Ch2: Primary Prevention Flashcards
the most cost effective form of healthcare
primary prevention
detecting disease in early, asymptomatic, preclinical state including screening tests (BP, mammogram, colonoscopy)
secondary prevention
minimizing negative disease-induced outcomes (adjusting therapies to avoid further target organ damage)
tertiary prevention
benefits of polio vaccination
10,000 children are not paralyzed, and 3,000 do not die per year
fecal-oral route of transmission (contaminated food and water)
benefits of rubella vaccination [MMR] (german measles)
20,000 newborns are spared congenital rubella syndrome (developmental disability, blindness, hearing loss) per year
rubella is one of the most teratogenic viruses known to humankind
benefits of measles vaccine [MMR]
12,000 deaths avoided in the US per year (and 2.7 million worldwide)
encephalitis, pneumonia, death, blindness
benefits of influenza vaccine
prevents 7 million cases of illness per year and 110,000 influenza-related hospitalizations and 9,000 deaths prevented (with most deaths being in children, elderly, and pregnant women)
5x more likely to be hospitalized with influenza complications in pregnancy
benefits of pneumonia [pneumococcal] vaccine
pneumonia death rate = 1 in 20 (1 in 5 if they develop septicemia or meningitis complication)
40,000 deaths per year, 50% could be prevented if everyone got the vaccine
mortality risk is greatest in early childhood, elderly, and underlying medical conditions
two options: Prevnar, Pneumovax
is it ok to give another vaccine if they are unsure their receipt status in the past?
better to give an extra vaccine dose than to give none. risk of reaction with re-immunization is minimal
when should a vaccine dose be deferred or delayed?
moderate-severe illness with or without fever (her personal rule is that the only time she will skip a vaccine that is due is when she is sending that person to the hospital)
do NOT need to defer in the presence of minor illness
what is active immunity
given via vaccine
resistance is developed in response to a vaccine, usually characterized by the presence of an antibody produced by the host
given in anticipation of exposure to an infecting agent
onset of protection is usually within 1 month of the dose
protection usually lasts years or lifelong
which is preferred: active vs. passive immunity
active
what is passive immunity
given via immune globulin
immunity is conferred by an antibody produced in another host, via administration of an antibody-containing preparation (antiserum or immune globulin [IG])
given post-exposure to select infecting agents
onset of protection is usually within hours of dose
duration of protection is time limited, usually 6-9 months
available for only a limited number of infectious agents
example infectious agents we have immune globulin available for? (5)
varicella, hepatitis A, hepatitis B, tetanus, rabies
what happens to your immunity if you get acute hepatitis B and then your body clears it without becoming chronic
lifetime immunity
can you get active hepatitis B infection from sexual contact with someone who has chronic (asymptomatic) hepatitis B
yes
tetanus organism
c. tetany
anaerobe - does better where there is less oxygen (deeper wounds, not superficial ones)
dirty wound, think of giving this prophylactically….
tetanus immune globulin and/or tetanus vaccine
characteristics of the type of wound you need to consider tetanus for
- > 6hrs old
- contaminated [soil, feces, saliva, dirt]
- puncture or crush wound
- avulsions
- wounds from missiles, burns, or frostbite
Pt presents with a clean, recent, minor, superficial wound. They don’t remember if they have ever completed their Tdap vaccine series. What do you recommend today?
Tdap today
they do not need TIG (immune globulin)
Pt presents with a clean, recent, minor, superficial wound. They completed their Tdap series on schedule, but their last dose was >10 years ago. What do you recommend today?
Tdap today
they do not need TIG (immune globulin)
Pt presents with a deep wound from 8 hrs ago that is visibly soiled with dirt. They do not know if they ever completed their Tdap vaccine series. What do you recommend today?
Tdap today
TIG (immune globulin) today 250 units IM (??)
Pt presents with a deep wound from 8 hrs ago that is visibly soiled with dirt. They completed their Tdap series on schedule, but their last dose was >5 years ago. What do you recommend today?
Tdap today
?? TIG (immune globulin) today 250 units IM ??
Pt has a history of anaphylactic reaction to neomycin. What vaccine(s) should they avoid?
inactivated polio vaccine (IPV), MMR, varicella
Pt has a history of anaphylactic reaction to baker’s yeast (in all commercially-prepared bread). What vaccine(s) should they avoid?
hepatitis B
Pt has a history of anaphylactic reaction to gelatin. What vaccine(s) should they avoid?
MMR
anaphylaxis is an acute, life-threatening systemic reaction that results from the ….
sudden systemic release of mediators from mast cells and basophils
most common presentation of anaphylaxis (3)
- urticaria (hives, may become coalescent, pruritic)
- angioedema (tissue edema most commonly involving the head and neck)
- respiratory compromise
Primary care interventions for anaphylactic reactions (6)
- assess airway, breathing, circulation
- place in supine position
- activate EMS
- administer IM epinephrine (anterior-lateral thigh)
- give an H1 (diphenhydramine [benadryl]) or H2 blocker (ranitidine [Zantac]) PO
- IV access if available, oxygen, ongoing clinical monitoring (do not leave them alone in the exam room)
Contraindications to epinephrine in emergency situations
NONE! it is life-saving
folks with a history of anaphylactic reactions should have prescriptions provided for… (3)
- epinephrine (EpiPen)
Also consider….
