Primary and Secondary Prevention Flashcards
Primary prevention
- Definition
- Examples
- preventing the health problem; the most cost-effective form of healthcare
- immunizations, counseling about safety, and disease prevention (diet & exercise, gun safety, counseling)
Secondary prevention
- Definition
- Examples
- detecting disease in early, asymptomatic, or preclinical state to minimize its impact
- Screening/survey tests (BP check, mammography, colonoscopy, labs, PSA)
Tertiary prevention
- Definition
- Examples
- Test Tip:
- minimizing negative disease-induced outcomes
- In established disease, adjusting therapy to avoid further target organ damage; potentially viewed as a failure of primary prevention
- Intervene at lowest level of prevention possible
What is avoided annually by vaccination in USA?
- Polio –> 10,000 children are not paralyzed; 3,000 children deaths are avoided
- Rubella (German measles) –> 20,000 newborns spared congenital rubella syndrome
- Measles –> Saves 12,000 deaths in US and 2.7 mil worldwide (most children)
- Influenza –> Avoids ~7 mil cases of flu illness, 110,000 hospitalizations, and ~9,000 deaths (children, elderly, and pregnant women)
- Pneumococcal disease –> ~40,000 deaths annually (50% could be prevented); 1/20 die from pneumonia, 1/5 die from septicemia and meningitis)
The results of vaccinations in the USA:
- EBP advises that vaccine-related risk < disease-related risk
- Cost of vaccines outweighed against expense of treating vaccine-preventable diseases (VPD)
- Higher immunization rates contribute to herd/community immunity where even the unimmunized have a degree of protection d/t less opportunity to spread
- Advocating patients protection against VPD is one of the most important primary prevention activities
Immunization (IZ) principles
- Remove geographic and clinical practice barriers whenever possible (reach out to populations in need including senior centers, schools, worksites, retail centers, etc)
- When in doubt, re-immunize (Better to give an extra vaccine dose than to give none; risk of reaction to reimmunization is minimal)
- IZ deferred = IZ denied (Presence of minor illness does not necessitate deferring or delaying immunization; Immunization should be deferred only in the presence of moderate-to-severe illness with or without fever)
Active Immunity
- Definition
- Why active immunity?
- Onset of protection?
- Duration of protection?
Active immunity via immunization
Resistance developed in response to a vaccine and usually characterized by the presence of an antibody produced by host
Protection on board in anticipation of possible exposure
Onset of protection: Usually within 1 month of vaccine dose
Duration of protection: Usually years or lifelong
Available for the prevention of a wide variety of infectious diseases
Passive Immunity
- Definition
- Why passive immunity?
- Onset of protection?
- Duration of protection?
Passive immunity via administration of immune globulin)
Immunity conferred by an antibody produced in another hot by administration of an antibody-containing preparation (antiserum or immune globulin [IG])
Given post-exposure to select infecting agents, patient needs to present with risk or report of exposure
Onset of protection: Usually within hours of dose
Duration of protection: Usually time-limited, usually 6-9 months
Available for a limited number of infectious diseases including varicella, hepatitis A/B, tetanus, rabies, etc.
Tetanus Prophylaxis in Wound Management
Clean, minor wounds
(Tdap/Td IM or TIG?)
1. Hx of tetanus vaccinations
2. Unknown or <3 doses
3. >/= 3 doses
- Tdap or Td IM
- Yes
- No, unless >10 years since last dose
- TIG, 250 units IM
- No
- No
TIG = Tetanus Immunoglobulin
Td = Tetanus diphtheria
Tdap = Tetanus, diphtheria, acellular pertussis
Tetanus Prophylaxis in Wound Management
All other wounds
(Tdap/Td IM or TIG?)
1. Hx of tetanus vaccinations
2. Unknown or <3 doses
3. >/= 3 doses
4. What are considered other wounds?
- Tdap or Td IM
- Yes
- No, unless >5 years since last dose
- TIG, 250 units IM
- Yes
- No
- Wounds >6 hours old; contaminated with soil, saliva, feces, or dirt; puncture or crush wounds; avulsions; wounds from missiles, burns, or frostbite
Tetanus Prophylaxis in Wound Management Considerations
1. Which vaccination should be considered for <7 year olds? What if pertussis is contraindicated?
2. A single booster of which vaccine is recommended for adolescents and adults?
3. A dose of which vaccine is indicated during pregnancy regardless of vaccination history?
4. Test Tip regarding true vaccination contraindications:
- DTaP should be used for children age <7 years old (DT if pertussis vaccine is contraindicated)
- A single booster dose of Tdap is recommended for adolescents and adults to replace one Td booster
- A dose of Tdap is recommended during each pregnancy regardless of prior history of taking Tdap
- True vaccine contraindications are rare. Localized vaccine reactions are common and self-limiting.
