Immigrants + Immunisations Flashcards
What to cover in immigrant hx
Assess vaccination status + provide necessary vaccines
Screen for depression, inquire about history of abuse + torture, assess for support
Consider ddx of infectious diseases (malaria, parasitic disease, TB)
Enquire about use of alternative medicine, spiritual/ herbal medicines
Medical Interpreter (consider CanTalk - telephone interpreter)
Document findings (scars)
Medication review, including alternative/herbal remedies
Infection
Consider malaria, TB, hepatitis, HIV, parasitic disease in differential
Chronic disease
Age-appropriate screening
Screening for immigrants as above (Hep B/C, TB, HIV, parasites, DM2, Iron-deficiency anemia, Dental)
Consider other screening
Sickle cell, Thalassemia
Vision
Mental Health
Depression, PTSD
Trauma (child neglect, genital mutilation, intimate partner violence, torture, abuse, war)
Culture/tradition/religion/gender roles
Women’s health
Contraception
Cervical cancer screening
HPV vaccine
Vaccination
Primary immunization schedule according to age (Tdap, MMRV, etc…)
Consider Hepatitis A/B
If positive for sickle cell or thalassemia
Consider pneumococcal, H influenzae, meningococcal
How to approach immigrant consults
Modify approach by cultural context
Use interpreters + recognize limitations of interpreters (different agendas, lack of medical knowledge, something to hide)
How to approach vaccine hesitancy
Counsel during prenatal
Present vaccines as default approach
Be honest about SE
Provide stories as well as facts, build trust w/ parents
Address pain
Focus on protection for child
Vaccine pain reduction
No aspiration
Inject painful vax last (MMR)
Breastfeed during
Position skin to skin
Consider topical anesthetic
Parents present
Distraction
Pts at higher risk of infection + need more imms
Pts at risk:
Elderly
Immunosuppressed
Sickle cell anemia
CHF
Asplenia
Imms for asplenia
Pneumococcal
HiB
Meningococcal
Influenza
COVID vax efficiacy, SE + CI
Efficacy of vax: 95%
SE of vax: injection site pain, fatigue, myalgia, HA
CI to vax: allergy, VTE, capillary leak
Diphtheria sx, complications + management
Complications: myocarditis, paralysis, fatality
Sx: fever, bloody nasal DC, sore throat, neck swelling, croup cough, paralysis
Management: erythromycin
Diphtheria vax efficacy, when to administer, SE + CI
Efficacy of vax: 99% for 10 yrs
When to give vax: 2, 4, 6, 18mo, 4-6yr, 14-16yr, q10yrs
SE of vax: fever, fussy, fatigue, poor appetite, red sore limb
CI to vax: reaction to prev vax
Hib complications, when to give vax, efficacy of vax, SE + CI to vax
Complications: bacterial meningitis, epiglottitis, PNA, cellulitis, fatality
When to give vax: 2, 4, 6, 18mo, HIV, asplenia, transplant recipients
Efficacy of vax: 99%
SE of vax: temp, sore red limb
CI to vax: allergy
Herpes zoster complications, sx, efficacy of vax, types, SE + CI to vax
Complications: sight-threatening infection, CNS infection, nerve palsies, post herpetic neuralgia
Sx: unilateral painful vesicular rash
Efficacy of vax: reduced shingles by 51% in >60y/o
SE of vax: site reaction, HA
CI to vax: immunocompromised, pregnancy
Types: Shingrix, Zostavax
HPV complications, efficacy of vax, SE + CI to vax
Complications: cervical cancer
Efficacy of vax: 95% against lesions, 99% against cervical cancer
SE of vax:site pain/ swelling, HA, fatigue
CI to vax: pregnant, immunocompromised
Measles cause, sx, complications
Cause: rubeola
Complications: OM, PNA, encephalitis
Sx: conjunctivitis, coryza, cough, fever, Koplik’s sports
Measles vax efficacy, SE, CI, when to vax
Efficacy of vax: 100%
When to vax: 1 yr + 4-6yrs
SE of vax: subclinical infection, malaise, fever, thrombocytopenia
CI to vax: neomycin + gelatin allergy, immunocompromised
Meningococcal vax efficacy, SE, CI, when to vax
When to vax: 1yr, asplenia
Efficacy of vax: 97% 1st year, decreases to 67%
SE of vax: site reaction, fever, irritability
CI to vax: anaphylaxis to vax
Mumps complications + sx
Mumps
Complications: acute parotitis, seizures, hearing loss, orchitis, paralysis
Sx: neck stiffness, parotitis, fever, trismus, fever
What’s involved in mandatory immigration medical?
