IC11 Immunization, Malaria, Surgical Prophylaxis Flashcards
List the 14 Vaccines required in NCIS
- MMR (Measles Mumps Rubella)
- VAR (Varicella)
- IPV (Inactivated Poliovirus)
- Hepatitis B (HepB)
- Diphtheria, Tetanus, Acellular Pertussis (DTaP)
- Tetanus, reduced Diphtheria, Acellular Pertussis (TdaP)
- Bacillus Calmette-Guerin (BCG)
- Pneumococcal Conjugate (PCV10 or PCV13)
- Pneumococcal Polysaccharide (PPSV23)
- Haemophilus Influenzae Type B (Hib)
- Influenza (INF)
- Human Papillomavirus (HPV2 or HPV4)
Characteristics and Distinctions among live attenuated vaccines and inactivated vaccines (including polysaccharide vaccines, toxoid vaccines and recombinant vaccines)
Live Attenuated Vaccines
- Weakened viruses that replicate in the body
- Efficacy – Stronger immune response + Lifelong immunity
- Safety – Immunocompromised patients should not receive
- Storage – Refrigeration
Inactivated Vaccines
- Present foreign antigens of pathogen but cannot replicate
- Efficacy – Weaker immune response + Require several doses
- Safety – Low risk of adverse reactions / cause disease
- Storage – Easier to store
4 Precautions for use of live attenuated vaccines
Pregnancy & Infancy (< 1 year old) ⇒ Possible fetal infections
Severe immunocompromised patients (e.g. HIV CD4 < 200)
28 day period from 1st live vaccine
3-10 month period from administration of Antibody products (Ig, blood transfusion)
What is Herd immunity? What is it for? Percentage depends on?
Sufficiently immunized population (%) ⇒ Contain transmission
Protection of both vaccinated and unvaccinated individuals
The extent to which the disease is contagious ⇒ Percentage immunization needed for herd immunity
Purpose of Booster doses?
Antibody concentration wanes over time
NAIS has everything in NCIS except which 5?
DTaP, BCG, IPV, PCV10, Hib
Efficacy of vaccine depends on? (4 points)
Patient response (Varies)
Site of injection (Deltoid vs Gluteal – Depth and amount of muscle)
Age and immune status (80 y.o. Vs 60 y.o.)
Cold Chain problems (Temperature affects quality)
List of ADRs of vaccines
Pain, red, swell at injection site; headache, myalgia (Mild, common)
Fever, hematoma (Uncommon)
Anaphylaxis, hypersensitivity (Severe, rare)
Contraindications for vaccine use?
- Allergy
- Fever > 38
- Bleeding risk precaution & IM administration
- Pregnancy (Live vaccine)
- Immunocompromised (Live vaccine)
Are simultaneous vaccine administrations safe? Which vaccines should not be administered together?
All efficacious/safe when simultaneously administered
Exceptions: PCV and Meningococcal conjugate vaccine in Functional or anatomic asplenia ⇒ Should have 4-week interval apart
Can live vaccines be administered on the same day?
Live vaccines (IM, SC) CAN BE ADMINISTERED ON SAME DAY, Else ⇒ 28 days apart after the first
What happens if you miss a dose of vaccine?
Just take ASAP, additional dose not needed
4 Recommended resources to provide advice on preventing infections in travelers
CDC Health Information for International Traveler
CDC Yellow Book
WHO Travel Advice
MFA Travel Restrictions and Requirements
Pre-travel consultations should be done _____ weeks before departure
4-6
Outline the structured and sequenced approach to address the necessary preventive and educational interventions for medical advice before international travel.
