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SCENARIO ONE Rhonda is a 25-month-old who comes into the Health Center in March for a routine follow-up visit for asthma. She receives cromolyn three times per day; albuterol is added when she has symptoms. She has a history of four hospitalizations for asthma and bronchopulmonary dysplasia. She received a 16-day course of daily oral corticosteroids 5 months ago during an exacerbation of her lung disease. Her vaccination record reveals that DTaP #3, Hib #2, IPV #2, hepatitis B #3 and PCV13 #3 were given at 11 months of age; MMR was given at 15 months of age. She does not have a history of varicella. She currently is on day 8 of a 10-day course of antibiotics for otitis media and is no longer symptomatic. She lives with her mother and a brother who has hemophilia and developed HIV infection from a transfusion. Combination vaccines are available. Questions What vaccinations does Rhonda need? Rhonda’s mother refuses to let her have more than three injections at one time. Which vaccination(s) would you defer until the next visit? When should she return for that visit and for which vaccines? Are additional visits needed? Are any vaccines contraindicated? What is the impact of the history of oral steroids? What dosage and type of influenza vaccine should be given? SCENARIO TWO Shasta, a 4-month-old infant, came to FNP Johnson’s office today for a complete physical examination and vaccinations. The examination was entirely normal. The second doses of DTaP, Hib, PCV13, and IPV were given. His mother called at 2:30 pm saying he had a temperature of 101.7°F (38.7°C) and was not eating well. She was instructed to administer acetaminophen and observe him. She called back at 4:45 pm indicating that he was limp and inactive. He was referred to the emergency department and found to be pale and listless. Physical examination showed a pale, inactive 4-month-old with a temperature of 102.6°F (39.2°C), decreased reaction to painful stimuli, and hypotonicity. Laboratory studies were normal. After 2 hours in the emergency department, he began to improve and started drinking from his bottle. He was sent home. The next day, the office nurse called his mother and found that he was active and playing. Questions Which vaccine is most likely to have been responsible for the adverse events? Should Shasta receive another dose of this vaccine? Do these adverse events need to be reported? If Shasta’s parents allege that vaccination caused a permanent injury, what could be done?

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