Quiz 2 Flashcards
Herpes Zoster Epidemiology
-Commonly called shingles
-reactivation of latent varicella zoster virus ‘
-Incidence and severity increase with age
-Risk increased by immunosuppression
Herpes Zoster complications
Post-therapeutic neuralgia - persistent pain after skin lesions healed
May limit daily activities and decrease quality of life
Zoster vaccines
Live attenuated zoster vaccine (ZVL)
-Licensed for individual > 50 years
-No longer marketed in the US cause not as effective
-Zostavax
Recombinant zoster vaccine (RZV)
-contains recombinant glycoprotein E and adjuvant
-two dose series 0 and 2-6 months
-Shingrix
RZV vaccine complications
-About 91% effective in prevention of zoster
-Injection site reactions are common (78%)
Immunocompromised
70% in auHSCT and 87% in hematologic malignancy
ACIP recommendations Herpes Zoster
Recommended for all adults >50 years
-Recombinant zoster vaccine two doses 2-6 months apart
All immunosuppressed individuals aged 19 years and older
-0 and 2 months
Respiratory Syncytial Virus (RSV) epidemiology
-Common seasonal respiratory virus
-Very contagious
-Well known to cause hospitalization with bronchiolitis and wheezing in infants
-Considerable burden of illness in adults
*65 and older
*Chronic illness, heart, hematologic, neurologic, diabetes, kidney, liver, immunocompromise, others
Respiratory Syncytial Virus (RSV)
Infants
-Acute respiratory illness symptoms
**runny nose
**decreased oral intake
Adults
-Acute respiratory illness
**Rhinorrhea
**Pharyngitis
**Cough
**Headache
**Fatigue
**Fever
RSV vaccines
Pfizer bivalent RSVpreF (Abrysvo)
GSK adjuvanted RSVpreF3
(Abrexvy)
-single dose
Both demonstrated efficacy against lower respiratory tract RSV infection over at least 2 seasons in individuals aged 60+ years
ACIP:
1. Single dose all adults > 75 years old
2. Adults aged 60-74 years with certain chronic medical conditions or other factors that increase risk of severe RSV –> single dose
Risk factors RSV
-CV disease
-Lung disease
-End stage renal disease
-Diabetes with end-organ damage
-Severe obesity
-Liver disorders
-Neurologic or neuromuscular disorders
-Hematologic disorders
-Moderate to severe immunocompromise
-Frailty
-Long term care resident
-Chronic med conditions
Adverse reactions RSV
Injection site reactions
-Arthralgia, myalgia, fatigue, headache
-No difference in incidence of serious adverse effects compared to placebo
Guillain-Barre syndrome
RSV for pregnant person
RSV vaccine during pregnancy weeks 32-36 gestation (passive immunity for infant)
-Injection site and systemic adverse reactions resolved in 2-3 days
-No risk to to preterm birth
Nirsevimab for infants
-Long acting monoclonal antibody with efficacy in the prevention of lower respiratory tract RSV infection
-Administer just prior or during RSV season - October to March
-Eligible infants < 8 months born prior to or during RSV season
-Eligible children aged 8-19 months at increased prior to or during second RSV season
Covid-19 pathology
-Respiratory symptoms by SARS CoV2 virus
-Fevers or chills
-Cough
-Shortness of breath
-Fatigue
-Myalgia
-Headache
-New loss of taste or small
-Sore throat
-Congestion
-Nausea, vomiting, diarrhea
COVID-19 epidemiology
Risk is substantially lower compared to early in pandemic
COVID-19 vaccine
mRNA vaccine
Target virus in same lineage
Moderna/Pfizer > 6 months
Novavax > 12 years
ACIP recommendation
All individuals aged 6 months or older
*Updated in Fall 2024 to improve response to currently circulating variants
Precaution
A condition in a vaccine recipient which may result in a problem if a vaccine is administered or a condition which could compromise the ability of a vaccine to induce immunity
Pregnancy
Benefit and risk assessment for vaccines
*risk cannot be ruled out by benefit may justify the risk
Routine prenatal care includes immunization history
Refer for prenatal care
*avoid live vaccines
*defer HPV immunization till after pregnancy
*Tdap in late 2nd or 3rd trimester
Influenza vaccine in pregnancy
Pregnant individuals at high risk for morbidity associated with influenza infection
4 fold increased risk of hospitalization and death
*vaccine recommended for pregnant individuals
RSV vaccine for pregnant individuals
RSV vaccine (Abrysvo) during pregnancy weeks 32-36
*passive immunity for infant
*Don’t use adjuvanted RSV
*Only vaccinate when gestation lines up seasonally (September to January)
Post partum (post birth) immunization
Rubella and/or varicella vaccines for seronegative
Tdap at hospital discharge if unimmunized
Influenza vaccine in season and unimmunized
Is lactation a contraindication?
