Immunizations Flashcards
What is the goal of immunization programs?
Goal of Immunization Programs
Protect individuals & communities from disease (e.g. Herd Immunity)
Prevent, control and/or eliminate transmission
e.g. eradication of smallpox
Saves lives and saves money
Who dvelops guidleines for immunizations?
Canadian
National Advisory Committee on Immunization (NACI)
Canadian Immunization Guide (CIG)
Define antigen/immunogen
the substance that stimulates or triggers an immune response
Define immunoglobulin/antibody
proteins produced in response to antigens which protect the body from disease
Define VAccine
highly regulated, complex biological product designed to induce a protective immune response
Define adaptive immune system
develops as a result of infection or following immunization
Defends vs a specific pathogen
Immunology memory – memory cells
Define innate immune system
e.g. physical barrier (skin); does not produce immunologic memory
Hos is her immunity established? Who does it protect?
Herd Immunity (or community immunity)
can be established by adequate vaccination rates
required to prevent person-to-person transmission of infectious diseases
indirectly protects individuals:
unvaccinated / under vaccinated e.g. infants
unable to mount a robust immune response to vaccines e.g. immunosuppressed
Describe herd immunity? Describe its role in certain disease states?
Describ ethe different types of vaccines regarding antigens?
Describe live vvacines?
Describe inactivated vaccines?
How long does one need to wait prior to another live vaccine?
Live Vaccines – Wait 4 weeks between vaccinations before another live vaccine
Examples of live and killed vaccines?
What are some different parts of a vaccine and examples?
What are some factors that affect vaccine response?
Viability of the antigen
Antigen Dose
Age (children and older adults get higher doses; adults have a weakned immune system; children immature immune reposne)
Immune status
Route & site of administration
Timing
Vaccine Storage
Routes of vaccinations
Vaccine administration. Exceptions?
May give multiple vaccines at the same visit
if possible, give in separate anatomic sites (different limbs)
if not, separate ≥1 inch
Exception:
–> LIVE vaccines give on same day or wait ≥4 weeks between live vaccines
Example: childhood immunizations, MMR and Varicella vaccines given at the same visit
–> Pneumococcal vaccines
Vaccine interchangeability
Ideally, complete vaccine series with the same product
Engerix-B
Most vaccines can be used interchangeably to complete series if the vaccine is not available
Exceptions
pneumococcal vaccines
some meningococcal vaccines
Vaccine Interchangeability Exceptions
Special Populations (high dosing if high risk)
HB – non-dialysis and dialysis
Twinrix
Interuptted Vaccine Schedule
Series do not need to be restarted regardless of time between doses
E.g. ideal hepatitis B vaccine schedule 3 doses (0,1,6 mos) in unvaccinated adults
Vaccine Contraindications
Very few true contraindications
Anaphylactic reaction to previous vaccine
Anaphylactic reaction to egg (yellow fever or RABAVERT rabies vaccine)
Pregnancy, Immunocompromised (live vaccines)
Guillian-Barre syndrome (GBS) ≤6 weeks of immunization
–> Tetanus containing vaccine and influenza vaccine
.
Caution of Vaccinations? Is it safe with illnesses?
Caution - Bleeding disorder
Okay to give vaccine if mild
URTI with/without fever
Egg allergy and VAccinations
Contain minuscule amounts of egg protein, which is also denatured, that they are safe for routine use in patinets with egg allergy
Adverse Effecrs of VAccinations
Expected (relatively common, predictable, self-limiting)
Local: tenderness, redness, swelling, pain at injection site
Systemic: fever, irritability/fussiness, drowsiness, decreased activity, decreased appetite, syncope (not often but can happen if nervous)
How is an adverse effect of vaccines reported?
Public Health Agency of Canada collects case reports
Part of post-marketing safety surveillance –> ensure safety
Data is stored in the Canadian Adverse Events Following Immunizations (CAEFI) database & used to signal AEs that require more investigations
Minor/expected reactions do not need to be reported
Serious, rare, or unexpected AEs thought to be caused by a vaccine:
Complete a Report of Adverse Event Following Immunization (AEFI)
Which vaccines cause most pain? Strategies to manage?
Rotavirus vaccine is sweet-tasting; usually given first & no additional sweet tasting solution is required – oral vaccine
Vaccines associated with more injection site pain:
Prevnar-20; M-M-R®II, HPV vaccines, (Shingrix as well)
Strategies: most painful give last (moderate confidence), give non-dominant arm (expert), cool compress (expert), use arm instead of resting it (expert)
Analgesic after vaccination
Administration of oral analgesics (such as acetaminophen or ibuprofen) to children to reduce pain prior to or at the time of vaccine injection is not recommended, as there is no evidence of a benefit from this intervention.
