immunizations Flashcards
- one of the greatest public health achievements of modern times
- saved more lives than any other medical invention in history
Immunizations
In the US, every infant requires more than __ doses of vaccines by age 18 mo to be protected against 14 or more childhood diseases.
If parents accept combo vaccines- it can be ___ injections from birth to 4.
25
18
Childhood immunization standards and recommendations in the US are formulated by the:
- Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (ACIP)
- American Academy of Pediatrics (AAP)
- American Academy of Family Physicians (AAFP)
2 main types of immunizations
Active & passive
induces immunity by vaccination with a vaccine or toxoid (inactivated toxin)
which type of immunization?
active
includes transplacental transfer of maternal antibodies and administration of antibody, either as immunoglobulin or monoclonal antibody
which type of immunization
passive
6 types of active vaccines
- Live Attenuated (Living )
- Inactivated or Killed Viruses
- Recombinant
- Reassortant
- Immunogenic Components of Bacteria
- Toxoids
- Vaccine created by reducing the virulence of a pathogen, although it is still a viable vaccine.
- replicate in the body after given
- induce immunity through a single dose
- susceptible to vaccine failure caused by circulating antibodies, including residual maternal antibodies in infants
which type of vaccination
Live attenuated (LAV)
7 LAV examples
- Measles (MMR)
- Mumps
- Rubella
- Varicella (chickenpox)
- Intranasal Influenza (Flumist)
- Rotavirus ( oral vaccine )
- OPV- Oral Polio Virus
- Administration of blood products and immunoglobulin can diminish response to what vaccination if administered before the recommended interval (generally 3 months)
- May inhibit the immune response
LIVE virus vaccines
- Live vaccines not administered simultaneously should be separated by at least ____ (ex: MMR and Varicella)
- reduce theoretical risk of interference from first vaccine on the subsequent vaccine
4 weeks
LAV are rarely used in who? (4)
immunocompromised patients, elderly, infants and pregnancy
Consists of virus particles which are grown in culture and then killed using a method such as heat, radiation or chemicals (formaldehyde)
what type of vaccination?
Examples? (3)
Inactivated or Killed Vaccines:
Polio, Hep A, Flu
Engineered viruses or bacteria into which harmless DNA encoded antigen is inserted and stimulates an immune response
what type of vaccination?
examples? (2)
Recombinant Vaccines
- Hepatitis B
- Human Papillomavirus (HPV)
Human-Bovine reassortant:
A vaccine made by combining antigens from several strains of the same virus
Considered live as well
what type of vaccination?
examples?
Reassortant Vaccines
Rotavirus (Rotateq) - oral vaccine
The use of bacterial surface components used to obtain immunity.
Protein polysaccharide conjugate
what type of vaccination?
Immunogenic Components of Bacteria
4 examples of Immunogenic Components of Bacteria vaccinations
- Pertussis
- Haemophilus Influenzae B (HIB)
- Meningococcal conjugate
- Pneumococcal conjugate
Bacterial toxin (usually an exotoxin) whose toxicity has been inactivated or suppressed either by chemical (formalin) or heat
what type of vaccination?
2 examples?
Toxoids
Diphtheria
Tetanus
how are most immunizations administered?
- intramuscular (IM) or a subcutaneous
- A few are oral
preferred sites to administer a vaccine?
- anterolateral thigh in infants up to age 3-4
- Deltoid region in children and adults 5 to 18 years old
T/F: Multiple vaccines can be administered simultaneously at anatomically separate sites (different limbs or separated by >1 inch) without diminishing the immune response.
T
oral vaccinations? (2)
- OPV
- Rotavirus
Intramusclar vaccines (5)
- DTwP, DTaP, DT, Td, TT
- Hep B
- IPV
- Hib
- PCV-7
SC vaccines (2)
- measules
- yellow fever
intradermal vaccines (1)
- BCG
what vaccine at birth?
Hep B
at 2 months - what vaccines?
- Pediarix ( DtaP/ HBV/IPV)
- HIB
- Prevnar
- Rota
4 months - what vaccine?
- Pediarix
- HIB
- Prevnar
- Rota
6 months - what vaccines
- Pediarix
- HIB
- Prevnar
12 months - what vaccines
- MMR
- Varicella ( or *MMRV ) plus Hep A
15 months - what vaccine?
- Dtap
- Prevnar
18 months - what vaccine?
- HIB
- Hep A
4 y.o - what vaccine?
- Dtap and IPV ( *Kinrix)
- MMR and Varivax ( *Proquad)
9 y/o - what vaccine?
