Immunization and Infectious Disease

Question 1

Which of the following is false about haemophilius influenzae type B meningitis in Canada?

a) still fairly common in immunosuppressed patients
b) still fairly common in unimmunized patients
c) uncommon healthy immunized Canadian children
d) increased in northern populations

Answer 1

D) non type B is on the rise in all parts of Canada, especially in Northern populations

Hib vaccine part of immunization in Canada since 1998

Question 2

Which of the following is false about the heptavalent vaccine for Strep Pneumoniae (PCV7) :

a) available in all Canadian provinces and territories since 2005
b) lead to the decrease of pneumococcal meningitis in all age groups
c) lead to a decrease in invasive pneumococcal disease
d) has not lead to serotype replacement

Answer 2

d) has lead to serotype replacement by other serotypes of pneumococcal meningitis - including 19A, 15B and 6A as well as other serotypes not present in the vaccine

PCV7 contains 4, 6B, 9V, 14, 18C, 19F and 23F

Question 3

Which of the following is true about the PCV13 vaccine for Strep pneumo?

a) available in all Canadian provinces and territories since 2001
b) contains the serotypes in PCV7 as well as 6 additional serotypes (1,3,5,6A,7F, 19A)
c) did not result in a significant decline in serotypes targeted by PCV13
d) PCV13 serotypes declined the same amount in children greater than and less than 5 years of age following introduction of PCV 13

Answer 3

answer is B

a)Available since 2011
c) did result in a significant decline in serotypes targeted by PCV13 (since they targeted serotypes that were major causes of pneumococcal disease that weren’t in PCV7)
d) 19A, 7F, 3 and 22F were the most common serotypes in 2012, 19A decreased from 19 to 14%
PCV 13 serotypes decreased more in children54-43% in children >5

Question 4

Which of the following is false about Listeria meningitis?

a) uncommon beyond the neonatal period
b) should be considered in immunosuppressed
c) should be considered if presents with brain stem infection
d) should be treated by adding vancomycin to the regular empirical treatment

Answer 4

d) is well covered by ampicilin, if patient is immunosuppressed should add ampicillin to the antibiotic regimen

they are gram positive rods

Question 5

Which of the following is false about S. pneumo antibiotic susceptibility?

a) penicillin susceptibility to S. pneumo in the CSF is at MIC 0.12
b) penicillin resistance is very common in invasive pneumococcal disease
c) 19A is most commonly associated with penicillin resistant disease
d) resistance of S. pneumo to third generation cephalosporin is very rare

Answer 5

b) Penicillin resistance is still quite rare for invasive pneumococcal disease 96.1 and 80.8% based on two different studies

Question 6

Ceftriaxone/Cefotaxime is a good choice for empiric treatment of meningitis for all the reasons below except:

a) good coverage of S. pneumo
b) good coverage of Hib (since many are beta-lactamase producing)
c) significant resistance of N. meningitis to penicillin (approx 18% in Canada)
d) best choice for coverage of GBS

Answer 6

d) penicillin is the best choice for GBS but for empiric treatment can chose ceftriaxone/cefotaxime until susceptibilities available
does not cover cephalosporin resistant subtypes of S. pneumo this is why we add vancomycin (don’t necessarily need to in areas of Canada where there isn’t as much cephalosporin resistant S. pneumo but safer to add)

Question 7

Which of the following is not associated with poor prognosis for meningitis?

a) delay in antimicrobials
b) delay in lumbar puncture performance
c) severity at presentation
d) penicillin resistant S. pneumo

Answer 7

b) the others were associated with worse prognosis in a study

Question 8

Which pairing of bug and treatment is false?

a) empiric treatment for meningitis in immunocompromised host: ceftriaxone, vancomycin and ampicillin
b) S. pneumo with MIC to penicillin 0.12ug/mL and ceftriaxone and ceftriaxone MIC>1.0 ug/mL treat with ceftriaxone
c) S. pneumo with MIC to penicillin> 0.12ug/mL and ceftriaxone MIC

Answer 8

add amp for immunocompromised to cover listeria
b this is resistant to both penicillin and intermediate ceftriaxone, add vancomycin to cover for the cephalosporin resistant S. pneumo and consult ID
add gentamycin for 5-7 days for GBS or until repeat culture is negative (24-48 hours)
penicillin for 14-21 days

S. pneumo resistant to ceftriaxone MIC 2.0

Question 9

which of the following s true regarding the use of steroids in meningitis?

a) it helps improve outcomes consistently in all types of bacterial meningitis when given before or shortly after antibiotic therapy
b) it help reduce hearing loss in strep pneumo meningitis
c) when a bacterial meningitis is suspected, and no contraindications, start dexamethasone 0.6 mg/kg/day in four divided doses
d) rebound of fever after stopping steroids warrants significant further investigation

