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Back to school: Infectious disease lessons learned
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Meeting your patients before the start of the school year is an opportunity to review their health maintenance records and deliver age-appropriate health advice. Besides checking up on whether there is a problem with bullying, making sure their backpacks are not making them hunchbacks, and promoting proper nutrition, there are some infectious diseases issues you should address.
Importance of immunizations
This year, you will be seeing children you have been following and are now either starting school or returning after a summer off. You may also be seeing children new to your practice; transferring from another physician’s practice, from out of town, out of state or even from another country. You must obtain their immunization records, review them and decide whether they are up-to-date with school and state requirements and AAP and Advisory Committee on Immunization Practices recommendations.
Marietta Vázquez
Robert S. Baltimore
This is also the time to answer questions of vaccine skeptics and address those who may have gone their own way in having their children immunized according to an unconventional schedule. Ensuring that immunizations are up-to-date is a crucial item that parents should include in the to-do list for “back-to schoolers” of all ages, just as purchasing basic school supplies and clothing.
Immunization issues depend on children’s ages and many of them are requirements for school entry (www.cdc.gov/vaccines/schedules/hcp/index.html).
Infants to 6 years of age
Young children should be vaccinated against measles, mumps and rubella; polio; diphtheria, tetanus and pertussis; Haemophilus influenzae type b; rotavirus; varicella; pneumococcus; and hepatitis A and B. All children aged 6 months and older should get influenza immunization annually.
With a change from 7-valent pneumococcal (Prevnar, Pfizer) to 13-valent pneumococcal vaccine (Prevnar13, Pfizer), children aged 14 to 59 months who had previously received a complete series of PCV7 and those aged 60 to 71 months with certain underlying medical conditions should receive a supplemental dose of PCV13. In addition, Menactra (MCV4-D, Sanofi-Pasteur), one of the quadrivalent meningococcal conjugate vaccines available, was recently licensed for use in children as young as 9 months of age in certain high-risk categories (those with persistent complement deficiency, residents or travelers to endemic areas, and in the setting of a vaccine-type outbreak) who receive two doses at aged 9 and 12 months. Previously unvaccinated children aged older than 2 years in high-risk diseases categories (complement component deficiency or anatomic/functional asplenia) should also receive the two primary dose series of either MCV4 or MCV4-D.
Many states are currently seeing higher than expected cases of pertussis. As of July, nearly 18,000 cases of pertussis have been reported to CDC; more than twice as many as at the same time last year. We may be on track for record high pertussis rates this year. We need concerted efforts, especially for vaccinating those who are around infants, such as pregnant women, family members and caregivers.
Influenza immunization should be administered annually for all children aged 6 months and older, remembering that those aged 6 months to 8 years receive two doses if not previously immunized, or one dose if they previously received at least one dose of the 2010-2011 vaccine.
Children aged 7 to 17 years
If they haven’t met the above recommendations, these children should receive “catch-up” vaccinations, with the exception of Hib and rotavirus. Back-to-school is an ideal moment (as is the case during all medical visits) to ensure that children receive a booster shot of the diphtheria-tetanus-acellular pertussis vaccine, the Tdap vaccine — a minimum age of 10 years for Boostrix (GlaxoSmithKline) and 11 years for Adacel (Sanofi-Pasteur). Tdap can be administered regardless of the interval since the last tetanus and diphtheria toxoid-containing immunizations and should be substituted for a single dose of Td vaccine in the catch-up series for children aged 7 to 10 years. They should also receive MCV4 at age 11 to 12 years with a booster dose at age 16 years.
Immunization against HPV is indicated in this age group for both boys and girls. Either HPV4 (Gardasil, Merck) or HPV2 (Cervarix, GlaxoSmithKline) is recommended in a three-dose series for girls aged 11 or 12 years and HPV4 is recommended in a three-dose series for boys aged 11 or 12 years. The HPV vaccine series can be started as young as aged 9 years. Providers should take this opportunity to emphasize that HPV vaccine prevents cervical, vaginal, vulvar and anal cancers, as well as genital warts.
In summary, this back-to-school time, don’t hesitate, vaccinate!
Hand hygiene
Hand hygiene is the most effective, least expensive practice to prevent transmission of pathogens. The term “hand hygiene” has replaced “hand washing” to emphasize the importance of alcohol gel hand rubs that can be used in place of soap and running water for most situations calling for cleansing of hands. Teach children that their hands should be vigorously lathered and rubbed together for at least 15 to 20 seconds with soap and warm running water.
In public places, hands should be rinsed and dried with a paper towel and the towel used to turn off the faucet. Children should perform hand hygiene at least after use of bathroom facilities, before eating or drinking and after physical education. In addition, experts recommend hand hygiene after arriving to school; after coughing or blowing your nose; after playing with animals; after playing outdoors; and before and after changing contact lenses. With current concern about transmission of methicillin-resistant Staphylococcus aureus in schools, emphasis on hand hygiene is paramount.
Head lice prevention
Head lice has been a growing problem in schools, especially in the lower grades. Warn your young patients to avoid head-to-head (hair-to-hair) contact during play and other activities at home, school and elsewhere. They should not share clothing such as hats; scarves; coats; sports uniforms; hair ribbons, barrettes or combs; brushes; or towels. Children should not lie on beds, couches, pillows, carpets; or stuffed animals that have recently been in contact with a person with lice.
Students diagnosed with live head lice can go home at the end of the day, be treated, and return to class after appropriate treatment has begun. Nits may persist after treatment, but successful treatment should kill crawling lice. Personal hygiene or cleanliness in the home or school has nothing to do with getting head lice. Misdiagnosis of nits is very common during nit checks conducted by nonmedical personnel.