Concern that antipyretics may reduce immune response.
Can give in first 1-2 days post vaccine if required for fever or pain.
Suggestion not to routinely administer prophylactic antipyretic/analgesic agents at the time of or within four hours after immսոizatiοո
VAccine Drug Interactions
immunosuppressants e.g. DMARDs, prednisone ≥20mg/d x 2 wks
Killed: give ≥2 weeks before starting therapy, if possible; but safe if given while on therapy
LIVE: give ≥4 weeks before starting therapy or delay until after treatment is discontinued ± waiting period
antithrombotics – caution, bleeding risk
Describe cause of diptheria
Bacterial infection caused by Corynebacterium diphtheria
Releases toxin –> inhibit cell protein synthesis & membrane formation
Transmission of Diptheria
Respiratory droplets (e.g. sneezing or coughing)
Signs and S xDiptheria. CPmplications?
Upper respiratory infection - mild fever, sore throat, lymphadenopathy
A grayish white membrane appears in the throat within 2 to 3 days
Can lead to acute respiratory distress & systemic complications e.g. myocarditis
Mortality Diptheria
Unimmunized 5-10%, highest in very young/old individuals
What type of vaccine is diptehria?
Diphtheria toxoid vaccine
Contains detoxified diphtheria toxin (antigen), so immune system produces antibodies towards the toxin
Vaccine protects against effects of the toxin, but not infection/transmission
Describe the formulation of Diptheria vaccine qand its importance
Only available as combo vaccine
“D” = pediatric formulation (higher concentration antigen - immature immune system, needs more for an adequate immune response)
e.g. DTaP-IPV
“d” = adolescent/adult formulation (reduced concentration antigen)
e.g. Tdap
Describe diptheria schedule
SK Primary Series (“D”): 4 doses (2,4,6,18 months), then
Booster (“d”): 4-6 years & in Grade 8
Describe NACI recommendation of diptheria vacciine
Td booster every 10 years (routine)
Can also get if serious cuts/deep wounds &last tetanus vaccine was more than five years ago
Should receive Tdap once in adulthood x 1 to replace Td booster
Should receive Tdap vaccine in each pregnancy (see pertussis, pregnancy special population) – protects fetus for 12 months
Pregnancy Diptehria VAccination
Should receive Tdap vaccine in each pregnancy (exam, see pertussis, pregnancy special population) – protects fetus for 12 months
Cause of tetanus
Bacterial infection caused by Clostridium tetani
Found in the soil & feces
Releases a neurotoxin – toxin similar to diphtheria
Transmission Testanus
Wound contamination with soil, feces, or dust
Not spread person-to-person
Signsa nd Sx Tetanus
Signs & Symptoms (onset 3-21 days)
Painful muscle spasms beginning with jaw muscles (tetanus also known as “lockjaw”)
Complications: convulsions, respiratory failure
Mortality etatnus
Unimmunized 10-80%, highest in very young/old individuals
Tetanus vaccine formulation
Tetanus toxoid vaccine
Contains detoxified tetanus toxin (antigen), so immune system produces antibodies towards the toxin
Only available as combo vaccine
e.g. DTaP-IPV, Tdap, Td
Tetanus VAccine Schedule
SK Primary Series: 4 doses (2,4,6,18 months), then
Booster: 4-6 years & in Grade 8
NACI Tetanus Recommendation
Td booster every 10 years (routine)
Can also get if serious cuts/deep wounds & last tetanus vaccine was more than five years ago
Should receive Tdap x 1 in adulthood to replace Td booster
Tetanus VAccination Preganncy
Should receive Tdap vaccine in each pregnancy (exam, see pertussis)
Regardless ssof when last vaccine –> maternal antibody transfer to fetus
Pertusiss Cause
Bacterial infection caused by Bordetella pertussis
Produce toxin paralyze respiratory cell cilia
Transmission Pertussis
Respiratory droplets (e.g. sneezing or coughing)
Close face-to-face contact (highly contagious)
Contagiousness of Whooping Cough
Can contract more than once, immunity wanes over time
Complications Pertussis
Complications are most often seen in infants
Pneumonia, seizures, encephalopathy
In Canada, 1 to 4 deaths/year related to pertussis, particularly in unimmunized or underimmunized infants less than 6 months
Pertussis in Canada
Pertussis is an endemic disease in Canada, regardless of ethnicity, climate or geographic location
Pertussis Formulation VAccine
Only available as acellular preparation in a combination vaccine
“aP” = pediatric formulation (higher concentration)
“ap” = adolescent/adult formulation (reduced concentration)
Tetanus and Pertussis Formulation Vaccine and Age
What is a concern pt’s may have regardinhg pertussis vaccination?