Answer 9

answer is c) especially if gram positive diplococci (strep pneumo) or gram negative cocci bacilli (hub) if strep pneumo or hib continue for 2 days otherwise if another aetiology found within 2 days then stop (no evidence that it helps in other aetiologies other than these two bugs)
controversial except for hib and hearing loss
**can have rebound of fever after stopping steroids, if otherwise improving and diagnosis is still clinically meningitis only , no need to investigate further

Question 10

Which of the following is not an indication for repeat CSF sampling?

a) S. pneumo meningitis not improving with treatment
b) Hib meningitis improving with treatment
c) GBS meningitis
d) E. coli meningitis (and other enteric bugs)

Answer 10

b) don’t need for meningitis with typical bugs that improves to treatment
for GBS and not improving do within 24-48 hours, some experts recommend repeat CNS sampling
meningitis with gram negative bugs (i.e. E coli) - recommend repeat LP within 24-48 hours

indications for CNS imaging, failure of sterilization of CSF, neurological findings other complications of meningitis

contraindication to LP, local skin findings, coagulopathy, symptoms of herniation

Question 11

Which duration of treatment is incorrect?

a) Strep pneumo 10-14 days
b) Neisseria meningitis 5 - 7 days
c) Hib 7-10 days
d) GBS 10-14 days

Answer 11

d) GBS 14-21 days (can vary if cerebritis is present) (with gent for first 5-7 days)
audiology should be prior to discharge or within one month of discharge

Question 12

Which serotype of Neisseria meningitis causes the most of cases of meningococcal infection in children <5 years old in Canada?
A) A
b) B
c) C
d) Y
e) W-135

Answer 12

Serogroup B causes over 70% of cases in <5 years old in Canada
most cases of invasive meningococcal disease in Canada
new vaccine targets it (separate statement)

Question 13

Which serotype of Neisseria meningitis peaks in adolescents?

a) A
b) B
c) C
d) Y
e) W-135

Answer 13

Serogroup C occurs in outbreaks, most in adolescents age 15-19
higher rate of septicaemia and mortality especially in teenagers
since immunization for serogroup C introduced, decrease in this type of meningitis with no increase in the other types

Question 14

Which of the following patients is adequately vaccinated for meningitis?

a) 12 month old with combined immunodeficiency, receiving his first shot of MCV-C
b) 3 year old with sickle cell disease, has only received one dose of MCV-C
c) 13 year old healthy child who has received MCV at 12 months of age and MenC ACYW booster in grade 7
d) 13 month old who has received the polysaccharide vaccine for meningitis

Answer 14

C

a) not because children with antibody deficiencies should get doses at 2,4, and 12 months
b) children at risk should receive MCV-4 after 2 years of age
c) THE ANSWER - need the dose at 12 months and then the conjugate booster.
d) the old vaccine was not immunogenic enough in children and did not offer enough long term protection at any age

approved in Canada - conjugate vaccine menactra (2007), covers ACYW-135; Menveo being studied in infants, approved since 2010
unclear if MCV-4 will protect infants

Question 15

Which of the following groups is not at increased risk for invasive meningococcal disease?

a) functional (ie sickle cell) or anatomical asplenia
b) children with primary antibody deficiency disorders
c) complement, properdin or factor D deficiency
d) travellers to areas where meningococcal disease is high
e) infants of HIV positive mothers
f) laboratory personnel exposed to meningitis
g) the military

Answer 15

e)

the others are on the list of people at increased risk of invasive meningococcal disease and they should begin MCV-C immunization at 2 months of age.
MCV-4 should be given to infants 2 years of age or older who are at increased risk. May also want to consider for HIV positive children 2 years of age or older.

Question 16

Which of the following patients is at the lowest risk of sepsis from encapsulated bacteria?

a) 15 year old post splenectomy (4 years ago) for trauma
b) 5 year old with sickle cell disease
c) 2 year old with hereditary spherocytosis
d) 4 year old with thalassemia minor
e) 12 year old post splenectomy (2 years ago) for trauma

Answer 16

A

patients who have undergone splenectomy for trauma are lower risk than those with splenectomy for other reasons

children

Question 17

Which organism is the most common cause of sepsis in asplenic children?

a) Haemophilus influenzae
b) Strep pneumo
c) Neisseria meningitis
d) Salmonella
e) E coli

