an excellent reference for travelers and for practitioners who advise international travelers of health risks. To enhance the usefulness of travel notices, the CDC Travelers' Health Web site issues and removes travel notices under 1 of 4 levels: in the news, outbreak notice, travel health precaution, and travel health warning. Travel information and recommendations can be obtained from the CDC by fax (888-232-3299) or telephone recording (877-394-8747, or 877-FYI-TRIP). Local and state health departments and travel clinics also can provide updated information. Information about cruise ship sanitation inspection scores and reports can be found at www2.cdc.gov/nceh/vsp/vspmain.asp/. RECOMMENDED IMMUNIZATIONS Infants and children embarking on international travel should be up-to-date on receipt of immunizations recommended for their age. For travel to many countries with highly endemic rates of hepatitis A infection, HAV immunization also may be recommended (see Hepatitis A, p 326). Duration of travel is only one indicator of risk of acquiring infections. Depending on the situation, people can be at high risk even if their stay in the area with endemic infection is brief. Destination, activities, and exposures, as well as host factors, are important in deciding whether to immunize against certain diseases. To optimize immunity before departure, vaccines may need to be given on an accelerated schedule (see Table 1.15, p 99). Worldwide poliovirus eradication efforts have decreased the number of countries where travelers are at risk of poliovirus infection. Most wild-type poliovirus is found in 6 countries: Afghanistan, India, Pakistan, Nigeria, Niger, and Egypt. The Western Hemisphere was declared free of wild-type poliovirus in 1994, and the Western Pacific Region was declared free in 2000. The finding of vaccine-derived poliovirus (VDPV) in stool samples from several asymptomatic unimmunized people in a community is the first occurrence of VDPV transmission in a community in the United States since OPV immunizations were discontinued in 2000.* This finding raises concerns about the risk of transmission to other communities with a low level of transmission and the risk of a polio outbreak occurring in the United States. To ensure protection, all children, including pediatric travelers, should be fully immunized against poliovirus. Three doses of IPV vaccine should be administered before departure as shown in the Recommended Childhood and Adolescent Immunization Schedule (Fig 1.1, p 26). If necessary, the doses may be given at 4-week intervals, although 6- to 8-week intervals are preferred. Children should receive a supplemental fourth dose at 4 to 6 years of age (see Poliovirus Infections, p 542). * Centers for Disease Control and Prevention. Poliovirus infections in four unvaccinated children-Minnesota, August-October 2005. MMWR Morb Mortal Wkly Rep. 2005;54:1053-1055 Importation of measles remains an important source for measles cases in the United States. Therefore, people traveling abroad should be immune to measles to provide personal protection and minimize importation of measles. People should be considered susceptible to measles unless they have [...]... wk 2- 1 4 mo 4 wk IPV3 6-1 8 mo 14 wk 3-5 y 4 wk IPV4 4-6 y 18 wk Pneumococcal 2 mo 6 wk 2 mo 4 wk conjugate vaccine (PCV)15 PCV2 4 mo 10 wk 2 mo 4 wk PCV3 6 mo 14 wk 6 mo 8 wk PCV4 1 2- 1 5 mo 12 mo Measles-mumps-rubella 1 2- 1 5 mo7 12 mo 3-5 y 4 wk (MMR)1 MMR2 4-6 y 13 mo 8 Varicella 1 2- 1 8 mo 12 mo 4 wk8 4 wk8 Hepatitis A1 1 2- 2 3 mo 12 mo 6-1 8 mo 6 mo Hepatitis A2 1 8-4 1 mo 18 mo Influenza, trivalent 6 -2 3... B33 6-1 8 mo 24 wk Diphtheria and tetanus 2 mo 6 wk 2 mo 4 wk toxoids and acellular pertussis (DTaP) 12 DTaP2 4 mo 10 wk 2 mo 4 wk DTaP3 6 mo 14 wk 6-1 2 mo 6 mo4 DTaP4 1 5-1 8 mo 12 mo 3y 6 mo DTaP5 4-6 y 4y 2 mo 6 wk 2 mo 4 wk Haemophilus influenzae 2, 5 type b (Hib)1 Hib2 4 mo 10 wk 2 mo 4 wk Hib36 6 mo 14 wk 6-9 mo 8 wk Hib4 1 2- 1 5 mo 12 mo Inactivated poliovirus 2 mo 6 wk 2 mo 4 wk 2 (IPV)1 IPV2 4 mo... weight 90 kg Male, weight 6 0-1 18 kg Male, weight >118 kg 1 Newborn is first 28 days of life 5/8 (16) 5/8 (16) 1 (25 ) 5/8 -1 (1 6 -2 5) 1-1 1/4 (2 5-3 2) Anterolateral thigh muscle Anterolateral thigh muscle Anterolateral thigh muscle Deltoid muscle of the arm Anterolateral thigh muscle 5/8 -1 (1 6 -2 5) 1 (25 ) 1 1 /2 (38) 1 (25 ) 1 1 /2 (38) Deltoid muscle of the arm... 15-min period, every 6-8 h (50 mg, maximum single dose) IV: 10 0 -2 00 mg, every 4-6 h IV: 1. 