Myth/patient concern – pertussis vaccine leads to seizures
Old vaccine (whole cell) –> AEs (seizures, hyporesponsive episodes)
Pertusssis Schedule
Children: part of routine immunizations
SK Primary Series: 4 doses (2,4,6,18 months), then
Booster: 4-6 years & in Grade 8
Pertussis NACI
Td booster every 10 years (routine)
Can also get if serious cuts/deep wounds &last tetanus vaccine was more than five years ago
Should receive Tdap x 1 in adulthood to replace Td booster (vaccinate for pertussis once in adulthood)
Consider timing, recommended all parents/extended family/caregivers if haven’t received as an adult (limit transmission to un/undervaccinated infant/children – 4th dose at 18months)
Preganncy and Pertussis
Should receive Tdap vaccine in each pregnancy
POlio Cause
Viral infection cause by the Poliovirus
3 serotypes (1,2,3)
Transmission Polio
fecal-oral
Signs and Sx Polio. COmplications?
Signs & Symptoms (70-95% asymptomatic)
Flu-like e.g. fever, headache, sore throat, N/V, weakness
Can lead to meningitis, limps, post-polio syndrome paralysis
Polio Mortality
Mortality (paralytic polio): 2% to 5% among children and 15% to 30% for adults
Polio Vaccin Formulation
inactivated poliomyelitis vaccine (IPV)
Available as combo vaccine
e.g. Tdap-IPV or individually i.e. IPV IMOVAX Polio
Vaccine contains three types of wild poliovirus - trivalent
Other polio vaccine. Where is it used?
Live attenuated oral polio vaccine (OPV)
Used internationally, associated with paralytic polio (Not used here in Canada)
What is difdferent about the IPV vaccine?
IPV IMOVAX Polio –> Given SC which is different than an inactivated vaccine
Polio Schedule
Hib Stands for
Haemophilus influenzae (“h flu”) ≠ influenza or the “flu”
Haemophilus influenzae type b (Hib)
Hib Causative agent
Bacterial infection caused by Haemophilus influenzae serotype b
6 Serotypes “a” to “f” (typeable, encapsulated)
Hib is the most pathogenic
Since Hib vaccine, most invasive disease due to non-b H.influenzae in Canada
“invasive” = infection beyond the respiratory tract, e.g. meningitis
Transmission Hib
Respiratory droplets (e.g. sneezing, coughing)
Hib complicatuons
In Canada, most commonly infects children under 5 years old
Acute otitis media, meningitis, pneumonia, bacteremia, epiglottis
Death rate up to 5% & deafness up to 20% (secondary to meningitis)
Hib Vaccine Formuolation
Available as combo vaccine e.g. DTaP-IPV-Hib or individually e.g. Hib Act-HIB
Hib Schedule
Adult Immunizations: Tetanus, diphetheria hib, Polio, Pertussis
NACI: Td Td Adsorbed booster every 10 years
Can also get if serious cuts/deep wounds &last tetanus vaccine was more than five years ago
Tdap should replace one of the Td doses
Tdap ADACEL, BOOSTRIX vaccine in each pregnancy
No routine IPV booster in adults
No routine Hib booster in adults
Rotavirus cause
Viral infection caused by Rotavirus
Many serotypes
Rotavirus Transmission
Transmission: fecal-oral route
Sx of Rotavirus. Occurence rate?
cause of diarrhea and need for hospitalization for dehydration secondary to diarrhea in children < 5 years
Almost all unimmunized children will have at least 1 rotavirus infection by age 5
Can get multiple times, but each new infection is usually milder (initial infection provides partial immunity)
Signs and Sx of Rotavirus
Appear 1-3 days after a person has become infected fever, vomiting, diarrhea, stomach pain
Diarrhea can last from 3-8 days
Rotavirus Conatgiousness
Contagious - before the individual becomes ill and for 24 hours after diarrhea stops
Rotavirus Formulation. Ci?