HPV series
11 y.o - what vaccines?
Tdap and Meningitis ( ACYW)
16 y.o - what vaccine?
Meningitis #2
17 y.o - what vaccine?
Meningitis B vaccine - booster in one month
Plus FLU and COVID :)
Every state in the US requires some immunizations for school entries, typically for what grades?
pre-k/kindergarten, seventh grade, 11th grade, college entry
However, there are exemptions , and parents can elect to exempt
types of immunization exemptions
- Medical Exemption (ex: hx of anaphylaxis)
- Religious
- Philosophical
commonality of immunization exemption
- All states allow medical exemptions
- Nearly all allow religious exemptions ( Not WV)
- Nearly ½ allow philosophical- you can imagine how this could go
- WV does not allow nonmedical exemptions
MC why parents refuse immunization?
safety and SE (60-70%)
- SE like pain, fever, GBS
- they do not want too many vaccines to overload the immune system
other reasons to refuse vaccinations other than SEs
- Belief they do not work
- Belief that their child is not at risk or the disease is not dangerous
- Belief that it is better to be naturally infected than vaccinated - Chicken pox parties
- Belief that parents know what is best for their child
- Lack of trust
- Ethical, Moral, or Religious Objections
Most outbreaks have been related to ?
religious groups or communities opposed to immunizations
how to approach vaccine education?
- positive dialogue
- Identify parental concerns - Test the waters at the newborn check up!
- Provide education targeted to those concerns
- Maintain relationship with family
- Make every effort to follow recommended vaccine schedule
how to establish positive dialogue?
- Begin at first encounter and continue at subsequent
- Establish/maintain trust is very important
- Acknowledge shared goal (what is best for child)
- Acknowledge large volume of complex, conflicting information about vaccine benefits and safety
- Offering to help parents gather and interpret best information to make informed decision.
how to identify concerns when educating about vaccines?
goal: identify concerns that influence parental concerns
- respectful listening, establish plan for targeted education
- A lot get medical info from social media which is not provided by medical specialists at times
what are alternative schedules?
- wanting one or two vaccines at a time, or spread out
- offers incomplete and delayed protection
- Should only be considered only after other options have failed and family would otherwise refuse entirely
- Increase duration of vulnerability that continue to cause outbreaks, increase risk of undervaccination
mgmt with alternative schedules
- Make a schedule for parents
- Put in as an actual appt instead of “shot only” or on nursing only schedule
if no immunization records are found, what are your next steps?
should be presumed unvaccinated, and vaccine schedule should be catch-up schedule
3 immunization rules
- if behind - catch-up ASAP
- Always obtain IC for immunizations
- premature - immunized, regardless of birth wt, at the same chronologic age and according to the same schedule as infants born at term
- premature babies weigh how much?
- what weight signifies that you should delay the first HBV to 1 mo WCC?
- < 2000 g
- 4# 6 oz
what is the national childhood vaccine injury act?
Requires that all health care providers provide parents or patients with copies of Vaccine Information Statements prepared by the CDC (Centers for Disease Control and Prevention) BEFORE administering dose
General Contraindications to vaccination
- Serious allergic reaction (anaphylaxis) after a previous vaccine dose or to a vaccine component
- Immunocompromised states or pregnancy (for live virus vaccines)
- Moderate or severe acute illness with or without fever
LAV is CI in severe immunosuppression resulting from:
conditions
- Congenital immunodeficiency
- HIV
- leukemia
- lymphoma
- cancer therapy
- prolonged course of high-dose corticosteroids (>2 mg/kg/d x 2 wks)
For HIV infected children who DO NOT have evidence of severe immunosuppression, how is the MMR vax administered?
recommended at 12 mo of age with 2nd dose 1 mo later rather than waiting until 4-6 years for booster
Varicella vaccine is CI for persons with ?
cellular immunodeficiency
varicella vax recommendation if HIV-infected child?
Recommended at 12 mo of age w/o evidence of severe immunosuppression, given as 2 doses 3 mo apart
MMR is 2 doses a mo apart; Varicella is 2 doses, 3 mo apart
what are NOT CI to immunizations?
- Mild acute illness (+/- fever)
- Convalescent phase of illness
- Recent exposure to infectious disease
- Current antimicrobial therapy
- Breastfeeding
- Mild-moderate LOCAL reaction to previous vax
- H/o PCN or other non-vax allergy
- Receiving allergy extract immunotherapy (allergy shots)
National Childhood Vaccine Injury Act requires that clinically significant adverse events after vaccination be reported to the ?