5 -2 mg/kg, every 4-6 h (60 mg, maximum single dose) Oral: 1. 5 -2 mg/kg, single morning dose (60 mg, maximum single dose); use corticosteroids as long as needed Nebulizer solution: 0.5% (5 mg/mL), 0.0 5-0 .15 mg/kg per dose in 2- 3 mL isotonic sodium chloride solution, maximum 5 mg/dose every 20 min over a 1-h to 2- h... the CDC telephone hotline ( 1-8 0 0 -2 3 2- 4 636) Report adverse reactions to vaccines through the federal Vaccine Adverse Event Reporting System For information on reporting reactions following vaccines, please visit or call the 24 -hour national toll-free information line at 80 0-8 2 2- 7 967 Report suspected cases of vaccine-preventable diseases to your state or the local health department 1 Diphtheria and tetanus... receptor-blocking agents (antihistamines) Diphenhydramine Oral, IM, IV: 1 -2 mg/kg, every 4-6 h (100 mg, maximum single dose) Hydroxyzine Oral, IM: 0. 5-1 mg/kg, every 4-6 h (100 mg, maximum single dose) H2 receptor-blocking agents (also antihistamines) Cimetidine IV: 5 mg/kg, slowly over a 15-min period, every 6-8 h (300 Ranitidine Corticosteroids Hydrocortisone Methylprednisolone Prednisone B2-agonist... inactivated (annually) Influenza, trivalent live5y 6-1 0 wk 6 wk 9 attenuated Meningococcal 1 1-1 2 y 11 y conjugate vaccine (MCV4) 2y 5y 5y Meningococcal polysaccharide vaccine (MPSV4 )-1 MPSV 4 -2 7 y10 Tetanus toxoid, reduced 11 y 11 y 10 y11 diptheria toxoid, and reduced acellular pertussis (Tdap) Pneumococcal 2y 5 y 12 5y polysaccharide vaccine (PPV)1 PPV2 7 y 12 1 Combination vaccines are available Use of... conjugate IM 2 Hib conjugate-DTaP (PRP-T Polysaccharide-protein conjugate with IM reconstituted with DTaP) toxoids and inactivated bacterial components Hib conjugate (PRP-OMP2) Polysaccharide-protein conjugate with IM -hepatitis B recombinant viral antigen Influenza Inactivated viral components IM Influenza Live-attenuated virus Intranasal Japanese encephalitis Inactivated virus SC Measles Live-attenuated... vaccine 2 C-8 C Do not freeze Protect from light Meningococcal polysaccharide Lyophilized or vaccine reconstituted formulation: 2 C-8 C Do not freeze Discard reconstituted multidose vials after 35 days; use single-dose vial within 30 min Mumps virus vaccine, live See MMR Rubella virus vaccine, live See MMR Pneumococcal polysaccharide 2 C-8 C Do not freeze vaccine Pneumococcal conjugate vaccine 2 C-8 C... within 30 min Hepatitis A virus vaccine, 2 C-8 C Do not freeze Opaque, white suspension inactivated Hepatitis A-hepatitis B combination2 C-8 C Do not freeze Homogeneous white turbid vaccine suspension Hepatitis B virus vaccine 2 C-8 C Do not freeze After thorough agitation, a slightly inactivated (recombinant) opaque, white suspension Hib conjugate vaccine: HbOC 2 C-8 C Do not freeze Clear, colorless liquid . 5/8 (16) Anterolateral thigh muscle Term, age 2 -1 2 mo 1 (25 ) Anterolateral thigh muscle Toddlers and children 5/8 -1 (1 6 -2 5) 1-1 1/4 (2 5-3 2) Deltoid muscle of the arm Anterolateral. recommendations can be obtained from the CDC by fax (88 8 -2 3 2- 3 29 9) or telephone recording (87 7-3 9 4-8 747, or 877-FYI-TRIP). Local and state health departments and travel clinics also can provide updated. PRP-T, polyribosylribitol phosphate-tetanus toxoid; PRP-OMP, polyribosylribitol phosphate-meningococcal outer membrane protein; MMR, live measles-mumps-rubella; MMRV, live measles-mumps-rubella- varicella;