Live attenuated oral vaccine
CI in immunocompromised infants
Rotavirus Vaccine Formulation
Available as pentavalent ROTATEQ (3 doses) or monovalent vaccine Rotarix (2 doses)
SK Rotravirus Vaccine and Schedule
ROTATEQ (pentavalent)
3 doses at 2, 4, 6 mons (2mL po)
Counselling of Rotavirus
Babies can breastfeed, eat and drink any time before or after receiving the rotavirus vaccine
If infant spits up or regurgitates, a replacement dose should NOT be administered
Virus shed in stool for up to 10 days (caution: handwashing; immunocompromised household members – don’t do diaper changes)
Sk Timing Rotavirus
SK: 1st dose given before 15 weeks & last dose before 8 months of age
Adevrse EFfecrs of Rotavirus Vaccine
Common:
Fever, diarrhea, irritability, loss of appetite; some may get flatulence, abdominal pain, dermatitis
Intussusception (bowel obstruction)
–> If history of bowel obstruction, rotavirus usually not given
Menigicoccus Causitive AGent
Bacterial infection cause by Neisseria meningitidis
many serotypes; majority of invasive disease is associated with A, B, C, Y, & W-135
Transmission Meningicoccus
Respiratory droplets, close contact with respiratory secretions/saliva (kissing, sharing of vapes, lipstick, food/drink, toothbrushes, etc)
Risk Factors Meningicoccus
Risk factors: crowded housing (military barracks, post-secondary residence)
Complications Meningicoccus
Cause meningitis & bacteremia (invasive meningococcal disease); mostly in children <5 & 15-24 years
Complications: limb amputations, hearing loss, brain damage, seizures, and skin scarring
Even with antibiotic treatment, mortality rate is 10-15%
Meningicoccal Vaccine Formulation
Men-C-C=Meningococcal Conjugate (type) C Vaccine
Monovalent
Men-C-ACWY-135=Meningococcal Conjugate (types) A and C and Y and W-135 vaccine
Quadrivalent
Sk Series Meningicoccus VAccine
Men-C-C=Meningococcal Conjugate (type) C Vaccine
Monovalent
SK Primary Series: 1 dose at 12 months
Effective in infants and children < 2 years of age
Adults: no routine booster
NEISVAC-C or MENJUGATE
Men-C-ACWY-135=Meningococcal Conjugate (types) A and C and Y and W-135 vaccine
Quadrivalent
SK Primary Series: 1 dose at Grade 6
Adults: no routine booster
MENACTRA or MENVEO or NIMENRIX or MENQUADFI
Meningicoccal Type B Vaccines
Serogroup B meningococcal vaccines
Not routine in childhood or adulthood
Meningicicoocal Serogroup B vaccines avilable and consideration
Available as (non-interchangeable)
Bexsero: 2 months-25 years, potential public funding in SK
Trumenba: 10-25 years, not publicly funded in SK
Are the different types of Men-C-ACWY-135 vaccine inetrchanageable?
YES
Measles Causative Agent
Viral infection caused by the measles virus
Measles Trasnmission
Transmission: respiratory droplets; highly infectious
Measles SIgnificance
Leading cause of vaccine-preventable deaths in children worldwide
Signs and Sx of Measles
Fever, sore throat, cough, runny nose, red rash (URTi)
Complications Measles
Otitis Media and Pneumonia
Encephalitis
Seizures, deafness, or brain damage
Death
Mumps CAusative Agent
Viral infection caused by the mumps virus
Mumps Transmission
Transmission: respiratory droplets
Mumps SIgns and Sx
Fever, respiratory symptoms, parotitis (URTi sx)
Complications Mumps
meningitis or encephalitis
3/10 males develop swollen testicles and 1/20 females develop swollen ovaries
Congenital malformations or abortion in pregnancy
Rubella CAusative Agent
Viral infection caused by the rubella virus
Rubella Transmission
respiratory droplets
Sx Rubells
Cause rash, lymphadenopathy, arthralgia, fever
Not unlike the flu (non-specific symptoms)
Complications Rubella
Congenital malformations or miscarriage in pregnancy
Infection during pregnancy can lead to congenital rubella syndrome in the infant (heart disease, cataracts, deafness)
Varacella CAusative Agent
Infection caused by varicella zoster virus (VZV)
Transmission Varicella
respiratory droplets or direct contact with the blister fluid; vertical transmission
Varicella SIgns and Sx
Causes high fever, red itchy rash (begins at scalp and moves towards trunk). Rash begins as red spots that become fluid-filled blisters that gradually crust over
Varicella Complications
skin and soft tissue infections, pneumonia
Herpes Zoster or Shingles – reactivation of the varicella virus
MMR/MMRV/V Vaccine Type. CI? When is it given?