No for mother and infant immunization
Immunosuppression
Two pronged risk
*risk of vaccine induced mortality or morbidity
*risk of poor host response to vaccine
Various diseases
*HIV, cancer, generalized malignancy
Various meds
*alkylating agents, antimetabolites, radiation
*corticosteroids (>20 mg/day) or prednisone (> 2 mg/kg/day) for more than 2 weeks
-Biologics, transplant meds
Immunosuppressed recommendations
-No lives vaccines
-OPV and small pox vaccines should not be administered to a household contact (risk of developing live disease)
-LAIV not administered to contacts of those requiring protective environment
-Can do the pneumococcal vaccine, or zoster vaccine series
Asplenia
Increased risk for fulminant bacteremia
Give meningococcal and pneumococcal vaccines if under 2
Hib vaccine
*If the splenectomy is elective (meaning you have time) immunize two weeks prior to surgery
*Annual influenza vaccination recommended
Liver disease
-No viral hepatitis or other liver disease
*Need hep A, hep B, annual infuenza, pneumococcal
HIV
-Need pneumococcal, MenACWY, no annual activated influenza, Tdap, hep B
-Consider MMR or varicella
*Avoid live vaccines
Cancer patients
-Avoid immunization during chemo
-Annual LAIV should not be administered
Solid Organ Transplant
-Immunize while waiting
-Annual LAIV, pneumococcal, Tdap, Hep B (might need booster) vaccine needed
High Risk medical conditions
Diabetes: Hep B series (19-59 years), pneumococcal, annual inactivated influenza
Renal failure: pneumococcal, hepatitis B series, LAIV, Td/Tdap
Healthcare workers
-Up to date with adult immunizations
-Two doses of MMR
-Varicella if not immune (born before 1980 doesn’t count as immune)
-Hep B
-Pertusis
-Annual Influenza
Adolescents
-Important access point for many preventative health needs
Immunization
-11/12 years and 16 years
Tdap, MenACWY, MenB, HPV
Elderly
-Pneumococcal and annual influenza
-Tdap
-RZV
-RSV for >75 years and risk based for 60-74 years
-Decreased immune response to Hep B vaccine
Concurrent illness
-Mild illness not a contraindication
-Antibiotic therapy not a contraindication
-Wait till after moderate or severe illness is resolved
*Well enough to be in the pharmacy, well enough to be immunized
RZV
Recommended for immunosuppressed age 19 or older
Recommended for normal > 50 years
Revaccinate those who receive ZVL
Shared Clinical Decision Making
MenB - 16-18
HPV - 27-45
PCV20/21 for >65 years who previously had PCV13 +PPSV23
MenB series for 18-18
Uncommon disease
Serious disease
Availability of vaccines
Unknown degree of protection and duration of protection
HPV for 27-45 year olds
Very common no consequence
Infection most common in adolescents and young adult
New Sex partner –> risk
PCV20/21 for >65 years
Only if previously received PCV13 and PPSV23 after age 65
If decide to use PCV20/21 administer at least 5 years after last dose
Shared clinical decision making documentation
-As a practice group decide which patients you will have convo with
-Document the conversation in pharmacy notes
Hard to reach populations
Also called marginalized populations
Defined by barriers to vaccination
Difficult to vaccinate due to -Distrust
-Religious beliefs
-Lack of awareness
-Poverty or low SES
-Lack of time to access vaccine services
-Gender based discrimination
Vaccine Hesistancy
Three drivers
Complacency
Covienience
Confidence
*Don’t disparage patients who are vaccine hesitant; engage with them and answer their questions
Vaccine denier
Focus on countering arguments
Importance of recognizing that the audience is the public who are present not the vaccine denier
Pre travel counseling
Patients medication history
-Health status
-Medications
-Allergies
-Vaccine history
Patient’s itinerary/behavior
-duration of travel
-rural vs urban
-Planned or unplanned activities
-Visiting friends or relatives
-patient’s risk tolerance
Food and water precautions
Avoid Tap water and anything washed or made from it
-Uncooked meat
-unpasteurized stuff
Insect precautions
Use an EPA approved repellant
DEET and Picaridin are safe for children > 2 months of age and for pregnant women
Apply sunscreen then repellant
Dengue Fever pathology
Flavivirus infection transmitted through mosquitoes
-Endemic to tropics and subtropics
-Acute febrile illness with headache, retro-orbital pain, muscle/joint aches, rash
Dengue fever vaccine
Dengvaxia
For children 9-16 years old living in areas endemic
*Not approved for US travelers who are visiting but not living in areas where dengue is endemic
Zika Virus
Flavivirus infection from mosquitoes
-Intrauterine, perinatal, and sexual transmission
Endemic in tropics and subtropics found in rural and urban areas