Answer 17

B strep pneumo in 50%
the other options are common also: Hib, Neisseria , Salmonella, E. coli
less commonly can find pseudomonas, klebsiella, streptococci and staph
first three months of life E coli and Klebsiella more common (some evidence)
can get overwhelming sepsis from cat and dog bites (capnocytophaga)
more susceptible to malaria
to babesia protozoa (transmitted by tick bites)

Question 18

Which of the following is not part of the advice one should give parents of asplenic children?

a) seek medical attention promptly as death can occur in a matter of hours
b) wear a medic alert bracelet
c) increased risk of sepsis from cat and dog bites so should be treated with amox/clav if bitten
d) when travelling should carry a note from their doctor that mentions the diagnosis, risks, and suggested treatment should they become ill
e) should seek assessment of fever the same as other children

Answer 18

E)

the rest are true

Question 19

Which of the following regarding pneumococcal vaccines for asplenic patients is false?

a) should receive the conjugated PCV13 and the 23 valent polysaccharide vaccine
b) should receive four doses of PCV13 (2,4,,6,12-15 months)
c) if they missed the primary series of PCV13, should receive 2 doses 8 weeks apart if 12-24 months of age, only one dose if >24 months
d) PCV23 should be given at 24 months of age, should prime with pcv13 (give last required conjugate dose at least 8 weeks before PCV23)
e) if patient previously received PCV23 then give one dose of PCV13 immediately

Answer 19

e) dose of 13 should be one year after PCV23

Question 20

which of the following is false about meningococcal vaccines?

a) children 2 with known asplenia should get MCV4 (any quadrivalent vaccine) 2 doses 8 weeks apart
b) patients vaccinated with MCV4 only need one dose of the vaccine
c) the new 4 component vaccine to protect against serotype B vaccine (4Cmen B) should be given to all children who are asplenic including infants

Answer 20

b) should get repeat every 5 years until we know more about duration of immune protection

Question 21

Which of the following statements about rotavirus is false?

a) incubation period is 1-5 days
b) usually resolves after 3-8 days
c) generally severe disease in first 3 months
d) natural infection offers some protection against the disease
e) all children will experience an episode of rotavirus by age 5

Answer 21

c) false, more mild disease because of protection from maternal transplacental antibodies

clinical presentation: fever and vomiting (acute onset) then diarrhea

Question 22

Which of the following stats about rotavirus in Canada is false?

a) more than one half of hospitalizations in Canada from Rotavirus is in the 0-3 month age group
b) Canadian estimates 1/62 to1/312 children with rotavirus in age 5% of deaths in the

Answer 22

a) false, more than one half in 6-24 month age group

Studies on rotavirus: Rotavirus cohort model showed 1/62 hospitalizations, 1/7 seek health care, 1/20 will visit the ER

Question 23

Which of the following patient groups is at increased risk of severe rotavirus infection needing hospitalization?

a) lower SES
b) premature infants
c) children in daycare
d) breastfed infants

Answer 23

b) premature infants increased risk (partly because they lack the maternal transplacental antibodies)

immunocompromised infants are also at increased risk (including patients with organ transplant, congenital immune deficiencies or hematopoeitic transplant) severe, prolonged and even fatal gastro

daycare, SES, ethnicity and parental marital status did not affect the prevalence of severe infection in one Canadian study; breastfeeding might be partly protective
diagnostic test is stool test enzyme immunoassay antigen detection

Question 24

Which of the following patients should get the rotavirus vaccine?

a) history of hypersensitivity to the vaccine or its components
b) previous history of intussuseption
c) patient with severe combined immunodeficiency
d) premature baby (ex 30 weaker) now 6 weeks of age

Answer 24

d)should get it between 6 and 32 weeks chronological age

the other options are contraindications, intussuseption only based on previous association precautions for acute gastro, short gut, hirschprung malabsorption but benefits likely outweigh risks.

Contradindictions to rotavirus vaccine:

1. Hypersensitivity to the vaccine or any of its ingredients or components of the container.
2. History of intussusception (based only on previous association with RotaShield, with the pathogenesis still being unclear – no association has been shown between the new vaccines and intussusception).
3. Infants known or suspected to be immunocompromised, especially those with severe combined immunodeficiency.

Precautions include acute gastroenteritis and pre-existing chronic gastrointestinal conditions including congenital malabsorption syndrome, Hirschsprung’s disease or short gut syndrome. In these cases, the benefits likely outweigh the theoretical risks [31].