Live, attenuated vaccine:
Contraindicated in pregnancy & immunocompromised individuals
Deferred until 12 months of age (maternal antibodies decline at this point)
MMRV Vaccine Formuations
Available as a combo vaccine MMR or MMRV; Varicella is also available as a monovalent vaccine e.g. VARIVAX III
MMRV and Allergy Consideration
MMRV contains trace amounts of neomycin and gelatin: so be cautious in those with severe allergies
MMRV Efficaxy
Efficacy increases with age
Maternal antibodies can decrease live vaccine replication & impact efficacy
MMR+/-V is deferred until 12 months of age when maternal antibodies have declined
MMR/MMRV Schedule
SK Primary Series: MMRV x 2 doses (12, 18 months)
MMR/MMR Adults
Adults: no routine booster
Note (unvaccinated adult, special populations)
MMRV not indicated in adults, use MMR and V (if required)
Varicella (V) vaccine only indicated to 49 years of age
MMRV VS MMR and V adevrse EFfects
Febrile Seizures: Higher in MMRV vaccine (low risk still) – compared to MMR and univalent V vaccine
- Have to give live vaccines at the same time or else have to wait 4 weeks
MMRV Vaccine Adverse EFfects
Common reactions (e.g., soreness, redness and swelling at the injection site)
Mild subclinical infection occurring 1 week after (~5%)
Malaise and fever, with or without rash lasting for up to ~3 days
May occur ~7-12 days AFTER getting the vaccine
Possible joint aches from the rubella component may occur in teenage and adult women
Varicella Vaccine DAverse Effects
Swelling and redness, possible low grade fever
A varicella-like rash (blisters) at injection site may develop
3 to 5%; may last up to 3-6 weeks
Less contagious than the wild-type varicella virus; to prevent possible viral spreading, cover the rash until the blisters have dried and crusted over.
Herpes Zoster Causative Agent
Viral infection caused by reactivation of varicella zoster virus
Varicella zoster virus infection causes varicella (chickenpox) –> typically remains dormant in the dorsal root ganglia & may reactivate later in life–> reactivated infection results in herpes zoster (shingles)
Risk Herpes Zoster
Baseline risk of shingles in adults ≥65 years old is approximately 1% per year
Can you get herpes zoster if never had chicken pox?
No - if never had varicella vaccine or chicken pox
Varicella vaccine has a lower risk of herpes zoster than those who have had an infection with varicella
Hepres Zoster Signs and Sx
Prodromal pain can precede the rash by days to weeks in most individuals
Maculopapular vesicular rash (painful, itchy) occurring along 1 or 2 dermatomes (usually thoracic) that does not cross the midline (unilateral).
Usually lasts ~7-10 days
Complications Herpes zoster
postherpetic neuralgia (~13-20%)
Disseminated zoster: ophthalmic (10-15%), CNS, pulmonary & hepatic involvement
Association with increased risk of cerebrovascular event within ~1 year post herpes zoster infection (?↑ cardiac event)
<10% of individuals 65yrs + will be hospitalized
Mortality is uncommon
Herpes Zoster Vaccine Formulation
Shingrix: adjuvanted, recombinant subunit
Shingrix Recommendation
Recommended adults 50 years or older
Also recommended if :
Previously vaccinated with ZOSTAVAX II (wait 2 months [ACIP] to 1 year [NACI]) or
Zoster/shingles episode (wait post acute episode [ACIP] to 1 year [NACI])
How well doses the shingrix Vaccine Work?
ZOE-70 - Mean Age 76 years old
ZOE-50 - Mean age 62 years old
Shingrix VS placebo over 3 years
Decraesed risk of shingles by 91% (NNT = 32)
Decreased risk of PHN (90%)
> = 70 - NNT 263
Age > or = 50 NNT 333
Immune response maintained for 9 years, unclear if corrleates with shingles or PHN
Shingrix Vaccine Adults. NACI recommendation?
Recommended adults ≥18 with an immunocompromising disease (“new” indication)
NACI No recommendation yet
Pregnancy? No recommendation, delay until after ideal
Breastfeeding? May give, no known risk to infant
Shingrisx ACIP Recommendation Audts
Recommended adults ≥18 with an immunocompromising disease (“new” indication)
ACIP - confirm varicella immunity (vaccinate for varicella instead)
hx chickenpox or shingles, varicella vaccine documentation, positive varicella titre
if not immune to varicella then at risk of chicken pox, not shingles, give varicella
Herpes Zoter VAccine Schedule
2 doses (0, then 2-6 months)
For individuals who are or will be immunosuppressed the second dose can be administered 1 to 2 months after the first (if required).
E.g. starting immunosuppressant therapy
No furtehr doses at this time
Coverage Shingrix
SK: not publicly funded
NIHB: benefit 60 years plus OR immunocompromised (e.g. HIV)
Herpes zoster Shingix Indication Adults
Indicated for:
adults ≥18 years with an immunocompromising disease
adults ≥50 years
Still recommended in above populations in those with previous zoster infection or ZOSTAVAX II immunization
Describe heaptitis B caustive agent
Viral infection
Hepatitis B Infection Course
Most clear infection after 4-8 weeks
Some chronic HB carriers cirrhosis, liver cancer, and death
Canada estimated <0.5% of residents are chronic HB carriers
HEp B Transmission. Highest Risk?
