Case 16.5 – Febrile Child & Vaccination

HISTORY:

• Fever history: how was temperature measured? Maximum temp measured?
• Progression of illness over time: increasingly unwell, recent rapid deterioration, waxing and waning?
• Decreasing level of activity/increasing lethargy?. Increased sleepiness/difficulty waking?
• Irritability/inconsolable/difficult to settle
• Pallor/rash?
• Level of hydration:
  • Fluid in: eating and drinking pattern: compare with usual intake? Less than 50% usual?
  • Fluid out: Vomiting or diarrhoea? (Quantity and volume of each, blood?). no of wet nappies in last 24 hours compared to usual?
• Recent overseas travel: illnesses in contacts?
• Treatment with antibiotics during current illness (? partially treated.... signs may be masked)
• Immunization history? Incomplete
• Neonatal History: Born term or premature Any associated neonatal problems
• Past Medical history? background of chronic disease, immunosuppression, previous serious infection.
• How worried is parent/s?
• Note social history as to how parent/s are coping with illness, what supports they have etc. is also important

EXAMINATION

Focus is on vital signs, assessing hydration/perfusion status and identifying the source of infection:

• Vital signs. Temp:( rectal most accurate: axillary most practical ) PR RR O2sats Bare weight
• Appearance: level of alertness, interaction and activity, response to stimuli, irritability consolability. Colour: pallor mottling cyanosis
• Hydration peripheral perfusion: cap return (central more accurate than peripheral), skin turgor, sunken eyes, sunken fontanelles (if still open), lack of tearing when crying
• Rash?: (undress infant and look in all areas including axillary and buttocks)? petechiae/purpura
• Focus of infection: examine for signs of: otitis media, pharyngitis, pneumonia, osteomyelitis, septic arthritis, soft tissue infection, intrabdominal sepsis. Note classic signs of meningism do not manifest in children up to 2 yrs of age. Remember palpation of lymphnodes, hernial orifices and careful observation for joint/limb swelling redness or pain? Tenderness (move each joint separately/observe child at play or on floor). Identifiable viral infection: bronchiolitis, croup, gingivostomatitis, varicella, hand-foot-and-mouth disease

A, B, C, D, E, F3, P3 questions	"MILDLY UNWELL" answer	"SICK CHILD" answer
ALERTNESS	- mild lethargy - intermittent play - increased sleep	- drowsy / lethargic - not playing - very sleepy
BREATHING (rate/ effort/ noise)	- mildly altered	- slow or fast - stridor
COLOUR	- mildly pale / flushed	- pallor - mottling - rash (especially early in illness)
DROWSINESS / SLEEP PATTERN	- short daytime sleep - disrupted night sleep	- constant lethargy - no alert periods
EMESIS	- occasional vomit	- persistent vomiting
FLUIDS IN	- mildly reduced	- markedly reduced - not eating or drinking
FLUIDS OUT	- reduced urine - mild diarrhoea	- markedly reduced urine - persistent / bloody diarrhoea
FEVER	- mild fevers	- high fevers - prolonged fevers (several days)
PAIN	- mild headache - mild aches and pains	- severe headache / neck pain - severe musculoskeletal pain - lower limb pain
PATTERN	- gradual onset - gradual deterioration - waxing and waning	- rapid onset - acute deterioration - progressive deterioration - deteriorating despite treatment
PARENTS	- mild concern	- very worried

ADDITIONAL NOTES

• measure vital signs including bare weight degree of abnormality correlates with severity of illness
• increased height of temp in child with fever without focus assoc with increased risk of bacteraemia: however not a reliable indicator of seriousness of illness
• petechial or purpuric rash (= meningococcaemia until proven otherwise)
• signs of poor peripheral perfusion indicate likely severe dehydration or sepsis syndrome: pallor, mottling, cool peripheries, decreased cap return <2sec (central more accurate than peripheral), tissue turgor, sunken eyes, fontanelles, lack of tearing when crying
• when child is too young to give accurate verbal answers, pain is based on careful observation +/- parental report
• reduced level of interaction/response to examination, increased irritability reduced sleep /inconsolability also indicative of severity of illness

Pyrogens are substances that cause fever. Exogenous pyrogens are usually microbes or their products. The best studied are the lipopolysaccharides of gram-negative bacteria (commonly called endotoxins) and the Staphylococcus aureus toxin that produces toxic shock syndrome.

