Immune Flashcards
Attenuated Live Vaccines
Live attenuated influenza vaccine (LAIV) Measles, mumps & rubella vaccine (MMR) Oral poliovirus vaccine Rotavirus vaccine Varicella virus vaccine Herpes zoster vaccine Typhoid vaccine Yellow fever vaccine Bacillus Calmette-Guerin (BCG) vaccine
Live Vaccines: General Principles
Not administered to immunocompromised patients
Usually not given if patient has febrile illness
If patient needs two live vaccines:
- Give both the same day OR
- Administer at least 4 weeks apart
Not administered in pregnancy
- Pregnancy should be avoided for 1 month after vaccination
Drug interactions
- Antiviral drugs
Separate IG administration from live vaccine administration
Live Attenuated Influenza Vaccine
- LAVI (Flumist)
- Contains two strains of Flu A and one strain of Flu B
- Administered intranasally
- Live vaccine replicates in nasal mucosa
- Contraindicated: egg allergy, asthma, immunocompromised state, pregnancy
- Administered annually to healthy patients at 2 years to 49 years
- – Children ages 2-8 years need two doses the first year
MMR Vaccine
- 2 doses 99% effective in providing immunity for measles (88% for mumps)
- Contraindications: neomycin allergy, pregnancy, immunosuppression, febrile illness
- – Ok to give to those with egg allergy
- – May be given to breastfeeding women
- ADRs: fever 7-12 days after vaccination
- Drug interactions: IG, high-dose corticosteroids, chemotherapy
- First dose given at age 12-15 months
- Second dose given at ages 4-6 years or at least 4 weeks after first dose
- One dose given to any infants 6-12 months who will be traveling internationally
- – Does not “count” as first dose; give a dose at 12-15 months
Measles, Mumps, Rubella, and Varicella (MMRV) Vaccine
ProQuad
Similar to MMR
Contraindications are the same as MMR
- Use caution in patients with hx of cerebral injury, seizures, or where physiological stress caused by fever should be avoided
ADRs: fever greater than 102 (21.5% vs 14.9% with MMR); increased risk of febrile seizures
May administer on same schedule as MMR
- Use MMR+ varicella for first dose and MMRV for second dose if there is a fever
- Informed consent includes risk of fever and febrile seizures
Oral Polio Vaccine (OPV)
Not used in U.S. since 2000
Effective, easy to administer
Virus lives in GI tract for 4-6 weeks after administration
Rare risk of vaccine-associated paralytic poliomyelitis
- patient and household contacts
Still used throughout the world
- Bivalent vaccine sued worldwide- not valid in the US
- Only trivalent OPV counts
Rotavirus Vaccine
- RotaTeq and Rotarix
- Orally administered and replicated in small intestines
- Contraindicated: immunocompromised state, febrile illness
- ADRs: mild GI upset, no or slight risk of intussusception in new vaccination
- First dose administered to infants by age 14 weeks and 6 days and last dose by 8 months
- – Rotarix (RV1): given at age 2 months, 4 months
- – RotaTeq (RV5): given at age 2 months, 4 months, 6 months
Varicella
- Varivax Vaccine
- 2 doses 98.3% effective against any disease
- May be administered after exposure (within 3 days)
- Contraindications: neomycin allergy, febrile illness, immunocompromised state, high dose steroids, pregnancy
- ADRs: fever, rash, injection site reaction
- First dose at age 12-15 months
- Second dose at age 4-6 years
- Adolescents and adults with no hx of varicella given 2 weeks 4-8 weeks apart
Herpes Zoster Vaccine
- Shingles caused by reactivation of varicella
- Zoster vaccine live (Zostavax)
- Reduces risk of herpes zoster by 51.3 %
- Reduces risk of post-herpetic neuralgia by 66.5% (reduced severity in 57%)
- Contraindications: neomycin or gelatin allergy, immunocompromised state, pregnancy, acute illness, age less than 60 years
- Drug interactions: high-dose steroids, antivirals
- One dose given to all patients age 60 years or older
- Decreased effectiveness beginning 1 year after administration, with less than 35% effectiveness 6 years after dose
Miscellaneous Live Vaccines - Oral Typhoid Vaccine
Travelers to South or Southeast Asia, Africa, Caribbean countries, Central and South America
Oral Capsule for age 6 years and up
Revaccination every 5 years
Miscellaneous Live Vaccines - Yellow Fever
Endemic in Sub-Saharan Africa and tropical South America
Certification required to enter some countries
Vaccination for all persons over 9 months of age traveling to endemic areas
- Use cautiously in patients over age 60 years
Miscellaneous Live Vaccines - Cholera Live Vaccine (Vaxchora)
Antibodies are measurable 10 days after vaccination
Drug interaction: do not administer systemic antibiotics within 14 days; chloroquine may decrease immune response
Clinical use: administer 10 days before possible exposure to adults age 18-64 years
