Board Review

12/20/18
Ebrahim Ghazali
Dr Hsiang
Question 1
You are seeing a healthy 5-year-old boy referred to your outpatient clinic
because of parental “vaccine hesitancy.” The boy’s father tells you that
the school is requiring booster doses for diphtheria, tetanus, pertussis,
and polio vaccines before his son is allowed back in the classroom. Last
year, when his son was treated with amoxicillin for an ear infection, he
had a “severe” reaction requiring an overnight hospitalization for hives
and wheezing. The boy’s father is particularly concerned about the polio
vaccine dose because he read that it contains antibiotics and asks for a
medical exemption because of the allergy.
Of the following, the BEST response to the request is to
• decline the medical exemption
• grant the medical exemption
• postpone the medical exemption and initiate a penicillin desensitization
protocol
• postpone the medical exemption until an oral amoxicillin challenge can
be performed
American Board of Pediatrics Content Specification(s)
Know the composition of oral (OPV) and inactivated (IPV)
poliovirus vaccines, including nature of antigen(s) and vaccine
constituents (eg, neomycin, streptomycin)
Question 2
During a routine visit, the mother of a healthy 8-month-old girl states that
the family will be traveling to sub-Saharan Africa in 1 week to visit relatives.
The length of stay will be 1 month. The infant is up-to-date on her routine
2-, 4-, and 6-month vaccines, including receipt of influenza vaccine.
Of the following, the MOST appropriate vaccine recommendation for this
patient at this time is

• measles, mumps, and rubella vaccine; cholera vaccine; hepatitis A

vaccine
• measles, mumps, and rubella vaccine; meningococcal ACWY vaccine;
influenza vaccine
• typhoid vaccine (inactivated), meningococcal B vaccine, yellow fever
vaccine
• typhoid vaccine (inactivated), yellow fever vaccine, cholera vaccine
Question 3
A fully immunized 17-year-old college freshman has a 3-day history of
fever to 38.8°C, headache, decreased appetite, and right-sided salivary
gland swelling that began on the day of evaluation. He lives in a
dormitory, and during the past several weeks, other students in the
dormitory have had a similar illness. The student asks how he contracted
this illness.
Of the following, the BEST explanation for his developing this disease is
that

• he has underlying immune compromise

• a novel genotype of the virus has been introduced into the community
• there has been low vaccine coverage at the school
• vaccine-induced immunity is not completely protective
ABP Specifications
• Know the effectiveness of mumps vaccine in
disease prevention
• Know the reasons why young adults may be
susceptible to mumps
Question 4
A mother informs you that she doesn’t want to immunize her
child against pertussis, as she read on a blog that the vaccine is
not very effective. Assume the incidence of pertussis among
unvaccinated children in one year is 100 per 100,000, and the
incidence among vaccinated children in one year is 100 per
1,000,000.
What is the calculated vaccine efficacy?

• 10%
• 5%
• 80%
• 90%
Question 5
A 3-month-old full-term female infant presents to the clinic with episodes of
cough accompanied by post-tussive emesis and color change (facial redness).
The parents also note 1 apneic episode lasting a few seconds. The mother was
vaccinated against influenza during the third trimester, but declined the
diphtheria, pertussis, and tetanus (Tdap) vaccine, and does not have any
symptoms. Sick contacts include a 10-year-old fully vaccinated sibling with
cough. You suspect the infant is infected with pertussis and explain to the
parents that despite the sibling’s up-to-date vaccination status, the sibling is
the likely source case, given waning immunity to the pertussis acellular
vaccine.
Of the following, the BEST estimate of the duration of immunity after the last
pertussis vaccine dose for the sibling of the patient described in the vignette is
• 1–2 years
• 3–5 years
• 10–15 years
• 16–20 years
ABP Specifications
Understand the limitations of current timing of
pertussis immunization schedule in prevention of
pertussis (eg, disease in very young infants and
adolescents)
Question 6
The emergency department (ED) is treating a 17-year-old boy who had
anonymous anal-receptive sex and oral sex with another male without a
condom. The event occurred about 60 hours earlier, and the patient is
worried about contracting human immunodeficiency virus (HIV). He met
the partner through a dating website, where the partner advertised his
HIV status as negative. The partner has since deleted his profile from the
website, and the patient has no other way of contacting him.
The ED provider reports that the patient has no medication allergies, no
other medical history, and the physical examination findings are normal,
with no evidence of lesions, discharge, or trauma on genitourinary and
external anal examination. Result of a point-of-care rapid HIV test on the
patient is negative. Tests for gonorrhea and chlamydia from the
oropharynx, urine, and rectum have been performed and results are
pending. You recommend ceftriaxone intramuscularly and azithromycin
orally.
Question 6
Of the following, for HIV postexposure prophylaxis in
this patient, you are MOST likely to recommend
• abacavir-lamivudine fixed-dose combination and
darunavir boosted with ritonavir for 28 days
• no prophylaxis, because 60 hours is too long to
start postexposure prophylaxis
• no prophylaxis, because the partner stated his HIV
status was seronegative
• tenofovir-emtricitabine fixed-dose combination and
raltegravir for 28 days
Question 6