Exogenous pyrogens usually cause fever by inducing release of endogenous pyrogens (IL-1, tumour necrosis factor, interferon-γ, and IL-6). These are immunoregulatory proteins produced by host cells, particularly monocyte-macrophages, that elevate the hypothalamic set point. Prostaglandin E₂ synthesis appears to play a critical role.

Nurofen inhibits prostaglandin synthesis by inhibiting cyclooxygenase enzymes known as COX-1 and COX-2

Paracetamol Early work had suggested that the fever reducing action of paracetamol was due to a central activity directly on the hypothalamus Now, recent research has shown the presence of a new, previously unknown cyclooxygenase enzyme COX-3, found in the brain and spinal cord, which is selectively inhibited by paracetamol, and is distinct from the two already known cyclooxygenase enzymes COX-1 and COX-2. It is now believed that this selective inhibition of the enzyme COX-3 in the brain and spinal cord explains the effectiveness of paracetamol in relieving pain and reducing fever without having unwanted GIT side effects

See comprehensive table on following pages - this is a very large table covering 9 different infectious diseases

Due to the extensive nature of this table (covers pages 47-60 of the source material), the table includes detailed information for:

• Measles - including Koplik spots, maculopapular rash, complications (encephalitis 1 in 2000, SSPE)
• Roseola Infantum - fever then rash, HHV-6/7, seizures in 5-10%
• Rubella - mild disease, congenital rubella syndrome risk
• Erythema Infectiosum - "slapped cheek", parvovirus B19, lacy rash
• Varicella - vesicular rash in various stages, highly infectious
• Herpes Zoster - dermatomal vesicular lesions, reactivation of VZV
• Mumps - parotitis, aseptic meningitis 30%, orchitis 25%
• Scarlet Fever - Group A strep pharyngitis with rash, strawberry tongue
• Glandular Fever - EBV, atypical lymphocytosis, splenomegaly

Note: Students should refer to the full PDF source material for the complete detailed table with all epidemiology, clinical features, diagnosis, complications and management for each disease.

Passive and active immunity:

ACTIVE IMMUNITY: When a healthy person becomes infected with a virus, e.g. measles, the body recognises the virus as an invader, produces antibodies which eventually destroy the virus and recovery occurs. If contact with the measles virus occurs again in the future, the body's immune system 'remembers' the measles virus and produces an increase in antibodies to destroy the virus.

Vaccination is the process that is used to stimulate the body's immune system in the same way as the real disease would, but without causing the symptoms of the disease. Most vaccines provide the body with 'memory' so that an individual doesn't get the disease if exposed to it.

PASSIVE IMMUNITY: Immunity can also be acquired passively by the administration of immunoglobulins. Such immunity is immediate and is dose-related and transient. For example, measles or hepatitis B immunoglobulin can be used promptly after exposure in an unimmunised person to help reduce the chance of catching measles or hepatitis B from the exposure.

The key questions to ask before giving a child a vaccination:

These can be provided as a check list to give to parents/carers which act as screening questions pre vaccination

Is/does the child to be immunised:

• an Aboriginal or Torres Strait Islander
• unwell today
• have a disease which lowers immunity (e.g. leukaemia, cancer, HIV/AIDS)or is having treatment which lowers immunity (e.g. oral steroid medicines such as cortisone and prednisone, radiotherapy, chemotherapy) or does he/she live with someone who has a disease which lowers immunity (e.g. leukaemia, cancer, HIV/AIDS), or lives with someone who is having treatment which lowers immunity (e.g. oral steroid medicines such as cortisone and prednisone, radiotherapy, chemotherapy)
• have they had a severe reaction following any vaccine
• have they any severe allergies (to anything)
• have had any vaccine in the past month
• have they had an injection of immunoglobulin, or received any blood products or a whole blood transfusion within the past year
• do they have a past history of Guillain-Barré syndrome
• were they a preterm infant
• so they have a chronic illness
• do they have a bleeding disorder
• does he/she have a functioning spleen