Most infections are asymptomatic or mild
Congenital Zika virus infection
Microcephaly with brain anomalies and fetal loss
*Pregnant woman should avoid areas with Zika
Chikungunya Virus
Viral infection from mosquitoes
Endemic in tropics and subtropics and rural/urban areas
Acute febrile illness with headache, muscle/joint aches, conjunctivitis, nausea, vomiting, rash
*Joint pain can be severe and last from months to years
*New vaccine available in the US
Chikungunya Vaccine
Live attenuated vaccine for adults >18 years of age
One dose
May be considered to persons traveling to area with Chikungunya virus in last 5 years who are:
- above 65 years old with underlying medical conditions
- Persons who stayed for longer than 6 months
Chikungunya vaccine contraindications
Immunocompromising condition, history of allergic reaction
Precautions: Pregnancy and breast feeding
Some side effects are tenderness, fatigue, muscle and joint aches, etc.
Cholera
An acute bacterial intestinal disease that causes bacteria
*Transmitted through ingestion of contaminated water or food in endemic areas
Treatable with rehydration +/- antibiotics
Cholera Vaccine
Live attenuated single dose oral vaccine
Approved for 2-64 years old
Vaccine ingested orally by patient
Japanese B Encephalitis
Mosquito borne flavivirus infection
Most infections are asymptomatic, but when it fully develops it has high fatality rate
Occurs in Asia and parts of Australia
Japanese Encephalitis Vaccine
Recommended for long term travelers or for short term travelers
Inactivated Vero cell culture-derived vaccine
Approved for >2 months
2 dose series on day 0 and 28
Tick borne Encephalitis
Single stranded RNA virus
Transmitted to humans through Tick bite or by ingesting unpasteurized dairy products
Symptoms range from non-specific febrile illness to acute non-invasive disease
TBE vaccine
Inactivated whole virus vaccine with formulations for children and adults
3 dose schedule with third dose 5-12 months after 2nd dose
Booster >3 years after completion of primary immunization then every 3-5 years
Typhoid Fever
An acute febrile illness caused by bacteria
Transmission is through contaminated food and water and person to person contact
Typhoid vaccines
Injectable inactivated vaccine
2 years of protection
Approved for >2 years of age
Oral live attenuated vaccine
4 capsules 1 taken every other day, refrigerate
Duration of protection is 5 years
Approved for > 6 years
*NO LIVE VACCINE TO IMMUNOSUPPRESSED
Yellow fever
Single stranded RNA virus transmitted by mosquitoes
Symptoms are influenza like syndrome to severe hepatitis, hemorrhagic fever, and death
Proof of vaccination required in some African countries
Yellow fever vaccine
Live attenuated vaccine approved for > 9 months
Single dose
Prioritize unvaccinated vs. traveler who’s there longer but has been previously vaccinated
Medications for travelers
Travelers diarrhea
-OTC meds
-Antibiotics
Malaria Prophylaxis
Altitude illness
-acetazolamide
Motion sickness
-scopolamine patch
-OTC medicines (meclizine, dimenhydrinate)
Flight anxiety/sleep meds
Malaria pathology
Caused by parasites in mosquitoes
Symptoms include fever, chills, headache, body aches, generalized malaise
Severe disease can lead to seizures, mental confusion, kidney failure, acute respiratory distress, coma, death
Prevention
Avoid Mosquitoes when possible
Chemoprophylaxis
Malaria Medicine
Chloroquine: Areas w Chloroquine-Sensitive mosquitoes
Doxycycline: All areas
Atovaquone-proguanil: All areas
Mefloquine: All areas except SE Asia
Responding to vaccine denier
- Identify the technique used
- Disentangle the core points and address each separately
- Respond with evidence based message
Adverse events
Predictable based on pharmacology of vaccine
Unpredictable based on properties of vaccine
(alopecia after hep B vax)
Seizures following immunization
Stable controlled seizure disorder no effect on immunization
*Caution for MMRV vaccine if have personal or family seizure history
Acetaminophen effect on vaccines
Fever is a common adverse event following immunization
*Recent study found lower antibody response to pediatric vaccines in those who received prophylactic acetaminophen
Discourage use of prophylactic antipyretics
Vaccine associated paralytic polio
Reversion of vaccine virus to more neurovirulent phenotypes
Very rare in healthy vaccinees or their contacts
Gullain Barre Syndrome
-Neurological syndrome characterized by loss of reflexes and symmetric paralysis with recovery
-Immune response directed at myelin sheath of peripheral nerves or axon
-May be triggering event (acute infection, vaccination)
GBS epidemiology
Common in later adolescents to older adults
Seasonally in late summer