Blood or bodily fluids containing HB virus e.g., sharing injection drug equipment, sexual contact, vertical transmission (parent to baby, highest risk of leading to chronic HB)
Signs and Sx Hepatitis B
Asymptomatic in up to 50% of adults and 90% of children
Fatigue, fever, N/V, decreased appetite, jaundice
HEP B vaccine Formulations
Pediatric and adult formulations
High-dose e.g. renal disease, HIV, congenital immunodeficiency disorders
Combo vaccine (HAHB) or monovalent HB
Sk Series HEp-B
SK Primary Series: 2 doses in Grade 6 (0 months, 6 months)
Adult formulation of ENGERIX-B or RECOMBIVAX HB
No booster required
Exception: potentially some special populations based on serology e.g. dialysis
HEP B Serology Interpretation
Serology is not routinely ordered in most patients for immunization purposes; see special populations*
INterpretation of HEP B Serology
Healthy patients: if received appropriate immunizations series, then they are considered immune/protected for life even if anti-HBs (HB surface antibody) drop <10 overtime because immune memory to HB persists
Another HB vaccine dose is NOT required (exam)
Some special populations (immunocompromised, CKD etc) :
If anti-HBs <10, give another dose and repeat serology
Hepatitis A Causuative agent
Viral infection cause by hepatitis A virus
HEP-A Transmission
Transmission: fecal-oral
Contaminated food, water, drinks, etc
HA virus can remain infectious in the environment for several weeks
Signs and Sx HEP-A
Asymptomatic (younger); adolescents/adults anorexia, nausea, fatigue, fever, jaundice; rarely death
Lasts a few weeks to a few months
HEP-A Course of Illness
~25% of adult cases are hospitalized
Does not lead to chronic hepatitis or chronic carrier state (like HBV)
HEpatitis-A Vaccine Formulation
Many HA vaccines available
Pediatric and adult formulations
e.g. AVAXIM and AVAXIM PEDIATRIC
Combo vaccine or individually
Hepatitis A Schedule
Not routinely given in childhood vaccinations
Recommended for people at increased risk of infection
2 doses (0, 6 months)
No BOOSTER required
HEP-A and B VAccine Fomrulation
Twinrix (HAHB)
SK: not routinely given in childhood vaccines & not publicly funded
Role in SK today: convenience re travel
If someone requires hepatitis A for travel & unsure if they’ve received HB series/no HB series documented
But if they have already completed Hepatitis B series (or if serology was previously done & they are HB immune) then ONLY HA vaccination required
HPV Caustive agent
Viral infection caused by Human Papillomavirus
Over 200 types
12 oncogenic & 8-12 possibly oncogenic
Transmission HPV
Transmission: sexually by skin-to-skin contact (or mucosa contact), vertically
HPV Prevalence
The most common STI
If not immunized, up to 75% of sexually active individuals will have at least one HPV infection in their lifetime
HPV Signs and Sx
Most infections are asymptomatic & and are eventually cleared by the immune system within 24 months
Some develop genital warts (HPV types 6, 11, others)
Some develop cancer
Describe the different HPV types and the risks
anal, cervical, vaginal, penile (HPV types 16, 18, 31, 33, 45, 52, 58, and others)
Oropharynx (HPV type 16)
causes almost all cases of cervical cancer (HPV types 16, 18)
Describe the WH and CAnada Traget for hPV vaccination rates
WHO/Canada target: ≥17yrs 90% will be vaccinated with 2+ doses
Canada
2-dose series completion~60-90%
1-dose ≥14yrs ~80%
HPV Vaccines
HPV-9 (GARDASIL-9): human papillomavirus types 6, 11, 16, 18, 31, 33, 45, 52, 58
HPV-2 (CERVARIX) contains HPV type 16 & 18; only approved in females & not commonly used
HPV Vaccine EFficcay
In people who have never been infected with the 9 specific vaccine-types of HPV (6, 11, 16, 18, 31, 33, 45, 52, and 58), the vaccine will:
Prevent 7/10 cases of cervical cancer & 9/10 cases of genital warts
Does NOT protect against other STIs
HPV types included in HPV-9 (GARDASIL-9) cause ~90-95% HPV-attributable cancers
NACI Recommendations HPV
HPV-9 (GARDASIL-9) preferred – protection vs the greatest number of HPV types and associated diseases
Healthy individuals
9-20 years: 1 dose of HPV vaccine (previous recommendation was 2 doses)
21-26 years: 2 doses of HPV vaccine (previous recommendation was 3 doses)
≥27 years: 2 doses of HPV vaccine using SDM (shared decision making) (previous recommendation was 3 doses)
HPV vaccine may be offered in pregnancy (prev recommendation delay post-pregnancy)
≥9 years, immunocompromised or HIV: 3 doses (0, 2, 6 months)
How to talk about HPV vaccination in women over 26?