Complete physical examination (including vision/hearing screen)
>5yo - Urinalysis for protein, glucose (think diabetes), blood (think shistosomiasis)
If abnormal, urine microscopy
>11yo - CXR r/o TB
>15yo or risk factor (eg. known infected mother, unprotected sex)
HIV testing, Syphilis
What is the recommended screening for immigrants?
Hep B (Africa, Asia, Eastern Europe and parts of South America)
Vaccinate susceptible, refer chronic infection for treatment (and consider screen HCC as indicated)
Hep C (specifically subSaharan Africa [10%]; eastern Europe, especially Uzbekistan and Tajikistan [27%]; Egypt [25%–50%]; Vietnam [10%]; and Pakistan [5-35%]) and exposure to contaminated blood, usually as nosocomial transmission through unscreened blood products, surgery or receipt of intramuscular injections)
If positive, vaccinate Hep A/B, limit alcohol and refer for treatment
TB PPD skin test (Sub-Saharan Africa, Asia, and Central and South America, and some in Eastern Europe)
CXR to rule out active disease
HIV (sub-Saharan Africa, Caribbean, Thailand)
Post-test counselling and refer to HIV treatment program
Intestinal parasites if from endemic area, compatible sign/symptoms of infection (asthma) or evidence of peripheral eosinophilia
Strongyloides serology (consider in immigrants from Southeast Asia and Africa)
If positive, treat with ivermectin (or albendazole)
Shistosomiasis serology (Africa)
If positive, treat with praziquantel
DM2 >35yo South Asian, Latin American and African
Iron-deficiency anemia with hemoglobin for women of reproductive age, and children 1-4yo
Dental disease (ask all if any pain, and look for evidence of disease)
Refer to dentist (and treat pain with NSAID)
Mumps - when to vax, efficacy, SE + CI
When to vax: 1 yr, 4-6 yrs
Efficacy of vax: 90% after 2 doses
SE of vax: malaise, fever, parotitis
CI to vax: neomycin + gelatin allergy, immunocompromised
Parvovirus cause, complications + sx
Cause: fifth disease, slapped cheek
Complications: encephalopathy, meningitis, myocarditis, autoimmune hepatitis
Sx: cold sx, lacy rash, painful erythema on hands + feet
Pertussis cause, complications + sx
Cause: bordetella pertussis
Complications: PNA, sz, cerebral hemorrhage, apnea
Sx: cold sx, paroxysmal cough, insp whoop, post-tussive emesis
Pertussis - when to vax, efficacy, SE + CI
When to vax: 2, 4, 6, 18mo, 4-6yrs, 14-16yrs
Efficacy of vax: 92%
SE of vax: sore limb, fever, irritability, drowsiness, sz
CI to vax: anaphylaxis
Pneumococcal - complications, when to vax, efficacy, SE + CI
Complications: bacteremia, meningitis, PNA
When to vax: 2, 4, 12mo + if smoker/ asthma/ asplenic/ >65
Efficacy of vax: 90%
SE of vax: fever, sore limb
CI to vax: anaphylaxis
Polio - sx, complications, when to vax, efficacy, SE + CI
Complications: paralysis, aspiration, myocarditis
Sx: malaise, HA, fever, calf pain, neck stiffness
Efficacy of vax: 100%
When to vax: 2, 4, 6, 18 mo, 4-6 yrs
CI to vax: anaphylaxis
Rabies complications, sx, post exposure prophylaxis
Complications:
Sx: HA, malaise, fever, fatigue, paralysis, encephalitis
Post exposure prophylaxis: rabies Ig ASAP
Rabies vax on days 0, 3, 7, 14, 28
Rotavirus - CI to vax
hx of intusseception
Rubella - when to vax, efficacy, SE + CI
When to vax: 1yr, 4-6yrs
Efficacy of vax: 97%
SE of vax: rash, lymphadenopathy
CI to vax: neomycin + gentamicin allergy, immunocompromised
Rubella sx + complications
Complications: CRS in pregnancy (stillbirth, miscarriage, congenital heart defects)
Sx: erythematous rash, lymphadenopathy, arthralgia
Tetanus cause, complications + sx