- Risk Assessment
- Health background
- Trip details - Standard In-Office Interventions (Pharmacological)
- Travel Immunizations
- Malaria Chemoprophylaxis
- Traveler’s Diarrhea - Focused Education before trip (Non-pharmacological)
- Major routes of transmission
- Travel-related illness
- Medical Kit / Insurance - Post-travel Advice
- Malaria Chemoprophylaxis
- Self-assessment of abnormal symptoms
5 Major routes of Transmissions and Vector Borne Diseases?
- Food and Water Borne Pathogens (Fecal-oral route)
- Insect Vector Borne Infections
- Transcutaneous Spread (Contact / Droplet)
- Respiratory Spread (Airborne / Droplet)
- Blood and Body Fluids (Sexually transmitted / Needles Sharing)
Match the travel vaccines to each route of transmission
- Food/Water (Fecal oral) - HepA, Typhoid, Cholera, Poliomyelitis
- Vector borne - Yellow fever, Japanese Encephalitis
- Transcutaneous spread - Tetanus, Rabies
- Respiratory - Influenza, Meningococcus, MMR
- Blood & Body fluids - HepB
Which travel vaccines are mandatory in some countries?
Meningococcus and Poliomyelitis vaccines
6 inactivated / recombinant viral travel vaccines
Influenza, HepA, Poliomyelitis, Japanese Encephalitis, HepB, Rabies
3 live attenuated viral travel vaccines
MMR, Cholera, Yellow fever
For last minute travel, at least how long do you need to elicit protective vaccine response before travel?
2 weeks
For urgent travel, accelerated immunization schedules, risk avoidance counseling or drug prophylaxis
5 Plasmodium species
Prevalent – P falciparum (Most dangerous), P vivax
P malariae, P ovale, P knowlesi (New)
Transmission Mode of malaria
Female Anopheles Mosquito infected by plasmodium
Malaria symptoms
Fever, chills, sweats, headache, body aches, weakness, N/V/D
Severe = Sepsis, organ failure, death
Occurrence of Malaria is highest in _______ climate and _____ regions?
Tropical and Subtropical Climate
Highest in Africa South of Sahara & Oceania (Papua New Guinea)
3 Phases of plasmodium life cycle
Liver Phase (Exo-erythrocytic cycle)
- Multiply in Liver cells → No symptoms
- Dormancy for P vivax, P ovale
Blood Phase (Erythrocytic cycle)
- Multiply in RBCs and Differentiation (Gametocytes) → Clinical Symptoms
Mosquito (Sporogonic cycle)
Risk Factors for Malaria
Night biters – Dusk to dawn
Less risks in colder season/region
Less risks in deserts
Risk in urban areas of Africa and India
Less risks at high altitudes
More risks after rainy season
ABCDEs of Malaria Prevention Strategies
• Awareness – of risk, the possibility of delayed onset, and the main symptoms.
• Bite prevention – stay away from mosquitoes, especially between dusk and dawn. Use chemical or physical repellents.
• Chemoprophylaxis – adhere closely to antimalarial preventive medications when prescribed
• Diagnosis – early recognition and seek treatment
• Environments – keep off mosquito breeding places, such as swamps or marshy areas, especially in late evenings and at night.
Drugs used for malaria chemoprophylaxis?
• Atovaquone + Proguanil (Malarone®)
• Chloroquine
• Doxycycline
• Mefloquine
Considerations for choosing an antimalarial chemoprophylaxis
- Travel itinerary of utmost importance - chloroquine and/or mefloquine resistance in some areas of the world
- Traveler’s medical history:
- Medical conditions like pregnancy, G6PD deficiency, allergies, comorbidities
- Medications - check for drug-drug interactions - Traveler’s preferences that may affect adherence
- Regimen may be taken daily or weekly
- Cost consideration - Travel departure date and duration
- Regimen may need to be started as much as 2 weeks, some the day before
Risk and Prevention Types
Non-Falciparum (Type B) – Any 4 drugs
Falciparum (Type C) – All EXCEPT Chloroquine
Atovaquone 250mg / Proguanil 100mg (Malarone)
Dose, Regimen, CI, ADR, DDI
Dosing – 1 tab daily with food or milk
Regimen – Start 1-2 days before trip, End 7 days after return
Contraindications – Hypersensitivity, Renal (CrCl < 30 ml/min)
ADR – Less side effects, N/V/D, stomach pain, headache, dizzy
DDI – Rifampicin, Metoclopramide, efavirenz
Atovaquone 250mg / Proguanil 100mg (Malarone) should be avoided in ____________________________
pregnancy, lactation, baby < 5kg
What category of sales are each malaria agents under?