Gardasil 9 and Cervarix are approved for women up to age 45
Don’t feel compelled to bring up for most adults 27-45, especially if in long-term, mutually monogamous relationships
Consider discussing with unvaccinated adults who will have a new sex partner, especially those with few partners in the past. Vaccination might cover HPV strains they haven’t been exposed to before
HPV Sk Schedule
PAtiet Education Gardasil
Administer after other vaccines (known to cause more injection pain – adjuvanted)
May administer with other vaccines
HPV Vaccine EFficacy rgarding sexual activity
Primary series is expected to provide lifelong immunity
HPV vaccine is most effective when given at a younger age, before exposure to HPV.
HPV vaccine after onset of sexual activity is recommended because unlikely vaccine recipient has been infected with all HPV types in the vaccine
Still indicated in women with abnormal pap test, cervical cancer or genital warts
HPV-9 Vaccine Age Indication
Some choose to still get the HPV-9 vaccine x 1 dose e.g. ongoing risk (approved in those up to 45 years)
Males HPV-9 Vaccine
HPV-9 recommended 9-26 years (≥27yrs – SDM – approved in those up to 45 years)
SK: Only publicly funded for those born after 2006
~18yrs and younger..
Mpox CAusative Agent
Viral infection caused by monkeypox virus
MPOX Transmission
Skin to skin contact
Transmission is not prevented by condoms
Respiratory droplets (close, sustained face-to-face contact)
Animal to humans e.g. bites from rodents (Africa)
Low risk transmission: shared contaminated objects e.g. doorknobs, bed lines
MPox Common Populations
Most cases have been diagnosed in MSM
Also diagnosed in heterosexual persons
Rarely household transmission to younger children
Signs and Symptoms of Mpox and Contagiousness
Incubation period has generally ranged from 7 to 10 days following exposure
Signs & Symptoms
Systemic illness: fever, chills, headache, myalgias, rash (pimple-like / blisters, look similar to shingles but larger)
Atypical (2022 outbreak): oral, genital, and anal lesions without systemic illness
Usually self-limiting (2-4 weeks)
But 2022 outbreak: cases of mortality in those immunocompromised or those who developed encephalitis
Tecovirimat (TPOXX) treatment for high risk patients
Contagious for ~2-4 weeks (until all lesion scabs have fallen off)
Cover lesions, wear mask…
MPOX Vaccine Discovery
Smallpox vaccine protects against mpox
Mpox virus is an orthopoxvirus that is in the same genus as variola (causative agent of smallpox) and vaccinia viruses (the virus used in the smallpox vaccine).
MPOX VAccine Formualiton
Second generation smallpox vaccine; modified vaccinia Ankara IMVAMUNE
Live-attenuated, non-replicating virus (no risk of developing infection or transmission to others)
≥18 years at high risk for exposure
Safe immunocompromised e.g. HIV, pregnancy (limited data)
MPOX Risk Factors
Close COntact: 4-14 days
Transgender, 2s, bisexual, gay or MSM, or individuals who have sex with MSM and
ONE OF:
1) prior STD in last 12 months
2) 2 or more partners where one has other partners
3) Sex in sex-on premises
4) Have has or plan to have sexual contact with annonymous partner
5) Are planning to travel to area in Canada or workld reporting cases
6) Sex Workers
7) Volunteer or work at places with sexual activity
MPOX VAccine Schedule
PrEP: IMVAMUNE 2 doses (0.5 mL) subcut given 1 month apart (0, 1 month)
potential booster after 2 years
PEP: IMVAMUNE 1 dose ≤4 day (up to 14 days) since last exposure
consider 2nd dose in 1 month if ongoing exposure
Pneumonococcal Causitive agent
Bacterial infection due to Streptococcus pneumonia
~100 serotypes, each serotype has a different capsule
Vaccine lead to antibodies vs capsule
Transmission Pneumonococcal
respiratory droplets; direct oral contact or indirect contact with infectious oral secretions
children < 5years in daycare have 2-3x ↑ risk pneumococcal disease compared those who do not
Signs and Sx Pneumonococcal
Signs & Symptoms can cause:
sinusitis, acute otitis media, pneumonia
Invasive pneumococcal disease (infection in a normally sterile site): bacteremia, meningitis
Mortality: increased risk IPD risk factors older adults e.g. >10% case fatality in those ≥65yrs who develop IPD
Pneumonococcal Vaccines Available
NOT INTERCHANGEABLE
Pneomonoccal Types that CAuse Dx
The most common serotypes that cause disease vary across different populations and tend to change over time.