Personalized IZ Contraindications
If patient has a history of anaphylactic (not localized), reaction to the following, avoid which IZ?
1. Neomycin
2. Streptomycin, polymyxin B, neomycin
3. Baker’s yeast
4. Gelatin, neomycin
5. Gelatin
6. Eggs
- IPV, MMR, varicella
- IPV, vaccinia (smallpox)
- Hepatitis B
- Varicella zoster (Zostavax)
- MMR
- Nothing. Eggs have been removed.
Anaphylaxis (regarding IZ)
1. Definition
2. Causes
3. Most common presentation
4. Provider Precaution and Preparation for anaphylaxis risk
- An acute, life-threatening systemic reaction with varied mechanisms, clinical presentations, and severity that results from the sudden systemic release of mediators from mast cells and basophils
- From any cause, including drug reaction, bee sting, immunization, food allergy, etc
- Urticaria (hives), angioedema (tissue edema most often involving the head and neck), and respiratory compromise
- Risk is low (1-2 events per 1 mil vaccine doses given), all vaccines should be administered in settings in which personnel and equipment for rapid recognition and treatment of anaphylaxis are available
Anaphylaxis
1. Definition
2. Presentation
- Acute onset of an illness (minutes to several hours) after exposure to allergen with involvement of:
- Skin and/or mucosa (pruritis/itch, urticaria/hives, and angioedema)
AND EITHER
Respiratory compromise (Dyspnea, wheeze/bronchospasm, stridor)
OR
Anaphylaxis
1. Definition
2. Presentation
- Acute onset of an illness (minutes to several hours) after exposure to allergen with involvement of:
- Skin and/or mucosa (pruritis/itch, urticaria/hives, and angioedema) (1 of these)
AND EITHER
Respiratory compromise (dyspnea, wheeze/bronchospasm, stridor) (1 of these OR 1 of the below)
OR
↓ BP or end-organ dysfunction (collapse, syncope, incontinence)
Immediate interventions in anaphylaxis in primary care
- Assess ABC (airway, breathing, circulation)
- Place patient in supine position
- Activate EMS, facilitate transfer to ED
- Administer IM epinephrine (anterior-lateral thigh)
Note: NO contraindications to epinephrine use in anaphylaxis regardless of comorbidity or age - Give H1/H2 blocker PO (H1=Diphenhydramine, H2= Ranitidine) - Ideally liquid
- IV access, oxygen, ongoing clinical monitoring - Repeat epi Q5min dictated by response
- Generally, Epi is contraindicated in pregnancy, MI, stroke but NOT in anaphylaxis!
Anaphylaxis
In the ED, interventions based on initial response:
- Referral?
- What is biphasic reaction?
- Establish airway if compromised
- Rapid fluid infusion (IV, IO) as needed for compromised circulation
- Repeat IM epinephrine as needed or consider IV epinephrine infusion
- Bronchodilators based on respiratory compromise
- Systemic corticosteroids
- Glucagon
- Length of observation based on clinical presentation, response to therapy, risk factors for fatal anaphylaxis, access to medical care, reliability – Need referral to allergist
Biphasic Reaction –> Reaction again in 4 hours after initial better
Anaphylaxis
Determine disposition: Home vs Admission considerations
Based on presentation and response to therapy in ED
* Home (most common) – With patient education on the use of self-injected epinephrine (EpiPen, SIE), potential biphasic reaction, trigger avoidance. Consider prescriptions for oral antihistamines and systemic corticosteroids
- Admission – Inpatient or ICU depends on persistent respiratory and/or circulatory compromise
In a community undergoing a disaster, the use of select vaccines will be prioritized. Which vaccine or immunization is prioritized in the following types of disasters?
1. Uninjured adults and children evacuated to a crowded group setting
2. Adults with multiple deep lacerations from flying debris
3. A community exposed to unsafe water supply after a hurricane
- Immunization against influenza
- Immunization against tetanus
- Immunizations against hepatitis A
True or false:
1. Immune globulin is a concentrated solution of antibodies derived from pooled donated blood
2. Previously unvaccinated adults with diabetes mellitus type 1 or type 2 should be vaccinated against hepatitis B as soon as possible after the diabetes diagnosis is made
3. Given that contraindications to influenza vaccine are rare, nearly everyone >/= 6 months of age should be encouraged to receive this immunization
- True. Jehovah’s witness may refuse
- True. Risk for developing chronic HBV (ages 19-59), contracting HBV through group glucose testing; ages 19-59 are 2-9x more likely to get Hep B
- True.