Associated with campylobacter infection
Vaccine associated GBS
Tetanus toxoid–> extremely low risk
Hepatitis B vaccine and polio vaccine –> no association established
Influenza vaccine –> very low
RSV vaccine in individuals >60 –> very low risk
MenACWY–> no increased risk
Thimerosal in vaccines
FDA Modernization Act of 1997 called for review of mercury containing food and drugs
Thimerosal preservative contains very low levels of mercury
Thimerosal bottom line
Thimerosal free preparations now available in U.S
Risk of vaccine preventable disease much higher than the unknown, probably much smaller risk of thimerosal exposure
SIRVA
shoulder injury related to vaccine administration
-Injury to musculoskeletal structures of the shoulder
-Should pain, limited range of motion
-Inflammatory reaction resulting from unintended injection of vaccine or needle trauma
Allergic reaction
Risk of anaphylaxis following immunization is very low
Mediated IgE
Occur within minutes to hours of the vaccine
Require medical attention
Materials associated with Anaphylaxis
Vaccine antigen
Animal or yeast protein
Antibiotics
Preservatives
Stabilizers
Packaging
Anaphylaxis
Occurs shortly after exposure
Exposed to antigen previously
Mediated by IgE
IgE antigen complex attach to receptors on basophils and mast cells
Basophils and mast cells release mediators
Mortality due to Anaphylaxis
Direct
-Upper airway obstruction
-bronchial dysfunction
-Hypotension
Indirect
-myocardial infarction
-cerebral injury
-ischemia, hypoxia
-epinephrine use
Epinephrine
Indications: bronchospasm, laryngeal edema, urticaria, angioedema, hypotension
Goals:
maintain airway, reduce fluid, extravasation, reduce pruritis, maintain SBP
Complications:
Arrythmias, hypertension, nervousness, tremor
Epinephrine
Adult dose
Epinephrine 1:1000
0.3-0.5 mL sq or im
Pediatric dose
Epinephrine 1:1000
0.01 mL/kg sq or im
May repeat dose in 15 minutes if necessary
Antihistamines
Indication: urticaria
Goals: reduce pruritis, antagonize H1 effects of histamine
Complications:
Drowsiness, dry mouth, urniary retention
Dose
1-2 mg.kg im or iv
Typically 50-100 mg
How to prepare for anaphylaxis
Make an anaphylaxis kit
*Epinephrine auto injector
*Diphenhydramine syringe
*Alcohol wipes
*Tourniquet
*Management protocol
Fainting
Vasovegal reaction consisting of sympathetic nervous system stimulation
Often in a setting of fear or emotional distress
Sudden onset of hypotension
Assist to lying down
*don’t confuse with stroke
Legal requirements for immunization delivery by a pharmacist
Wisconsin Act 68 and 24:
No prescription
-Age 6 or older
-ACIP recommended vaccine
Pharmacy techs may administer vaccines
Students must complete course and be supervised by a healthcare provider authorized to administer vaccines
Prescription
-Any vaccine
-Age 0-5 years
A plan for implementing immunization services in a pharmacy
Screening
Vaccine ordering and storage
Record keeping
Reimbursement
Private insurance or managed care
Beneficiaries must check with their plans to determine if immunization must be obtained within the HMO
Medicare Part D
Covers vaccines for adults with Medicare Part D plans
*Used for zoster and RSV vaccine
Medicaid
Will pay for influenza or pneumococcal vaccines administered in pharmacies
Vaccines for Children program
VFC
Federal program provides vaccine at no cost to uninsured, underinsured or American Indian or Alaska native children 0-18 years
*No charge for vaccine but might have administration fee
Roster billing
simplified billing method for immunization
One CMS 1500 submitted with a list of claims
Roster billing can be used for mass immunization clinics
Exposure plan
Document that contains information about what to do in the case of an exposure
Contains:
-Facility name
-Determination of employee exposure
-Implementation of various methods of exposure control
*Universal precautions
*Engineering and work practice controls
*PPE
*Housekeeping
-Hep B vaccine
-Post exposure evaluation and follow-up
Communication of hazards to employees and training
-Recordkeeping
-Procedures for evaluating circumstances surrounding exposure incidents
*Person or department responsible for different aspects of program adminsitration
Promote immunization services in a locality
Educate other pharmacist staff to serve as vaccine educators and recommend immunizations
-Posters, flyers, bag stuffers
-Press release
-Local immunization coalition
*Immunize patients
consider process
continue immunization efforts all year long
*Share success
Medicare part B
covers annual influenza vaccine, pneumococcal vaccine, CMS priority to increase immunization rates
*covered in any setting
*No deductible
What to charge?