What type of vaccine is pneumonoccocal vaccines?
Conjugate vs. Polysaccharide
Longer lasting immune (create long-term memory cells)
More robust immune response – involve B & T cells
Polysaccharide – “T cell independent”
Infants – respond well to T-cell dependent antigens; do not respond well to T cell independent antigens e.g. previous, when pneumovax23 was used in infants at high risk of IPV, waited until 2 years of age
NACi Penumonococcal Childhood- No IPD Risk FActors
VAXNEUVANCE (PCV15) or PREVNAR-20 (PCV20)
Either should be used for routine childhood immunization programs
Considered similar benefit (immune response) and AEs as PCV13
NACiIPenumonococcal Adulthood - No IPD Risk FActors
≥65 years (& otherwise healthy), regardless of pneumococcal vaccination history with PREVNAR-13 PCV13, VAXNEUVANCE PCV15, or PNEUMOVAX-23 PPSV23 (wait ≥1 year from last pneumococcal dose)
PREVNAR-20 (PCV20) 0.5mL IM x 1 dose OR
CAPVAXIVE (PCV21) 0.5mL IM x 1 dose
How long to wait between penumonococcal vaccines?
PREVAR-20 (PCV21), minimum interval
Wait ≥1 year between PCV20 and PCV13 (minimum 8 weeks)
Waiting 1yr expands serotype coverage in a time-effective manner
8 weeks may be used if immunocompromised or rapid completion required
Wait ≥5 year between PCV20 and PPSV23 (minimum 1 year)
Waiting 5 years may maximize total duration protected given PNEUMOVAX-23 expected duration of protection ~5 years
CAPVAXVIE (PCV21), minimum interval
Product monograph – minimum interval between PCV21 and other pneumococcal vaccine is 1 year
Pneumonococcal Summary adult
Pneumonococcal Vaccination with IPD Risk Factors
≥18 years & medical or environmental IPD risk factors (regardless of pneumococcal vaccination history with PREVNAR-13 PCV13, VAXNEUVANCE PCV15, or PNEUMOVAX-23 PPSV23):
PREVNAR-20 (PCV20) 0.5mL IM x 1 dose OR
CAPVAXIVE (PCV21) 0.5mL IM x 1 dose
IPD Risk FActors
Chronic Herat Dise
Diabetes
CKD
Chornic Liver and LUng DX
Immunocompromising DX - HIVV, Transplant, Immunosuppressant TX
RSV Causative Agent
Viral infection
RSV-A, RSV-B subgroups commonly co-circulate
RSV Transmission
Transmission: respiratory droplets
RSV Contagiousness, Outbreaks, Population
Common, very contagious
Annual outbreaks in Canada late fall to early spring
Usually infants / older adults impacted
Almost all 2-year-old RSV infection
Older adults with comorbidities e.g. COPD – severe disease
Reinfections common, but illness usually milder with subsequent infection
Who are some individuals at high risk of RSv?
CArdiac
Respiratory Conditions
DM
Immunosupressed
Signs and Sx RSV
Signs & Symptoms
URTI - mild, cold-like symptoms e.g. sore throat, cough, headache, nasal congestion, etc
Lower lung infections e.g. bronchiolitis and pneumonia
Severe - requiring oxygen and hospitalization / ICU
Leading cause of hospitalization in infants (US)
RSV Vaccine Types and Recommendation
RSV NACI Recommendations
RSV Administartion Timing
Ideally admin before onset of RSV Season
RSV Study
RSV Prefusion F protein in Older Adults
Indicuduals aged 60 and older
Primary Endpoint: RSV-lower respiratory tract infection
Arexvy Vs. Placebo
Arexvy decreased RSV-LRTi by 83%
Those with commorbidities had a further reduction by 94%
Cannot Say Arrexvy is better than AByso
RSv Booster
- Long-term effectivenss unknwin
At this time, only one dose is recommended - CD: One dose of RSV vaccine can provide protection for atleast 2 years (2 RSV seasons)
RSV Vaccine Adverse FEfects
Arrexvy - Adjuvant
- Systemic Reactions, Injection Site Reactions
Abryso -No adjuvant
- GBS Abrexy and Abyso, A-fib with both