Question 25

which of the following statements is false?

a) rotarix is a human-bovine pentavalent vaccine
b) the minimum age for the first dose of Rotateq and Rotarix is 6 weeks, the maximum age 14 weeks (NACI recommendations)
c) doses should be given a minimum of 4 weeks apart, with the maximum age for the last dose 8 months of age
d) vaccine is equally effective in breastfed and non breastfed infants
e) dose can be given in transient mild illness with and without fever

Answer 25

a) rotateq is a live human-bovine pentavalent vaccine (targets G1 - g4) and rotarix is a monovalent human vaccine
* both are live vaccines

Question 26

Rotateq is associated with which of the following risks:

a) increased incidence of severe adverse events including SIDS
b) increased risk of hematochezia, meningitis, Kawasaki disease, myocarditis or gram negative sepsis
c) statistically increased incidence of vomiting, diarrhea, nasopharyngitis, otitis media and bronchospasm (but not felt to be clinically significant)
d) increased risk of intussusseption

Answer 26

c) statistically significant difference but not felt to be clinically significant (for Rotateq)
meanwhile rotarix (the two dose, monovalent one we get in ontario) does NOT have any increased risk 

the other risks are the same in patients who received the vaccine and in the control group
intusseption not associated with either of the approved vaccines (Rotateq or Rotarix)

Rotarix no difference in fever, cough, vomiting, irritability

fecal shedding - 80% in Rotarix and 12.7 % in Rotateq
rotateq 3 doses rotarix 2 (so more shedding in Rotarix than in Rotateq) potential for horizontal transmission is unknown
studies show both very effective, decrease in us rotavirus post vaccine

Question 27

Which of the following is not a impact of varicella immunization in Canada?

a) in provinces where instituted between 2000 and 2002, 84% decrease in varicella related hospitalizations
b) in provinces where instituted between 2004 an 2006 decrese in 65% in hospitalization
c) in Ontario, one study showed a 53% decrease in hospitalizations, 47% decrease in ER visits and 45% decrease in doctor visits
d) the national goal for varicella is to reduce incidence of varicella by 90% and reduce varicella related hospitalizations and deaths by 60%

Answer 27

d) the last stat should be 80%

Question 28

Which of the following statements is true?

a) IgM is induced by natural disease from varicella
b) Immunity induced by varicella disease is easy to test for
c) primary vaccine failure means that after vaccine is given a protective immune response dose not develop
d) surveillance shows that children who have been vaccinated >5 years ago have the same level of immunity as children who were vaccinated more recently
e) more patients had seroprotective antibodies after 1 dose than 2 doses

Answer 28

a) false, IgG is induced by natural disease
b) false, hard to test for immunity post vaccine, need special tests found in laboratory (ELISA and FAMA)
c) true - primary vaccine failure is when there is not protective immune response after getting the vaccine; even using the fancy assays, immunity can be hard to prove
d) false, children who received vaccine > 5 years ago were 2.6 x more likely to have severe breakthrough varicella than those vaccinated more recently. and rates of breakthrough varicella increased dramatically proportional to time since vaccination (secondary vaccine failure is when the immunity wanes)
e) false, more seroprotective antibodies with 2 doses than 1 (primary vaccine failure is when the antibodies fail to develop)

Question 29

Which of the following about varicella vaccination is false?

a) varicella immunization in the US has led to significant decrease in disease
b) varicella immunization has lead to increased disease in older population
c) effectiveness of single dose in preventing severe disease is >90% in US studies, and of preventing disease of any severity ranged from 70-85% , but as low as 20% in some studies
d) breakthrough disease is equally severe as naturally occurring varicella

Answer 29

d) usually less severe but can still have severe complications in 5%

Question 30

which of the following is regarding the recommended schedule for varicella immunization in Canada is false?
a ) the first dose of varicella containing vaccine should be between 12 -18 months of age
b) healthy children age 12 months to 12 years should receive two doses of varicella containing vaccine
c) the second dose of varicella containing vaccine may be given 3 months or longer after the first dose in children

Answer 30

d) at that age to prevent secondary vaccine failure (i.e. from waning immunity), the recommendation is 4-6 years for the second dose until there is a universal immunization program or until more information becomes available

adverse event of vaccine - most common is pain and redness at the site

some thought that with the varicella vaccine have shifted disease into older group (?check, is this from waning immunity)

Question 31

Which of the following is not considered adequate evidence of immunity to varicella?

a) IgG to VZV
b) IgM to VZV
b) documentation of two doses of varicella vaccine (do not do serology)
c) documentation by health care provider of varicella or herpes zoster infection
d) lab confirmation of varicella or herpes zoster from a lesion

Answer 31

b) IgG not IgM is evidence of natural disease

cannot measure vaccine induced immunity these days since the two antibody tests used in vaccine induced immunity (which are different tests than traditional varicella serology) is not commercially available *can’t measure if child who received the vaccine is immune

options are univalent varicella vaccine and MMRV

prenatal evidence of varicella immunity should be done, women who are not immune should be vaccinated when no longer pregnant (breastfeeding not a contraindication)
live vaccine so don’t give while pregnant