The immunisation provider then only needs to ask:

• Did you understand the information provided to you about immunisation?
• Do you need more information to decide whether to proceed?
• Did you bring your/your child's vaccination record card with you

Refer to the National Immunisation Program Schedule - valid from 1 July 2007 (see source document page 67)

ABORIGINAL AND TORRES STRAIT ISLANDER CHILDREN

Aboriginal and Torres Strait Islander children living in certain regions require extra protection against some diseases. Children from these states should receive all the routine vaccines given to other children, with the following differences and additions:

Pneumococcal infection
In Queensland, the Northern Territory, Western Australia and South Australia an additional booster dose of the pneumococcal vaccine (PneumoVax®23) is required between 18 and 24 months. This is required because Aboriginal and Torres Strait Islander children living in these areas continue to be at risk of pneumococcal disease for a longer period than other children. The vaccine used for this dose is different from the one used for babies.

Hepatitis A vaccination program
In Queensland, the Northern Territory, Western Australia and South Australia the Government provides free hepatitis A vaccine for all Aboriginal and Torres Strait Islander children less than five years of age because hepatitis A is more common among Aboriginal and Torres Strait Islander children in these areas than it is among other children. Two doses of vaccine are given between 12 and 24 months of age.

Hib (Haemophilus influenzae type b)
In the Northern Territory and certain remote areas of South Australia the preferred vaccine is a specific type, called Hib PRP-OMP. This vaccine provides increased protection to very young infants and is used because there is an increased risk for this age group among Aboriginal and Torres Strait Islander children living in these areas. This vaccine should be given at 2, 4 and 12 months of age, at the same time as other routine vaccines.

NSW NOTIFICATION MECHANISMS:

The Department's policy directive mandates that notifiable diseases must be reported to the local Public Health Unit (PHU).

Notifiable diseases
Notifiable diseases are classified according to the urgency of notification (some must be notified by telephone ideally as soon as diagnosis made) All case notification must be made within 24 hours. Infectious diseases are also classified according to who can/must notify: this may include treating doctor, hospital chief executive officers or general managers, laboratories and even school principles/directors of child care centres.

Notification Mechanism
Case notification must be initiated within 24 hours of diagnosis

1. Download the relevant notification form from the Notifiable disease list All infectious diseases notification forms are available from Public Health Units and on the NSW Health website
2. Fill in the form
3. Notify the PHU by phone if the notifiable disease is followed by a ★
4. Send in the form

Doctor and Hospital Notifications should be directed to the local Public Health Unit, except for HIV, which is notifiable only by reference laboratories direct to the Communicable Diseases Branch, NSW Department of Health.

Note: In order to protect patient confidentiality, notifications must not be made by facsimile machine except in exceptional circumstances and when confidentiality is ensured.

VICTORIA NOTIFICATION MECHANISMS

Step 1 (Mandatory for Group A diseases / optional for Group B/C/D diseases)

• Telephone our priority number 1300 651 160 (This number connects you directly to the Department of Health's Communicable Disease Prevention and Control Unit for the cost of a local call from most fixed phones)
• For urgent notifications outside office hours, please telephone the departments after hours service on 1300 790733 and advise the operator that you wish to make an 'urgent infectious disease notification'.

Step 2 (Mandatory for all diseases)

• Notify online using the secure e-Form OR
• Complete the Notification of Infectious Disease Form
• Fax the completed form to our priority number 1300 651 170

Disease groupings

• Group A - Diseases require immediate notification to the Department of Health by telephone or fax upon initial diagnosis (presumptive or confirmed) with written notification to follow within five days.
• Group B - Diseases require written notification only within five days of diagnosis (presumptive or confirmed).
• Group C - Diseases include the sexually transmissible diseases and should be notified using the same form. To preclude identification of the patient, only the first two letters of the given and family name of the patient are required.
• Group D - Diseases include HIV infection (Human Immunodeficiency Virus) and AIDS (Acquired Immunodeficiency Syndrome) and written notification is required within five days of confirmation of diagnosis. A separate form is used for this purpose due to the need to have national uniformity in collection of data.