- Store in freezer, mixed in bottled water
- Avoid eating or drinking for 60 minutes
Miscellaneous Live Vaccines - Bacillus Calmette-Guerin (BCG) Vaccine
Immune Stimulant
Most effective in children
ADRs: disseminated disease in patients with TB
- Skin lesions at injection site is normal reaction
May cause false-positive purified protein derivative (PPD) skin test result
Inactivated Vaccines
Diphtheria, tetanus, pertussis vaccine Haemophilus B conjugate vaccine Inactivated poliovirus vaccine Hepatitis B virus (HBV) vaccine Hepatitis A virus (HAV) vaccine Human papillomavirus (HPV) vaccine Influenza vaccine - Pneumococcal vaccine - Meningococcal polysaccharide vaccine Lyme disease vaccine Typhoid vaccine Cholera vaccine Japanese encephalitis virus vaccine Plague vaccine Rabies Vaccine
Inactivated Vaccines: General Principles
Inactivated vaccines: “killed” virus
May be co-administered with other vaccines
No need to restart series if patient gets off schedule (catch-up schedule used)
Diphtheria, Tetanus, and Acellular Pertussis Vaccine
- Diphtheria, tetanus, acellular pertussis vaccine (DTaP, or Tdap, or Td)
- Contrainidcations: anaphylactic reaction, progressive neurological disease, high temperature or seizure after previous DTaP dose (not Tdap)
- Diphtheria vaccine given before age 7 years and Tdap after
- ADRs: pain at injection site, low-grade fever, aches, HA
- Antipyretics given to children with hx of febrile seizures
- Dosing:
- – DTaP: 2 months, 4 months, 6 months, 15-18 months, & 4-6 years
- – Tdap: 11 to 12 years
- – Adults should receive Tdap or Td every 10 years
Haemophilus B Conjugate Vaccine
- Protects against invasive H. influenzae
- Contraindications: allergy to components of vaccine, moderate to severe illness, only given to children younger than age 6 years
- ADRs: injection site pain and redness
- Dosing: depends on vaccine used
- – ActHib or Pentacel: 2 mos., 4 mos., 6 mos., 12-15 months (booster dose)
- – PedvaxHIB or Comvax: 2 months, 4 months, 12-15 months (booster dose)
- – If first dose given after age 15 months, then child only needs one dose
Inactivated Poliovirus Vaccine
- Inactivated poliovirus vaccine (IPV), IPV/DTaP (Pediarix), DTaP/HIB/IPV (Pentacel)
- Contraindications: allergy to neomycin, streptomycin, polymyxin B
- Drug interaction: immunosuppressants
- Dosing: 2 mos., 4 mos., 6-18 mos., 4-6 years
Hepatitis A Vaccine
- HAV vaccine provides 100% protection with 2 doses
- – HAVrix (0.5 mL for children/adolescents; 1.0 mL for adults)
- – VAQTA (0.5 mL for children/adolescents; 1.0 mL for adults
- – Twinrix (HAV & HBV) adults only
- Contraindications: severe reaction to HAV, moderate illness, younger than 12 months
- ADRs: soreness at injection site
- Dosing: 2 doses 6 months apart
- – All children 12 months, dose 2 at 18-24 months
- – Persons age 6 months and older traveling internationally
- ——- HAV dose given between age 6-11 months does not “count”
- – High risk adults
- – Post-exposure prophylaxis for immunocompetent persons age 12 months or older within 14 days of exposure
Hepatitis B Vaccine
- HBV stimulates antihepatitis B surface antigen antibodies
- Alone or in combination (Pediarix, Twinrix, Combax)
- Contraindications: yeast allergy, moderate or severe illness, immunosuppression (give larger doses)
- ADRs: local reaction, 15% experience systemic complaints of fever, malaise
- Dosing: all ages, three doses over 6 months
- – 4 weeks between dose 1 & 2, 2 months between dose 2 & 3, and 4 months between dose 1 & 3
- – Newborns weighing less than 2000 g receive first dose within 24 hours of birth
Human Papillomavirus Vaccine (HPV)
- 9-valent HPV (Gardisil9) vaccine for females, males (types 6, 11, 16, 18, 31, 33, 45, 52, 58) is 97.9% effective against covered strains
- Contraindications: allergic reaction
- ADRs: syncope, injection site pain, and redness
- Dosing: three doses at 0, 2, and 6 months
- – Two doses if started age 14 years or younger
- – Three doses if started age 15 years or older
Inactivated Influenza Vaccine
- Three or four strains of influenza: two type A and one or two type B
- Strains change annually based on predicted circulating strains
- Contraindications: anaphylaxis to eggs or influenza vaccine, Guillain-Barre Syndrome within 6 weeks of influenza vaccine, febrile illness
- ADRs: local reaction, mild systemic effects
- Drug interactions: immunosuppressants, theophylline, phenytoin, warfarin
- Dosing: annual vaccine to all persons 6 months of age or older
- – Patients younger than 9 years of age get 2 doses the first year
- – High-dose flu vaccine for age greater than 65 years
- – FluBlok or Flucelvax may be used in patients with egg allergies
Pneumococcal Polysaccharide Vaccine (PPV)