Question 32

Which of the following about rubella in Canada is false?

a) Between 1998-2004, there were fewer than 30 cases per year of Rubella in Canada
b) Prior to vaccination for Rubella, most Canadians had Rubella as children - cases 15000 per year between 1941 and 1958
c) Initially, boys were not included in the vaccination program for Rubella
d) There were 200 cases of congenital Rubella syndrome between 1999-2004

Answer 32

d) only 11 cases in that time period, evenly distributed

boys included since 1983
keep having small epidemics, especially in communities that don’t get vaccinated - 300 in Southwestern ontario in 2005

incidence of stillbirth and abortion related to rubella in Canada is not known

Question 33

Which of the following is not a common reason why congenital rubella syndrome continues to occur in Canada?

a) introduction of Rubella virus by travellers
b) pregnant women who are susceptible because of vaccine failure or missing vaccine
c) failure to seroconvert after rubella vaccine
d) come from countries that include the monovalent measles vaccine rather than MMR

Answer 33

c) almost 100% of people immunized with rubella vaccine seroconvert, BUT failure of one dose of rubella vaccine to protect against disease occurs in 10% of cases, now there should be even less vaccine failure because most Canadian children get 2 doses of MMR (age 12 months at 4-6 years in Ontario)
secondary vaccine failure is rare (infection in a previously immune mother)
small number of cases of CRS in infants born to women with primary or secondary vaccine failure or rubella reinfection

the others are all true
recent alberta study 8.8% of women were seronegative for rubella at time of routine prenatal screening

Question 34

Which of the following women is not a way to prevent congenital rubella syndrome?
a) ensuring that you determine the serostatus of women of child bearing age new to Canada prior to providing immunization with MMR
b) childhood immunization
c) postpartum rubella vaccine for women who did not have previously documented rubella immunization or rubella seropositivity
D) reviewing the immunization status of women of child-bearing age who are new to Canada and giving MMR in initial encounter with health care system

Answer 34

a) this could delay the immunization with MMR and lead to more CRS

Question 35

Which test is the best test to help differentiate primary from secondary infection of rubella in a pregnant woman? s

a) IgM serology
b) IgG avidity testing
c) virus detection
d) acute and convalescent IgG serology

Answer 35

rubella IgG serology helped differentiate between primary infection - high risk for CRS from past infection (low risk of CRS) **
in place like canada IgM serology has low PPV so need to do the acute and convalescent and/or viral detection

IgM serology - low positive predictive value (for both measles and rubella) in a low-prevalence situation such as in Canada, especially in the absence of epidemiological links or travel history to endemic areas , so need to also do additional testing for patients with symptoms of rubella or measles (do acute and convalescent IgG serology, look for fourfold or greater rise in titer), virus detection

Question 36

A 25 year old woman has symptoms of stuffy nose, red eyes, lymphadenopathy, a rash spreading from head to toe and aching joints. She has not had any recent travel outside the country. Which of the following does NOT strongly suggest that she has rubella infection?

a) IgG that increases 4 fold (convalescent tigers)
b) Rubella IgM positive
c) rubella virus detection
d) IgG avidity test positive

Answer 36

b) igM serology - low positive predictive value (for both measles and rubella) in a low-prevalence situation such as in Canada, especially in the absence of epidemiological links or travel history to endemic areas , so need to also do additional testing for patients with symptoms of rubella or measles

Question 37

Which of the following is not a symptom suggestive of congenital rubella?

a) Macrocephaly
b) cataracts
c) glaucoma
d) pigmentary retinopathy
e) hearing impairment
f) PDA
g) hepatosplenomegaly
h) thrombocytopenia
i) radiolucent bone densities

Answer 37

a) micro not macrocephaly

radiolucent bone densities look like celery stalking

Question 38

Which of the following is a known side effect of rubella immunization?

a) chronic arthropathies
b) acute arthritis or arthralgia (5-10%)
c) neurological conditions
d) miscarriage in pregnant women who accidentally receive the vaccine

Answer 38

b) higher percentage may complain of arthalgias when warned of potential adverse event
acute and persistent forms of arthritis after natural rubella infection are common, with up to 30% of naturally infected women experiencing recurrent joint manifestation for up to two years , no adverse effects of inadvertent immunization of women who are already immune or pregnant, although still recommended that pregnancy be delayed 28 days following immunization
live vaccine, contraindicated in immunodeficiency