- Malarone - POM with exemption
- Chloroquine & Mefloquine - Pharmacy only
- Doxycycline - POM
Chloroquine Phosphate 250mg (150mg base)
Dose, Regimen, CI, ADR, DDI
Dosing – 2 tab weekly with or after meals
Regimen – Start 1-2 weeks before trip, End 4 weeks after return
Contraindications – Hypersensitivity, Region resistance
ADR – N/V, stomach pain, skin rash/itch
DDI – QTc prolonging CYP3A4 inhibitors (clarithromycin, voriconazole)
Chloroquine should be taken with precaution in
Exacerbate psoriasis, myasthenia gravis, auditory damage, liver impairment, seizure disorders
Doxycycline 100mg
Dose, Regimen, CI, ADR, DDI
Dosing – 1 capsule daily with full glass of water, 30min upright
Regimen – Start 1-2 days before trip, End 4 weeks after return
Contraindications – Hypersensitivity, special populations
ADR – GI discomfort, sunburn, vaginal candidiasis
DDI – Multivalent ions
Doxycycline should be avoided in ________
< 8 y.o., pregnancy, lactation
Mefloquine 250mg
Dose, Regimen, CI, ADR, DDI
Dosing – 1 tablet weekly after meals
Regimen – Start 1 week before trip (preferred - 2-3 week), End 4 weeks after return
Contraindications – Hypersensitivity,
ADR – GI discomfort, dizzy, fatigue, headache, insomnia, vivid dreams, neuropsychiatric disorder
DDI – Ketoconazole
Non-pharmacological protection examples
Barrier protection – Clothing / Light color clothing / Avoid dusk to dawn / Permethrin Impregnated Bed Net
Insect Repellent
DEET (Alpine) – 20-50% for 6-12h protection
Picaridin (Kiwi) – 20%
Oil of Lemon Eucalyptus (OLE) or PMD
IR3535
2-undecanone
Define surgical site infections (SSIs)
Healthcare-associated Infection
Within 30 days after surgical operation or within 1 year for implants left affecting the incision or deep tissue at operation site
Indications for SAP
Clean surgery = Healthy skin incised (Sites not usually traversed) only when:
1. Prosthesis or implant will be inserted
2. SSI poses catastrophic risk / Immunocompromised
Clean-contaminated surgery = Penetrated under controlled conditions without unusual contamination (Respiratory, alimentary, genitourinary)
Contaminated ⇒ Antibiotic treatment not prophylaxis
Antibiotic of choice should be ______ spectrum, based on ________________
Narrow spectrum
Local resistance pattern, Site with expected pathogen, MDR bacteria and CDAD risks, MRSA Risks, Beta Lactam Allergy
For those with MRSA risk, SAP with _______ +/- _______ is suitable
Vancomycin, Cefazolin
When to administer antibiotic for surgeries?
30-60 min before surgical incision – Complete infusion
1h before incision for fluoroquinolones and vancomycin – Longer infusion time needed
Factors requiring intraoperative redosing
Procedure Duration > 2 half-lives of drug
Intraoperative Blood loss > 1500mL
Extensive burns
Antibiotic duration should be how long?
< 24h (CDAD and AKI risk for > 24h)
List non-antimicrobial strategies recommended to reduce the risk of SSI
Hair removal only if it interferes with operation – NO RAZOR, use clipper, depilatory agent
Blood glucose control postoperative < 180 mg/dL (10 mmol/L)
Postoperative temperature > 35.5oC
Postoperative supplemental oxygen
Preoperative alcohol-containing skin preparatory agents
Plastic wound protectors (GI, biliary surgery)
WHO checklist
Surveillance
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