• Type of Exposure Risk per 10,000 Exposures

• Parenteral
• Blood Transfusion 9,250
• Needle-Sharing During Injection Drug Use 63
• Percutaneous (Needle-Stick) 23
• Sexual
• Receptive Anal Intercourse 138
• Insertive Anal Intercourse 11
• Receptive Penile-Vaginal Intercourse 8
• Insertive Penile-Vaginal Intercourse 4
• Receptive Oral Intercourse Low
• Insertive Oral Intercourse Low
ABP Specification
Know the appropriate methods of post-exposure
prophylaxis and their indications after possible non-
occupational exposure to HIV
Question 7
You are caring for a 9-month-old boy who is hospitalized with Haemophilus
influenzae type b meningitis. The infant has received intravenous
ceftriaxone for 3 days and is in stable condition. He lives with his parents
and 3 siblings, who are 5, 3, and 2 years of age. All household contacts are
healthy. The parents state that all their children are not immunized
because of personal philosophical reasons.
Of the following, the MOST appropriate chemoprophylaxis for this infant
and his household contacts is

• no chemoprophylaxis for index patient or household contacts

• rifampin for all household contacts
• rifampin for the household contacts now and for the index patient at the
end of therapy
• rifampin for the 2-year-old and 3-year-old children
ABP Specifications
Recommend rifampin chemoprophylaxis for
household and child care contacts of patients with
invasive Haemophilus influenzae type b disease,
based on the immunization status of the contacts
Question 8
A case of measles has just been reported in a preschool in your
community. You are asked to advise management for a family whose 2
boys, ages 20 months and 3.5 years, are in the same child care center
classroom. The 3.5 year old is in the maintenance phase of
chemotherapy for acute lymphoblastic leukemia. The 20 month old is
said to be well with no significant medical history except for a
maculopapular eruption that occurred after eating eggs. Both children
are said to be up to date with their immunizations.
Of the following, the BEST recommendation for the 20-month-old child
in this situation is to
• administer a dose of immune globulin intramuscularly
• immunize him with a second dose of measles-mumps-rubella vaccine
• isolate him from his brother for 21 days
• refer him to an allergist for egg allergy evaluation
ABP Specification
Plan a routine schedule for measles immunization,
including age of the patient, number of doses, and
intervals and their reasons
Manage a patient who has a contraindication (or
precaution) for measles immunization
Question 9
• You are seeing a 12-year-old boy with Bruton disease for routine
follow-up. He has been receiving immunoglobulin replacement
therapy since 9 months of age. He tells you that his weekly
subcutaneous immunoglobulin infusions are much easier than
the monthly intravenous infusions he used to receive. He has
been well since his last clinic visit 4 months ago. He has had no
breakthrough sinopulmonary infections. On review of his
electronic medical record, you note that he has received an
annual influenza vaccine every fall since he was very young. He
also received a booster dose of tetanus, diphtheria, pertussis
vaccine and a dose of quadrivalent conjugate meningococcal
vaccine last year before starting 6th grade. All of his early
childhood vaccine series are complete except for the measles,
mumps, and rubella and varicella vaccines.
Question 9
The boy’s father asks you whether his son should receive
the human papillomavirus (HPV) vaccine.
Of the following, the MOST appropriate response to the
father’s question is that his son should

• not receive the HPV vaccine series because he is male

• not receive the HPV vaccine series because he receives
immunoglobulin replacement
• receive the HPV vaccine series starting today
• receive the HPV vaccine series when he turns 16 years of
age
ABP Specifications
• Know the composition of and indications for human
papillomavirus (HPV) vaccine
Question 10
A healthy 11-year-old girl is undergoing a health
supervision visit. She has no medical problems. She
was born in the United States, where she lived until
age 2 years, when her family moved to Iceland. There
she continued to receive vaccinations. The family has
now moved back to the United States. The girl’s
vaccination records follow
 Child’s Age
Vaccine
Birth 2 months 4 months 6 months 12 months 15 months 18 months 5 years
Hepatitis B X X X
Rotavirus X X X
Diphtheria- tetanus-acellular pertussis X X X X X
Haemophilus influenzae type b X X X
Pneumococcal conjugate X X X X
Inactivated polio vaccine X X X
Measles-mumps-rubella X
Varicella X
Hepatitis A X X