Question 39

Which of the following is not part of Canada’s vaccine safety program prelicensure programs?

a) Prelicensure programs which involve 1000s to 10000s of people
b) adverse events closely scrutinized to determine if related to vaccine or not.
c) efficacy determined either directly or by an agreed upon surrogate (for low incidence diseases) before starting trial
d) prelicensure programs with data monitoring committees ran by the principle researchers
e) the licensing of drugs and vaccines in Canada is regulated by the Biologics and Genetics Therapies Directorate of Health Canada

Answer 39

d) separate from researchers
the rest are true
if not enough evidence of safety/efficacy, approval for licensure is halted.
regulatory bodies also determine labelling for vaccines and content information for product monograph

Question 40

Which of the following statements is false?

a) manufacturing plants must meet the good manufacturing practices (GMP) to produce vaccines which are accepted
b) each lot of vaccine is tested for potency, safety and purity by the manufacturer prior to release
c) the lot assessment of vaccines is very similar to that of other drugs
d) manufacturers can be asked to submit samples for assessment and inspectors often visit plants that make vaccines

Answer 40

c) false, not as rigorous for drugs, if problem identified later can withdraw the lot

the rest are true

Question 41

Which of the following statements is true?

a) passing the licensing review ensures that a vaccine is recommended for routine use in Canada
b) public health authorities in most provinces will consult the NACI committee recommendation before recommending a vaccine be routinely given
c) the NACI committee is a government committee
d) rare adverse events should be detected in the prelicensure studies

Answer 41

b) is true

the rest are false

a) false - need to formal independent review by national advisory committee on immunization (NACI), in US similar process
b)
c) false, is independent of vaccine manufacturers and government with respect to decision making
d) rare events (1/100000-1-1000000) would not be detected by prelicensure studies

serious adverse events must be reported by health professionals using a standardized database (one in Canada and US) - passive surveillance

Question 42

All but which of the following is a component of the IMPACT program?

a) searches all Canadian hospitals
b) ran by specially trained nurses
c) allows the early detection of vaccine efficacy
d) allows the timely detection of vaccine safety alerts

Answer 42

a) searches all 12 Canadian paediatric hospitals for adverse events, for vaccine failures and for infectious diseases that are soon to be vaccine preventable
US equivalent is VAER (showed the intusseption increased rates with earlier rotavirus vaccine)

if safety alert or detected problem, program for immediate recall
expert causality review - looks in detail at all severe events, i.e. deaths/hospitalizations, board is called Advisory Committee on Causality Assessment hey are used to detect signals of rare, vaccine-attributable adverse events as well as being used for vaccine recommendation adjustments and education purposes in collaboration with the National Advisory Committee on Immunization and with the provincial and territorial immunization programs.
Canada shares with other countries
vaccines not mandatory for school entry in Canada

Question 43

Which of the following statements is false?

a) after a bite is sustained, it is imperative to obtain testing for children involved
b) biting is the most common injury suffered by children
c) the approximate incidence of biting in a child care setting is one bite per day
d) most bites in child care settings don’t break the skin

Answer 43

a) is false, look at detailed questions for more details, depends on the case, usually don’t do testing.

the rest true
b) true
35% of injuries in one study were biting
highest with toddlers
most to hands and face
bite rate 1.5 /100 days of child care attendance
assumes average attendance of 60 kids, only 1 every 8-10 weeks would break the skin
children with infections including HBV, HBC and HIV can’t be excluded from child care settings (unless behavioural issues)

Question 44

Which of the following is the order of most easily transmitted to most difficult?

a) HIV->hepatitis B->hepatitis C
b) hepatitis B->HIV->hepatitis C
c) hepatitis C->hepatitis B->HIV
d) hepatitis B->hepatitis C->HIV

Answer 44

d) is the answer

Question 45

Which of the following statements is false?

a) parents whose children attend child care should advocate for their children to receive the hepB vaccine even if not part of the program
b) if two children with unknown hepB status bite each other, they should both get the hep B vaccine
c) children in childcare with known hepB carrier should be vaccinated against hepB and hepB status should be revealed to all parents and staff
d) all child care centre staff should be immunized against hepB

Answer 45

c) false - should all be immunized but WITHOUT telling everyone the child’s status

the rest are true
if two kids bite each other, low risk so need to test for serology but should give them both the vaccine

Question 46

A child with hepB bites another unimmunized/nonimmune child and breaks the skin. Which of the following is the appropriate management for the victim?

