Immunizations

Question 1

Live attenuated vaccines

Answer 1

Note: Children younger than 1 year cannot develop an immune response to live vaccines.

i. Measles, mumps, and rubella (MMR) ii. Varicella iii. Zoster iv. Rotavirus v. Intranasal influenza vi. Oral polio – Unavailable in the United States

Question 2

Difference between pure polysaccharide and conjugated polysaccharide

Answer 2

. Pure polysaccharide i. Immune response does not require helper T cells; is mediated through B cells ii. Children younger than 2 years cannot form an immune response by this method because of immaturity of the immune system.

Conjugate polysaccharide i. Polysaccharide vaccine combined with protein that changes the response to a T cell–mediated response ii. Allows children younger than 2 years to form an immune response iii. Types of conjugate polysaccharide vaccines (a) Haemophilus influenzae type B (Hib) (b) Pneumococcal conjugate vaccine (PCV13) (c) Meningococcal vaccine (MenACWY)

Question 3

Recommendations for dosing of live attenuated vaccine and antibody preparations

Answer 3

Antibody-vaccine interactions i. Live, attenuated vaccines may be affected by circulating antibodies. (a) Vaccine given first: Wait 2 weeks before administering antibody. (b) Antibody given first: Wait 3 months before administering vaccine

Question 4

Number of vaccines that can be administered at one visit

Answer 4

There is no limit to the number of vaccines that can be administered in one visit. ii. Live, attenuated injectable vaccines not given during the same visit must be separated by at least 4 weeks.

Question 5

Grace period for early (ahead of schedule) vaccination

Answer 5

Vaccines may be given up to 4 days before the next scheduled dose.

Question 6

Immunosuppressive limits for live attenuated vaccines

Answer 6

Chronic therapy with high-dose oral steroids: Defined as prednisone 20 mg/day (or 2 mg/ kg/day or more) for more than 14 days; is contraindicated with live, attenuated vaccines (may vaccinate once discontinued for more than 1 month)

Live, attenuated vaccines can be given 3 months after the cessation of chemotherapy or at least 2 weeks before the initiation of immunosuppressive therapy.

Question 7

Pneumococcal vaccination for newborns

Answer 7

PCV13 i. Children younger than 2 years (a) Series of four doses (b) Given at 2, 4, 6, and 12–15 months

Question 8

Pneumococcal vaccination risk groups ages 6-18

Answer 8

Children and adolescents 6–18 years of age who are PCV13 naive and asplenic with cochlear implants, or who have chronic renal failure, HIV infection, diseases treated with immunosup- pressive therapy or radiation, or CSF leaks, or who are immunocompromised should receive one dose of PCV13.

Question 9

PPSV indications 2-64

Answer 9

Asthma – Children and adolescents 2–18 years of age who are using high-dose oral 
corticosteroids or adults 19 and older
 (2) COPD
 (3) Emphysema
 (b) Chronic heart disease
 (c) Diabetes mellitus
 (d) Chronic renal failure or nephrotic syndrome
 (e) Anatomic or functional asplenia
 (f) Cochlear implants
 (g) CSF leak
 (h) Immunocompromising conditions
 (i) HIV infection

Question 10

PPSV revaccination

Answer 10

Revaccination (a) Individuals receiving one or two PPSV23 doses before age 65 should receive another dose at age 65 or in 5 years, whichever is longer. No further doses are needed if patients were vaccinated at or after age 65.

Question 11

Meningococcal vaccine products

Answer 11

MPSV4 (Menomune) (a) Quadrivalent polysaccharide vaccine that contains serogroups A, C, Y, and W

Meningococcal conjugate vaccine (MenACWY-D [Menactra] and MenACWY-CRM [Menveo]) (a) Quadrivalent vaccines that contain serogroups A, C, Y, and W conjugated to either a diphtheria toxoid (MenACWY-D) or a CRM197 (MenACWY-CRM)

Serogroup B meningococcal vaccines (MenB-4C [Bexsero] and MenB-FHbp [Trumenba])
(a) Contains N. meningitidis serogroup B

Question 12

Routine meningococcal vaccination in children

Answer 12

Administer one dose of MenACWY-D or MenACWY-CRM to all children 11–12 years of age and one booster dose at 16 years.

Question 13

Non-routine meningococcal vaccine recommendations

Answer 13

Unvaccinated college freshmen living in a dormitory through age 21 years

High-risk children with functional/anatomic asplenia (including sickle cell)

High-risk children with functional/anatomic asplenia (including sickle cell)

Individuals 2–55 years of age at increased risk of meningococcal disease
(a) Microbiologists routinely using N. meningitidis isolates (single dose)
(b) Military recruits (single dose)
(c) Patients traveling to countries with N. meningitidis epidemics (single dose)
(d) Patients with terminal complement component deficiency (two doses administered at least
2 months apart)
(e) Patients with anatomic or functional asplenia or complement component deficiencies (two
doses administered at least 2 months apart)
(f) Patients at risk during an outbreak because of a vaccine serogroup

Revaccination every 5 years is recommended for patients who remain at high risk,

Question 14

Difference between varicella and zoster vaccines

Answer 14

Herpes zoster vaccine a. Live, attenuated vaccine b. Administered subcutaneously c. Contains the same antigen as the varicella vaccine, but is at least 14 times more potent

Question 15

Zoster vaccine recommendations

Answer 15

Recommendations a. Individuals 60 and older regardless of their history of chickenpox or herpes zoster infection b. The herpes zoster vaccine is FDA approved for use in patients 50 and older.

Question 16

High-level immunosuppression definitions for vaccination

Answer 16

• with combined primary immunodeficiency disorder (eg, severe combined immunodeficiency), • receiving cancer chemotherapy, • within 2 months after solid organ transplantation, • with HIV infection with a CD4 T-lymphocyte count <200 cells/mm3 for adults and adolescents and percentage <15 for infants and children, • receiving daily corticosteroid therapy with a dose ≥20 mg (or >2 mg/kg/day for patients who weigh <10 kg) of prednisone or equivalent for ≥14 days, and • receiving certain biologic immune modulators, that is, a tumor necrosis factor-alpha (TNF-α) blocker or rituximab

After HSCT, duration of high-level immunosuppression is highly variable and depends on type of transplant (longer for allogeneic than for autologous), type of donor and stem cell source, and posttransplant complications such as graft vs host disease (GVHD) and their treatments.

Question 17

low-level immunosuppression for vaccination

Answer 17

• asymptomatic HIV-infected patients with CD4 T-lympho- cyte counts of 200–499 cells/mm3 for adults and adolescents and percentage 15–24 for infants and children, • those receiving a lower daily dose of systemic corticoste- roid than for high-level immunosuppression for ≥14 days or receiving alternate-day corticosteroid therapy, and • those receiving methotrexate (MTX) ≤0.4 mg/kg/week, azathioprine ≤3 mg/kg/day, or 6-mercaptopurine ≤1.5 mg/kg/ day [10].

Question 18

Vaccine timing for planned immunosuppression

Answer 18

Live vaccines should be administered ≥4 weeks prior to immunosuppression (strong, low) and should be avoided within 2 weeks of initiation of immunosuppression (strong, low). 5. Inactivated vaccines should be administered ≥2 weeks prior to immunosuppression (strong, moderate)

Question 19

Live Vaccine recommendations for household contacts of immunosuppression patients

Answer 19

OPV should not be administered to individuals who live in a household with immunocompromised patients (strong, moderate).

Immunocompromised patients should avoid contact with persons who develop skin lesions after receipt VAR or ZOS until the lesions clear (strong, low).