Cause: clostridium tetani
Complications: neurotoxic
Sx: sweating, drooling, fever, incontinence
Tetanus - when to vax, efficacy, SE + CI
When to vax: 2, 4, 6, 18 mo, 4-6yrs, 14-16yrs, q10yr
SE of vax: sore red limb, lymphadenopathy, fever
CI to vax: anaphylaxis
Rubella complications + sx
Complications: CRS in pregnancy (stillbirth, miscarriage, congenital heart defects)
Sx: erythematous rash, lymphadenopathy, arthralgia
Rubella - efficacy, when to vax, SE, CI to vax
When to vax: 1yr, 4-6yrs
Efficacy of vax: 97%
SE of vax: rash, lymphadenopathy
CI to vax: neomycin + gentamicin allergy, immunocompromised
Tetanus cause, complications, sx
Cause: clostridium tetani
Complications: neurotoxic
Sx: sweating, drooling, fever, incontinence
Tetanus - when to vax, SE + CI
When to vax: 2, 4, 6, 18 mo, 4-6yrs, 14-16yrs, q10yr
SE of vax: sore red limb, lymphadenopathy, fever
CI to vax: anaphylaxis
CI to vaccinations generally
Anaphylaxis or other serious reaction (eg. Guillain-Barre syndrome) upon administration of previous dose of a particular vaccine
Anaphylactic reaction or other serious reaction to a component of a vaccine (eg. egg, gelatin, latex, neomycin, thimerosal)
Pregnant or immunocompromised/suppressed, active TB should not receive LIVE vaccines (BCG, Zostavax, LAIV, MMRV, rotavirus, Smallpox Typhoid [oral], Yellow fever)
Consider delaying inactivated vaccines 1-3 months after immunosuppressive therapy
CI to flu vax
Severe asthma
Medically attended wheezing in the 7 days prior to vaccination
Rotavirus vax CI
Uncorrected congenital malformation of GI tract
Previous intussusception
When can you NOT immunise because of illness?
GI illness for rotavirus (if does not affect dose scheduling age limit), oral cholera, and traveller’s diarrhea vaccine
Significant nasal congestion that will impede delivery of live-attenuated influenza vaccine
When you should think about vaccinations
In infancy
Before pregnancy
Before traveling
When new to the country if not previously immunized
Vaccine fears - how to approach fears about SE
Most common side effects are mild fever and sore extremity. Serious reactions (death, encephalopathy) are so rare that their incidence cannot be calculated.
Vaccine hesitancy - how to approach fears about autism
The original paper in the Lancet publishing this association was recently withdrawn and there have been no definitive cases to support this claim. This was originally associated with a preservative agent called thimerosal. The only vaccines in Canada that are given to children and contain thimerosal are the multidose influenza vaccine and Hepatitis B. Both these vaccinations are available in formulations that do not contain thimerosal (ex. Vaxigrip for children and pregnant mothers). The only true contraindication to thimerosal is anaphylaxis.
Vaccine hesitancy - how to approach fears about vaccines not working
No vaccine is entirely effective. If a vaccine-preventable disease outbreak does occur, some vaccinated individuals will contract the disease. However the proportion of unvaccinated individuals who contract the disease will be much higher than the proportion of vaccinated individuals.
Vaccine hesitancy - how to approach people that say vaccine preventable diseases no longer exist
Certainly some vaccine-preventable diseases are rarely, if ever, seen in Canada and herd immunity for unvaccinated individuals does occur. However, unvaccinated individuals may still be exposed in their lifetime given the immigrant population that may not have been vaccinated or if the unvaccinated chooses to travel later in life.