a) review the tetanus status and give vaccine if necessary, give prophylactic antibiotics, hep B vaccine and immunoglobulin and hepB serology at 6 months
b) review the tetanus status and give vaccine if necessary, give hepB immunoglobulin and hepB vaccine (including at , as well as hepB serology at 6 months
c) reassurance for the parent
d) review the tetanus status and give vaccine if necessary, give hepB immunoglobulin and hepB vaccine (including at , as well as hepB serology at 6 months, test for other viruses including HIV and HCV

Answer 46

b) is the answer, same thing if the non immune kid is either the biter or the victim,
always check tetanus
antibiotics prophylactically only if deep puncture wounds or wounds, or to face, hand, foot, genital that are more than just superficial (these rarely occur in child care setting)
if one of the kids is known HBV carrier, then give the other kid the immunoglobulin (0.06 ml/kg) and vaccine, and test serology at 6 months
also make sure follow up to complete immunization
transmission including blood into oral mucosa
rare transmission in child care settings
bacterial infection in child care bites very very rare, (almost 0), as long as you do basic wound care, i.e. wash the wound with soap and water and watch for infections
blood in contact with mucosa presents a risk to the biter

hep B vaccine - most common at 0.1. and 6 months

Question 47

Which of the following is true of HIV in childcare settings?

a) there are some reports of HIV transmission i child care
b) saliva is inhibitory to HIV
c) parents of children with HIV are required to divulge their child’s status to child care personnel
d) parents of other children in a child care setting should be informed of the HIV status of a positive child in the setting

Answer 47

b) is true, infectivity of saliva very low because saliva is inhibitory to HIV

a) false - no reports of HIV in child care
c) false, not required to divulge, HIV in canada is very rare
d) don’t need to tell other parents, only the child’s doctor and parents need to know

Question 48

A child with HIV bites another child, there is a mild superficial wound. Which of the following is the correct management?

a) disclose the status to the parents of the victim, test the victim for HIV serology, post infectious prophylaxis with anti-retroviral drugs and consult an ID specialist, serologies at 6 weeks, 3 and 6 months
b) disclose the status to the parents of the victim, test the vicim for HIV serology at 6 weeks, 3 and 6 months, no need for post infectious prophylaxis
c) don’t disclose the status to the parents, reassure them that the risk of infection to their child is extremely low

Answer 48

c) is the answer, the risk of transmission is very low, can’t break confidentiality, unless very significant and need to talk about prophylaxis, etc, rate of seropositivity of HIV in Canada is very low, if child of unknown status bites another, no indication to test the child for HIV.

if very significant and bloody wound, talk to expert before starting anti retroviral prophylaxis, needs to be started within a few hours, no point if after 72 hours, test serologies at 6 weeks, 3 and 6 months.

hep C virus - if significant bite with bloody exchange, then need to organize appropriate testing of the exposed child, including serology at 6 months, no prophylaxis currently exists in Canada

Question 49

Which of the following is true of the incubation period of chicken pox?

a) 14-16 days
b) 10-14 days
c) 8-10 days
d) 6-8 days

Answer 49

a) generally considered to be 14-16 days, can be as early as 10 days, as long as 21 days after contact, humans are the only known reservoir for VZV
chickenpox assumes that contacted via respiratory route, 24 hrs and up to 96 hours before the development of the rash
however, have not been able to grow VZV from respiratory secretions (while it is very easy to get it from vesicles); but VZV DNA can be detected by PCR from the nasopharyngeal secretions, support the hypothesis that transmitted by respiratory route
higher viremia equals more severe disease ->therefore excluding the sickest kids will likely exclude those with most severe disease and likelihood of transmission

Question 50

Which of the following statement is false?

a) excluding children for 5 days after chicken pox rash develops reduces the amount of chicken pox transmission
b) hospitals will put a child who has been exposed to VZV into isolation from day 8-21 after VZV contact
c) according to the CPS, a child with chicken pox should be allowed to return to school or daycare as soon as he can participate in all normal activities, regardless of the state of the rash
d) parents, particularly of immune suppressed children should be informed that chicken pox in the classroom, as well as about incubation period, and how to detect early VZV

Answer 50

a) false - there is no evidence that an exclusion policy which excludes children after chicken pox develops slows down the spread of chicken pox
ohio study - classmates of children with chicken pox 3.5 x more likely to get it 12-17 days after
subsequent cases not more severe

the rest true
b) true - when this hasn’t been done and isolation only done after rash develops, there have been extended outbreaks, the logic is that this will isolate them for the whole range of the incubation period (starting 2 days before), for all hospitalized non immune patients

policies that use the sate of the rash don’t make a ton of sense, a lot of schools and daycare use that though as the guidelines, CPS doesn’t agree
American Public Health - 5 days after rash
AAP - agrees with above, and says in mild cases can return sooner if all lesions have crusted