Live, Attenuated Virus Vaccines
1. Definition
2. Examples + Precautions for use in special populations
- Vaccine prepared from live microorganisms cultured under adverse conditions leading to loss of virulence but retention of their ability to induce protective immunity
- MMR (measles, mumps, rubella)
Varicella (chickenpox)
Intranasal influenza virus vaccine (FluMist)
* Pregnancy, d/t theoretical risk of passing virus to unborn child –> can cause infection
* In severe immunocompromised, d/t potential risk of becoming ill with virus or lack of clinical effect (live vaccines does not work well)
* See pediatric and adult immunization guidelines for further info on using live virus vaccines with HIV infection ( CD4 <200; if benefit outweigh risks, give vaccine)
Rotavirus vaccine (oral vaccine only given to young infants)
* Use contraindicated in infants diagnosed with severe combined immunodeficiency (SCID), a condition readily recognized in early infancy or history of intussusception (lower GI obstruction)
* Harmless virus shed from stool in first weeks post-vaccine
* Standard diaper hygiene and handwashing advisable
Indicate if each of the following individuals should receive vaccination with zoster vaccine recombinant (Shingrinx), yes or no?
1. A 50-year-old woman who will start treatment with adalimumab (Humira) for rheumatoid arthritis therapy in 2 weeks
2. A 65-year-old man who received one dose of zoster vaccine live (Zostavax) 5 years ago
3. A 55-year-old man who had shingles 3 months ago and all signs and symptoms have resolved
- Yes.
- Yes. At least 8 weeks from the zostavax
- Yes. Give vaccine as long as lesions are crusted over
Comparison of Herpes Zoster (Shingles) vaccines:
Shingrix vs Zostavax
1. Vaccine type
2. Dosing
3. FDA indication
4. Contraindications
5. ACIP recommendation
6. Most common adverse events
7. Do not give in which population?
8. Billing?
Shingrix
– zoster vaccine recombinant, adjuvanted, no live virus, near 100% efficacy, few exclusions to use, preferred zoster vaccine
1. Recombinant, adjuvanted (last up to 9 years)
2. 2 doses at 0 and 2-6 months, IM
3. Prevention of herpes zoster (shingles) in adults aged 50 years or older
4. Hx of severe allergic reactions to any component of vaccine. Able to be given in immune suppression; not studied or advised for use in pregnancy
5. Adults age >/=50 years, including those who previously received live zoster vaccine
6. Local – pain at injection site (78%), redness at injection site (38.1%), swelling (25.9%)
General – Myalgia (44.7%), fatigue (44.5%), headache (37.7%), shivering (26.8%), fever (20.5%), GI symptoms (17.3%)
Zostavax
– zoster vaccine line, ~50% efficacy, many exclusions to use, no longer used
1. Live, attenuated virus (lasts up to 6-7 years)
2. One dose, subQ
3. Prevention of herpes zoster (shingles) in individuals 50 years of age or older
4. Hx os severe allergic reaction to any component of vaccine; immunosuppression, immunodeficiency, pregnancy
5. Immunocompetent adults aged >/= 60 years
6. Injection site reaction (63.6%), headache (9.4%)
- Do not give in pregnancy
- Medicare under part D (drug pharmacy) - Bill for vaccination (Trasx-Rx)
Know ACIP Recommendations on Influenza Immunization
- Egg allergies removed as a contraindication to getting the flu shot
- Flu: most optimized time to obtain is Sept-Oct
- For ages 6 months and older, annually
- Pregnant women should get vaccinated
- When limited supply, vaccinations should be given to persons at higher risk for complications
- Avoid if anaphylactic reaction
- Consider observing patients for 15 minutes after vaccination to decrease risk of injury if syncope
Common reactions to immunization
- discomfort and erythema at injection site, generally expected
Hepatitis B
1st dose: Birth
2nd dose: 1-2 months
3rd: 6-18 months
*4 weeks between doses 1 and 2
*8 weeks between doses 2 and 3 + 16 weeks after 1st dose
For children 7-18 years
*b/w dose 1 and 2: 4 weeks
*b/w dose 2 and 3: 8 weeks and at least 16 weeks after 1st dose
Rotavirus
- RV1 (2-dose series)
- RV2 (3-dose series)
1st dose: 2 months
2nd dose: 4 months
*4 weeks between dose 1 and 2
*Minimum age for 1st dose is 6 weeks, maximum age for 1st dose is 14 weeks, 6 days
* Maximum age for final dose is 8 months, 0 days
- Contraindicated SCID (severe combined immunodeficiency)
- Precaution in HIV infection; give if benefit outweighs risk
- N/A in pregnancy
Diphtheria, tetanus, acellular pertussis (DTaP <7 years)
1st dose: 2 months
2nd dose: 4 months
3rd dose: 6 months
4th dose: 15-18 months
5th dose: 4-6 years
*Minimum age for 1st dose is 6 weeks
*4 weeks between dose 1 and 2
*4 weeks between dose 2 and 3
*6 months between dose 3 and 4
*6 months between dose 4 and 5
- N/A in pregnancy