Vax in premature babies
Premature infants should receive immunizations at the same time (chronological age) as term infants, ie. do not delay vaccinations - in Quebec first vaccines at 2 months old
Exception: In jurisdictions where Hep B vaccine is given at birth in HbsAg negative mother, delay until infant 2000g or discharged from hospital
Vax for asplenia/ hyposplenia
Pneumococcal (most common infection in asplenia)
Meningococcal
Haemophilus Influenza Type B
Influenza
Hep A and B if repeated transfusions
Vax for chronic liver disease
Hepatitis A and B
Influenza
+/- Pneumococal
Who gets pneumococcal
≥65yo, <65 with specific risk factor
Who gets herpes zoster
≥60yo (consider 50-59yo), immunosuppressed
Live attenuated (Zostavax) vs. Non-live recombinant adjuvanted (Shingrix)
1 dose vs. 2 doses (2 months apart)
Herpes Zoster relative risk reduction 51% (NNT 59) vs. 97% (NNT 37)
Post-herpetic neuralgia RR reduction 67% (NNT 364) vs. 89%
Adults ≥50yo who are known VZV seronegative should be given univalent varicella vaccine rather than herpes zoster (routine testing not recommended)
Who gets HPV
9-26yo and ≥27yo who are at ongoing risk
PIQ recommends vaccinating women 9-45yo, men 9-26yo even if previous HPV exposure
Who gets meningococcal
Up to 24yo not immunized, or risk
Immigrant health guidelines
testing for HIV, HCV, TB, strongyloides, schistosomiasis, vaccines, offer interpreter, screen for dental disease, diabetes, eye disease, screen for depression, test for IDA in women + children, contraception, paps, mammograms, HPV vax
Test for TB
mantoux skin test, intradermal or IGRA test for latent TB
Rx for TB: RIPE
rifampicin, isoniazid, pyrazinamide, ethambutol
RF for strongyloides
walking barefoot in high risk area (Caribbean, SE Asia)
Immigrant vaccines to give vs to test first
vax first Tdap (4 dose series) + MMR, test for HBV + varicella
Populations that have unique immunisation needs
immunosuppressed, immigrants, HCW, travellers, elderly, infants, military
When to give TDap in pregnancy?
give tdap in every preg after 13wks ideally 27wks
Which vax are safe in breastfeeding women
all safe except BCG, jap encephalitis, yellow fever
When is it appropriate to delay vaccines (which vaccines + when)?
- nasal congestion - dont give nasal influenza
- acute gi illness - defer oral cholera vax
- mod-severe gi illness - defer rotavirus
Flu vax - who to give to
children >6mo, high risk adults (neuro conditions, healthcare, working with poultry), >65
Anti-vaxxer couselling
safe to vax, danger in not vaccinating, pain can be reduced
Preventing painful pokes
don’t aspirate, most painful last, breastfeed, skin-to-skin, topical anesthetic, oral sugar
Shingrix regime, when to give
2 doses, 2 months apart, >50y/o
HPV - which strain
9 valent
Men C for who?
travellers to Hajj or Africa, military recruits, asplenia/ sickle cell, all canadian adolescents
What are the CI in these populations?
Anaphylactic to prev vax
Pregnancy
Active TB
Severe asthma
Congenital GI malformation
HIV
Allergic to chicken or eggs
Anaphylactic to prev vax = same vax CI
Pregnancy = MMR, BCG
Active TB = MMR, varicella, herpes zoster, BCG
Severe asthma = live attenuated influenza
Congenital GI malformation = rotavirus
HIV = MMR, BCG, polio, varicella (all live vax)
Allergic to chicken or eggs = don’t give yellow fever, tick borne encephalitis or rabies
CI to COVID-19
prev anaphylaxis or allergy
Precautions to covid-19
polyethylene glycol, myocarditis, thrombosis, thrombocytopenia
Advice for vax in Immuncompromised
no live vax, caution vaxing close contacts w/ live vax, consider consulting public healt