Question 51

What is the best timing for vaccination when a patient is undergoing elective or semi-elective splenectomy?

a) 2 weeks before
b) 1 week before
c) the day before
d) 2 weeks after

Answer 51

a) 2 weeks before is the best time to give the vaccines before surgery, if can’t do this, optimal to start 2 weeks after (but better to give it sooner if it ensures that the person will get it)

Question 52

Which age group absolutely requires antibiotic prophylaxis amongst asplenic patients?

a) <5 year old and 2 years post splenectomy
c) none of the above

Answer 52

b) t protect fully so antibiotic prophylaxis is important for asplenic patients

Question 53

Which is the 1st line treatment to consider for a 2 month old baby with asplenia?

a) amoxicillin with penicillin
b) penicillin
c) amox/clav
d) erythromycin

Answer 53

0-3 months: amox clav and penicillin; e. coli and klebsiella are of concern; amoxicillin is an alternative if amox/clav not tolerated
3 months - 5 years: penicillin or amoxicillin
>5 years: pen V or Pen VK

for older kids with penicillin allergy (aka anaphylaxis), send to allergist to confirm that it was severe consider erythromycin, but note that it does not work as well
unclear evidence about patients with poor splenic function/hyposplenia (rather than asplenia)

Question 54

Name two infections that an asplenic individual travelling to India is at risk for and what you should recommend to prevent them?

Answer 54

a. salmonella typhi - should be immunized for salmonella typhi
b. malaria - at increased risk for severe malaria
prophylaxis
advise to sleep in mosquito net
if have fever within first month and up to one year, consider malaria in the Ddx

Question 55

An asplenic individual arrives in hospital with fever. Looks reasonably well. vitals stable other than temperature of 39. What is your management?

a) discharge home with instructions to return if worse
b) blood culture then discharge home
c) blood culture then admit for IV ceftriaxone +/- vancomycin
d) blood culture then admit for observation

Answer 55

c) these kids can go downhill quickly!
need to do blood culture and start Abx asap
if in clinic, go to ER immediately
blood culture then start antibiotics empirically
IV ceftriaxone, if lots of resistant S. pneumo then add vanco also
if allergy to ceftriaxone/penicillin, then try vanco and cipro

Question 56

True or false - patients with asplenia who have a life threatening Hib infection are protected against further infections?

Answer 56

(from the asplenia statement)

false - they need to get the Hib vaccine because they are not protected

Question 57

patient with aspen who is travelling to the developing world?

Answer 57

should be immunized against salmonella typhi since they are at risk
also increased risk of malaria - should take prophylactic medications and precautions

Question 58

kid getting an elective splenectomy, when should you give them their immunizations?

Answer 58

2 weeks before - best responses
if can’t do that, then optimal to do it two week after splenectomy - however, since sometimes it might get missed, often a better idea to give the vaccines before they leave the hospital

Question 59

which asplenic patients need antibiotics prophylaxis accord to Canadian guidelines?

Answer 59

minimum 2 years post splenectomy
all kids <5 years old
lifelong prophylaxis is recommended ideally

Question 60

2 month old with asplenia, what antibiotic for prophylaxis?

Answer 60

age t tolerate then penicillin or amox, orbs are e coli, klebsiella

Question 61

5 months old with asplenic, what antibiotic for prophylaxis?

Answer 61

age 3 months - 5 years old: penicillin or amox for

Question 62

age> 5 years, what antibiotic for prophylaxis

Answer 62

amox or penicillin

Question 63

kid with asplenia and suspected anaphylactic reaction to penicillin, what to do?

Answer 63

Children who have had or are believed to have had an anaphylactic-type reaction to penicillin should be referred immediately to an allergist to verify the diagnosis and for challenge or desensitization as warranted. Erythromycin is a recommended alternative; however, this antibiotic is less successful at preventing invasive disease because of higher rates of pneumococcal resistance.

Question 64

Steps of vaccine safety system in Canada

Answer 64

1. prelicensure review and approval
2. current good manufacturing process
3. lot assessment before release
4. independent expert review of recommendations
5. post marketing surveillance for adverse events
6. rapid response to safety concerns
7. expert causality assessment of adverse events after immunization
8. international collaboration

Question 65

true or false - vaccines are mandatory for school attendance in Canada?

Answer 65

false

Question 66

Meningitis vaccine

Answer 66

Normal kids - MCV-C (Menjugate) at 12 months
get booster of MCV-C or MCV4 (ACYW135) at approximately grade 7/8

High Risk kids : MCV-C at 2/4/ and 12 months + MCV - 4 at 2 years