- oral antihistamines
- systemic corticosteroids
Refer to an allergist!!!!
Community disaster: Uninjured adults and children are evacuated to a crowded group setting. Which vaccine will you prioritize?
influenza (respiratory droplets)
Community disaster: Adults with deep lacerations from flying debris. Which vaccine will you prioritize?
tetanus (contaminated wounds)
Community disaster: community is exposed to unsafe water supply after a hurricane. Which vaccine will you prioritize?
hepatitis A (fecal-oral route through contaminated food and water)
what is immune globulin made of
a concentrated solution of antibodies derived from pooled donated blood
previously unvaccinated adults with newly diagnosed T1DM or T2DM should be vaccinated against ______ as soon as possible d/t risk for contracting from their glucose testing
hepatitis B
higher risk of developing chronic hepatitis B
people with DM in a group setting (e.g., hospital, LTAC), there are outbreaks of Hepatitis B from caregivers who did not properly disinfect the testing equipment or not changing the lancet
for routine tetanus immunization UPDATE (booster) in adults, which version should you use?
either Td or Tdap is ok
discuss PCV13 vs. PPSV23
PCV13 = stronger protection, more narrow coverage
PPSV23 = broader coverage, less strong protection
both tend to be pretty well-tolerated
anticipatory guidance for patients regarding pneumococcal vaccine adverse reactions
30-50% will experience local reactions including pain and redness
systemic reaction (fever, myalgia) is rare, highest in children (11-40% of children will have short-term mild systemic reaction)
severe reactions are rare
what is a live attenuated vaccine
live, weakened virus
vaccine prepared from live microorganisms that are cultured under adverse conditions leading to loss of virulence but retention of their ability to induce protective immunity
live vaccines most commonly used in the US (4)
- MMR
- varicella (chickenpox)
- intranasal flu (FluMist)
- zoster (only zostavax, shingrix is not)
difference between zostavax and shingrix for zoster vaccination?
zostavax (old version) was a live vaccine (no longer being manufactured). was only 50% efficacious
shingrix is NOT LIVE!!! nearly 100% efficacy :)
in which populations do we avoid live vaccine use? (2)
- pregnancy d/t theoretical risk of passing along virus to fetus
- severe immunocompromise d/t potential risk of becoming ill with the virus or a lack of clinical effect (e.g., HIV with AIDS, on immunemodulators)
if CD4 count is above _____, it is generally safe to give a live vaccine to someone with HIV
> 200
if someone had zostavax in the past, should they still receive shingrix?
yes, shingrix is more efficacious
if someone had shingles in the past, should they still receive shingrix?
yes, can prevent severity and post-herpetic neuralgia
wait 6-8 weeks after last outbreak before giving
ACIP recommendation for who should receive the Shingrix vaccine
adults 50yo+, including those who previously received the live zoster vaccine (Zostavax)
patient counseling: Shingrix
- vaccine type
- dosing
- FDA indication
- contraindications
- ACIP recommendation
- adverse effects
- vaccine type: recombinant adjuvanted (NOT live)
- dosing: two doses, IM injection (0 and 2-6 months)
- FDA indication: prevention of herpes zoster (shingles) in adults 50yo and older
- contraindications: h/o severe allergic reaction to any component of vaccine. it is ok to give to folks who are immunosuppressed. has not been studied in pregnancy
- ACIP recommendation: adults 50yo+ including those who previously received Zostavax
- side effects: pain at injection site (78%), redness at injection site (38%), swelling (26%), myalgias (44%), fatigue (44%), headache (37%), shivering (26%), fever (20%), GI symptoms (17%)
expected adverse reactions: Hepatitis A vaccine
COMMON (>25%)
- injection site soreness
LESS COMMON (<25%)
- headache
- poor appetite
RARE (<1%)
- allergic reaction
expected adverse reactions: Hepatitis B vaccine
COMMON (>25%)
- injection site soreness
LESS COMMON (<25%) - mild fever
RARE (<1%)
- allergic reaction
expected adverse reactions: Influenza vaccine
COMMON (>25%)
- injection site soreness
- injection site redness
LESS COMMON (<25%)
- muscle aches
- mild fever
RARE (<1%)
- allergic reaction
expected adverse reactions: MMR
COMMON (>25%)
- fever
- arthralgias
LESS COMMON (<25%)
- mild rash
- lymphadenopathy
RARE (<1%)
- seizure
- allergic reaction
- potential teratogen