- Polyvalent pneumococcal polysaccharide vaccine (PSV23) contains 23 highly purified capsular polysaccharides from Streptococcus pneumoniae
- Contraindications: moderate to severe febrile illness, give 10-14 days before splenectomy, organ transplant, or chemotherapy. No PPV in children age less than 2 years
- ADRs: local reaction, mild systemic effects
- Drug interactions: immunosuppressants (give 10-14 days before)
Pneumococcal Polysaccharide Vaccine (PPV): Dosing
- All adults over age 65 years
- Persons 2 years to 65 years of age with chronic cardiac or pulmonary disease, chronic liver disease, or alcoholism, diabetes mellitus, cerebrospinal fluid leaks
- Persons 2 years to 65 years of age with asplenia
- Immunocompromised persons
- Smokers age 19 years to 65 years of age
- 12-24 months after bone marrow transplant
- PSV23 given to children 2 months after last pneumococcal conjugate vaccine (PCV) dose
Pneumococcal Conjugate Vaccine (PCV)
- Pneumococcal 13-valent conjugate vaccine (Prevnar) targets the 13 most common strains of invasive pneumococcus in infants
- Contraindications: moderate to severe febrile illness, give 10-14 days before splenectomy, organ transplantation, or chemotherapy; no PPV in children age less than 2 years or PCV in adults
- ADRs: local reaction, mild systemic effects
- Drug interactions: immunosuppressants (given 10-14 days before)
- Dosing:
- – Four doses given at ages 2, 4, 6, and 12-15 months
- – Immunocompromised adults 19 years of age or older get one dose
- – Adults older than 65 years of age get one dose
- – PCV13 1 given year after PPV
Meningococcal Vaccine
- Meningococcal polysaccharide vaccine (MPSV) groups A, C, Y, and W-135 (Menomune A/C/Y/W-135) used to prevent meningococcemia and meningitis caused by Neisseria meningitidis serogroups A, C, Y, and W-135
- MCV4 (menactra, menveo) is a tetravalent meningococcal conjugate vaccine that also provides protection against serogroups A, C, Y, and W-135
- Contraindications: febrile illness, age guidelines
- ADRs: local reactions
- Drug interactions: none
Meningococcal Vaccine: Dosing
- Hib-MenCY for infants age 2-18 months with persistent complement deficiencies for functional or anatomic asplenia (2, 4, 6, and 12-15 months)
- MCV4 at age 11-12 years with booster at age 16 years
- MCV4 functional asplenia, travelers to high-risk areas, lab workers
- MCV4 unvaccinated college freshmen or military recruits
- MPSV adults older than age 55 years
Typhoid Vaccine (Inactivated)
- Parenteral typhoid vaccine
- – Purified Vi polysaccharide (Typhim Vi)
- Contraindications: acute febrile illness, children age less than 2 years
- ADRs: mild local and systemic reactions
- Drug interactions: immunosuppressants
- Dosing: one dose to travelers, lab workers, household contacts; booster dose every 2 years
Japanese Encephalitis Virus Vaccine
- Inactivated Vero cell culture-derived vaccine (IXIARO)
- Contraindications: pregnancy, thimerosol allergy
- ADRs: local systemic reactions; urticaria and angioedema of face, lips and oropharynx
- No drug interactions
- Dosing: persons in endemic or epidemic areas, travelers spending more than 1 month in rural endemic areas
Rabies Vaccine
- Rabies vaccine (Imovax, RabAvert)- Inactivated rabies virus
- Contraindications: moderate-to-severe illness
- ADRs: mild local and systemic reactions, serum sickness may occur (6%)
- Drug Interactions: chloroquine (Aralen), immunosuppressants, rabies IG (RIG)
- Dosing:
- – Pre-exposure vaccine given on day 0, day 7, and either day 21 or day 28; booster every 2 years
- – Post-exposure prophylaxis given on days 0, 3, 7, and 14, with RIG given on day 0
IG Serums
- Provide passive immunity to infectious diseases
- Derived from the pooled plasma of adults, processed by cold ethanol fractionation
- Contraindications: not to be given within 3 months of live vaccine
- ADRs: mild local and systemic reactions
- Drug Interactions: live virus vaccines
- Dosing: depends on IG serum used
Tuberculin PPD
- Used to screen asymptomatic individuals for infection with Mycobacterium tuberculosis
- Contraindications: tuberculin-positive reactors, immunodeficiency
- ADRs: In highly sensitive people, vesiculation, ulceration, necrosis can occur at the administration site
- Drug interaction: live virus vaccines, BCG, and immunosuppressants
- Dosing:
- – Test consists of injecting 5 TU of PPD intradermally
- – Reactions read in 48-72 hours
- – Positive reading based on risk category
Immunomodulators
- Cyclosporine (Sandimmune) and azathioprine (Imuran) prescribed to organ transplant recipients and patients with severe rheumatoid arthritis
- Drug interactions: many caused by liver metabolism, live virus vaccines
- Dosing: specialty drug