Must charge all patients the same price
Small Pox epidemiology
Globally eradicated in 1980
Biological warfare
-French and Indian wars
Storage of virus stocks in Russia and US
Small Pox vaccine
Live vaccine
Live, non replicating
Cross protection for Orthopoxviruses
(monkey, cow, variola)
Small pox vaccination procedure
Vaccine vial contains about 100 doses
Vaccinator wears gloves
Remove aluminum seal and rubber stopper
Choose vaccine sit
Cleaning site unnecessarily
Bifurcated needles supplied with vaccine
(scratch surface of skin)
Scarification
vaccination process that involves scratching the skin
Needle at right angle to skin
Strokes vigorous enough to cause trace of blood to appear
Small pox vaccine response
Primary vaccination
-Pustular lesion must be present on day 6-8
Revaccination
-Pustular lesion or significant induration surrounding a central lesion on day 7
Public health approach in case of bioterrorism?
Mass preexposure not in plan
-Risks outweigh benefits (people can die from getting vaccine induced small pox)
Surveillance and containment strategy
Small pox vaccine strategy
Ring vaccination
Focused contact tracing
Deliver vaccine to those who are at highest risk
Avoid adverse effects associated with mass immunization
Limited vaccine and VIG supplies
Monkeypox
vaccine recommended for
-People having contact with someone with M. Pox
-Sexual partner had M. Pox
-Multiple sexual partners in area with M. Pox
Vaccine:
2 doses separated by 4 weeks
Subcutaneous administration
Anthrax vaccine description
Cell free filtrate of anthrax culture
*No dead or live bacteria
Vaccine schedule:
-Vaccine doses administered intramuscularly
-Primary vaccination at 0,1,6,12, 18 months
-Maintain immunity with annual boosters for people at risk
Anthrax postexposure prophylaxis
Three doses (0,2,4, weeks) in combo with antimicrobials
contraindications for anthrax vaccine
History of anthrax infection
Anaphylaxis following dose
Postpone for moderate to severe illness
Adverse events for Anthrax
Local reactions
Systemic symptoms
Safety assessed extensively in military populations
Ebola epidemiology and pathology
Rare deadly viral infection
Transmitted through contact with infected body fluids
Fever, myalgia, internal hemorrhage, vomiting, or coughing blood
-70-90% fatal
-Supportive care
Ebola vaccine
Live recombinant
prevents infection
*not effective in outbreaks
-Healthy non pregnant, non lactating adults with occupational exposure
Adverse effects (anaphylaxis, arthritis)
CASE
Corroborate
About Me
Science
Explain + advise
VAERs
Report adverse events requiring medical attention occurring within 30 days of getting vaccine
Purpose:
Designed to generate, not test vaccine safety hypotheses
Detect possible signals of adverse events associated with vaccien
What vaccine is required to gain entry into Saudi Arabia during the the Hajj?
Meningococcal vaccine
Personal Liability insurance
$1 million per occurrence and $2 million per year
Sub Q vaccine
5/8 in and 25-37 gauge needle
1 mL and/or 3 mL syringe
45 degrees
IM vaccine
1 to 1 1/2 in with 22-25 gauge needle
1 mL and/or 3 mL syringe
90 degrees