Vaccine Adverse Event Reporting System (VAERS)
The primary objectives of VAERS are to:
- Detect new, unusual, or rare vax adverse events;
- Monitor incr in known adverse events;
- Identify potential RF for particular types of adverse events;
- Assess safety of newly licensed vax;
- Determine and address possible reporting clusters
- Recognize persistent safe-use problems and administration errors
- Provide national safety monitoring system that extends to entire general population for response to public health emergencies
what is the National Vaccine Injury Compensation Program
A no-fault system in which persons thought to have suffered an injury or death as a result of administration of a covered vaccine can seek compensation
when to report
- Suspected cases of vaccine-preventable dz reported to state or local health departments.
- If any lab tests for a traceable disease , it reports to the
- local Health Department
- We use this for tracking many disease states, for prophylaxis and prevention (ex: flu, pertussis, measles)
Persistent viral infection with high-risk HPV genotypes causes ?
what are the MC HPV genotypes?
- virtually all cancers of the cervix
- 16 & 18 - cervical anal cancers
- HPV vaccine targets what HPV types?
- recommended to who?
- dosing of the vax?
- 6, 11, 16, 18, 31, 33, 45, 52, and 58
- ages 11 or 12; can start at age 9, catch up from 13-26 with option up to age 45
- Before 15 years of age: 2 doses: 0 and 6-12 months later
- After 15: 3 doses: 0, 1-2 months and 6 months
- Immunocompromised: Gets all 3 doses
Optimal time for HPV vaccination is ?
prior to individual’s sexual debut
T/F: the HPV vaccines treat or accelerate the clearance of preexisting vaccine type HPV infections or related disease
F - it doesn’t
T/F: Individuals who are sexually active should still be vaccinated consistent with age-specific recommendations
T
T/F: A history of genital warts, +HPV test result, abnormal cervical, vaginal, vulvar, or anal cytology all indicate prior HPV infection but not necessarily with types in vaccine, therefore it is not recommended to get the vaccination
F - still recommended
Why are HPV vaccinations low?
- Lack of sexual activity
- Parents believe the vaccines promote sexual activity
- Parents don’t think it is needed
- There is lack lack of knowledge about the disease
- Perceived influence by pharmaceutical industry
- 2 types of Meningococcal Vaccine (Neisseria Mengitidis)?
- Where is bacterial meningitis high risk?
- Meningitis ACWY (Menactra, Menveo, MenQuadfi)
- Meningitis B (Trumenba or Bexsero)
college & Army
dosing for Meningitis ACWY (Menactra, Menveo, MenQuadfi)
- before 7th & 12th grade
- 1 dose @ 11-13 y/o, then 16-18 y/o
dosing for Meningitis B (Trumenba or Bexsero)
1st dose @ 16-18 y/o, 2nd either 1 mo apart or 6 mo apart (depends on vax)
recommendations for influenza vax?
- annually for >6 mo of age
- 6 mo - 8 y/o - 2 doses 1st time, with one annual doses after
- Can do Flumist (LAV) at 2 y/o - sometimes not as effective
inactivated CI of flu vaccine? (2)
- < 6 mo old
- H/o severe allergic reaction to influenza virus or any component of the vaccine
majority of flu vaccines are cultured on fluid from chicken embryos, thus providing theoretical risk of what?
Egg allergic reaction
T/F: The presence of egg allergy in an individual is a contraindication to receive a flu vaccine.
F - it is not
- Should be administered by a health care provider who is familiar with the potential manifestations of egg allergy
- Should be observed for >30 mins for signs of a reaction after administration of dose
Flu vax recommendations for:
- Egg allergy, hives only?
- Egg allergy with symptoms other than hives (angioedema, rsp distress, need for emergency medical services or EPI)?
- Egg allergy, hives only: Any influenza vaccine appropriate for age and health status annually
- Egg allergy with sx other than hives: Any influenza vax appropriate for age and health status annually in medical setting under supervision of health care provider who can recognize and manage severe allergic reactions
flu vax should be withheld from children with ?