expected adverse reactions: Meningococcal types A, C, Y, W-135 (Menactra)
COMMON (>25%)
- injection site redness
LESS COMMON (<25%) - fever
RARE (<1%)
- none
expected adverse reactions: Meningococcal serogroup B (MenB)
COMMON (>25%)
- injection site soreness
- injection site redness
- injection site swelling
- mild generalized malaise
LESS COMMON (<25%) - fainting
RARE (<1%)
- allergy
expected adverse reactions: Pneumococcal conjugate vaccine 13 (PCV13, Prevnar)
COMMON (>25%)
- injection site redness
- temp >100.4 (children)
LESS COMMON (<25%) - none
RARE (<1%)
- none
expected adverse reactions: pneumococcal polysaccharide vaccine 23 (Pneumovax 23)
COMMON (>25%)
- injection site redness
LESS COMMON (<25%)
- fever
- myalgia
RARE (<1%)
- allergy
expected adverse reactions: HPV-9 vaccine (Gardasil-9)
COMMON (>25%)
- injection site soreness
- injection site redness
- injection site swelling
LESS COMMON (<25%)
- generalized body aches
- mild fever
- headache
RARE (<1%)
- syncope
expected adverse reactions: Tdap
COMMON (>25%)
- injection site redness
LESS COMMON (<25%)
- myalgia
- fever
RARE (<1%)
- allergy
expected adverse reactions: Td
COMMON (>25%)
- injection site redness
LESS COMMON (<25%) - none
RARE (<1%)
- allergy
expected adverse reactions: varicella (chickenpox)
COMMON (>25%)
- injection site soreness
LESS COMMON (<25%)
- fever
- mild rash up to 1 month post-administration
RARE (<1%)
- seizure
- pneumonia
expected adverse reactions: zoster (Shingrix)
COMMON (>25%)
- injection site soreness
- injection site redness
- injection site swelling
- myalgias
- fatigue
- headache
- shivering
LESS COMMON (<25%)
- fever
- GI upset
RARE (<1%)
- none
when should everyone have received their hepatitis B vaccine series
childhood (birth, 1-2 mo, 6-18mos)
when should everyone have received their tetanus/diphtheria/acellular pertussis vaccine series
DTaP in childhood (2 mo, 4 mo, 6 mos, 18mos, and 4-6 yrs)
DTaP is for <7yo
Tdap is for > or = 7 yo
when should everyone have received their first pneumonia vaccine
PCV13 in childhood (2mos, 4mos, 6mos, 12-18mos)
when should everyone have received their inactivated polio vaccine
childhood (2mos, 4mos, 6-18mos, 4-6 yrs)
when should everyone have received their MMR vaccine
childhood (1 yr, 4-6yrs)
when should everyone have received their varicella vaccine
childhood (1yr, 4-6 yrs)
when should everyone have received their hepatitis A vaccine series
childhood (~1 yr)
when should everyone have received their HPV vaccine series
childhood (9-11yo ideally; <15yo is a two-dose series; 15-26yo is a three-dose series)
when should everyone have received their meningococcal vaccine series
adolescence (7-10yrs, and 16yo)
when should everyone have received their haemophilius influenza type B (HiB) vaccine
childhood
which vaccines should all folks have been offered before 18yo (11)
- hepatitis B
- hepatitis A
- rotavirus
- DTaP (<7yo) or Tdap (>7yo)
- Hib (haemophilius influenza type B)
- pneumonia (PCV13)
- inactivated polio
- MMR
- varicella (chickenpox)
- meningococcal
- HPV
can you still give the IM flu vaccine to someone with an egg allergy?
yes!
if they had only hives, ok to give
if they had more severe allergic reaction, must give in a setting where possible to manage severe allergic reactions
adult influenza vaccine, general recommendation
1 dose annually, no age limit for IM flu
adult Tdap or Td vaccine, general recommendation
1 dose Tdap, then Td OR Tdap booster Q10 years, no age limit
adult MMR vaccine, general recommendation
if they do not have demonstrated immunity, can give 1 or 2 doses depending on the indication. not ok to give when severely immunocompromised or pregnant. no recommendations on use beyond 64yo
adult varicella vaccine, general recommendation
if they do not have demonstrated immunity, can give 2 doses. not ok to give when severely immunocompromised or pregnant. no age limit
adult zoster recombinant (Shingrix) vaccine, general recommendation
everyone after 50yo, 2 dose series, no age limit
Shingrix preferred over Zostavax (live attenuated)
adult HPV vaccine, general recommendation
should have received in adolescence. if >15yo, 3 dose series. if not received, recommend catch-up vaccination through age 26. after 26yo, shared decision making through 45yo. No guidance on recommendations after 45yo
adult pneumonia vaccine, general recommendation
PPSV23 is recommended for everyone 65yo and older 1 dose. PCV13 is recommended for shared decision making for everyone 65yo and older.
May receive either dose earlier based on comorbidities/risk factors