- moderate to severe acute illness until sx resolve
- Minor illnesses +/- are not excluded
CI to LAFV
- < 2 y/o
- Children of any age with asthma and children 2-4 with a h/o recurrent wheezing
- Children who are close contacts of severely immunocompromised individuals
causes an acute infection characterized by fever, cough, coryza, conjunctivitis, rash, that may be followed by severe complications, including encephalitis and death
what virus?
measles
causes an acute viral syndrome with parotid swelling, usually self-limited, but may be associated with orchitis, aseptic meningitis, and encephalitis
what virus?
mumps
causes German Measles, a generally mild infection with a characteristic rash. However, rubella infection is a severe teratogen, causing hearing loss, cardiac disease, cataracts, neurodevelopmental defects if it occurs early in fetal life
what virus?
rubella
two forms of the MMR vaccine?
what is the routine vaccination? what is the reasoning?
A LIVE attenuated vaccine
- MMR and MMRV (MMRV also includes varicella)
-
MMR - at 12-15 mo, and a 2nd (MMRV) at 4-6 y/o
- d/t incr risk of febrile seizures when MMRV is administered < 4 y/o
- caution with 1st dose if FHx febrile Sz
MMR CIs
- Hypersensitivity
- Pregnancy - do not get pregnant for at least 28 d after MMR d/t theoretical risk of rubella
- Immunodeficiency
“I got the flu from the flu shot” why is this a myth
- Not true - May have mild flu sx, very mild
- Can still get flu if the vaccine does not match current subtypes
- BUT IT DOES NOT GIVE YOU THE FLU. It is killed :)
“Immunizations are 100% effective”
how is this a myth?
- MMR is only 88% effective at protecting against mumps
- Can get mild chickenpox (1/25)
- Flu vaccine 2015 was only 23% effective
biggest lie ever
vax = autism
came from MMR vax
what was the Disneyland outbreak
- 12/2014 - 4/2015
- traveler became infected overseas with measles, then visited disney
- 147 people infected across various states, 131 in California alone
- conclusion - only way measles spread is from not getting kids vaccinated
- greatest number of cases reported in the U.S. since 1992.
- The majority of cases were among people who were not vaccinated against measles.
when was this?
Measles cases in 2019
January 1-December 31, 2019, 1,274 cases of measles were confirmed in 31 states.
may include antibiotics, immunoglobulin or monoclonal antibodies, vaccine or in combination and may be used post exposure, for perinatal exposure and pre-exposure for persons at increased risk for infection
Prophylaxis
types of Prophylaxis
Primary - used to prevent infection before a first occurrence
Secondary - used to prevent recurrence after a first exposure.
prophylaxis protocol for meningococcus?
- Primary prophylaxis to all contacts ASAP - Rifampin BID x 2 days, ceftriaxone once and cipro once
- Recommended for:
- all household contacts, esp young children
- child care or nursery school contacts in the last wk
- direct exposure to index pt’s secretions
- frequently sleep or eat in same dwelling as the index pt
- passengers seated directly next to pt during airline flights lasting >8 hrs
when is chemoprophylaxis for meningococcus NOT recommended?
- casual contacts with no history of direct exposure to the patient’s oral secretions (work or school mate)
- indirect contact with the index patient
- medical staff without direct exposure
Tetanus prophylaxis after wound cleansing includes who?
- vaccination (Toxoid) of person with incomplete immunization
- tetanus immunoglobulin for contaminated wounds (soil, feces, saliva), puncture wounds, avulsions, crushing, burns or frostbite
T/F: Rabies immune globulin (RIG) and rabies vaccine are extremely effective for prophylaxis after exposure to rabies and after sx appear
F - no known benefit after sx appear
mgmt of animal that caused the bite
rabies
- ANY healthy-appearing domestic animal responsible for an apparently unprovoked bite - observed x 10 d for signs of rabies w/o immediate tx of victim
- Prophylaxis if animal is rabid, suspected, or develops during observation
- captured wild animal - euthanized w/o observation and its brain examined for rabies - If not captured, esp a wild animal known to harbor virus = give prophylaxis
HF animals for rabies
- Skunks
- Raccoons
- Foxes
- Woodchucks
- Bats
Most other carnivores are regarded as rabid unless proved negative by testing
Prophylaxis for rabies also should be provided following exposure to a _____ for persons who might be unaware or unable to relate that a bite or direct contact has occurred (mentally disabled person, a sleeping child or an unattended infant)
bat
mgmt for pt with suspected rabies/animal bite
- soap, water, and virucidal agent (iodine)
- RIG : 20U/kg administered as a full dose of RIG infiltrated SC into area around wound if possible–the rest in the arm
-
Rabies Vaccine:
- Dosed at day 0, 3, 7, 14
- Day 28 for
immunocompromised
prophylaxis for whooping cough
- Azithromycin
- monitor for 21 days after exposure
