Vaccinations Part 2 Flashcards
Name all the vaccines (14)
- Diphtheria
- Tetanus
- Pertussis
- Haemophillus Influenzae Type B (HIB)
- Measles, Mumps and Rubella (MMR)
- Varicella/Zoster
- Hep A
- Hep B
- Influenza
- Pneumococcal
- Meningococcal
- Human Papillomavirus (HPV)
- Rotavirus
- Poliovirus
Diphtheria
- acute bacterial respiratory/cutaneous illness
- caused by Corynebacterium diphtheriae (C. diphtheria)
- may involve any mucus membrane
- *but classically has gray pseudomembranes of the tonsils and oropharynx
-classified based on site of infection
(laryngeal, cutaneous, ocular, genital, ect)
- sx/complications most attributable to toxin
- most common complications: myocarditis & neuritis
- Death occurs in 5-10% from respiratory disease
Tetanus: Pathogenesis
Tetanus = nervous system disorder
- characterized by muscle spasms
- caused by toxin producing anaerobe Clostridium tetani
- anaerobic conditions
- allow germination of spores and production of toxins - toxins bind to CNS
- Blocks inhibitory NT release
-Leads to unopposed muscle contraction and spasms
(spastic paralysis)
uncontrolled muscle contraction –> breaking bones & writhing in pain
Tetanus: Clinical Features
-Incubation period = 8 days
3 Clinical Forms
- local (not common) 1 area affected, ex arm
- cephalic (rare)
- generalized (most common)
Generalized Tetanus
- descending sx of truisms (lockjaw)
- difficulty swallowing
- muscle rigidity
- spasms
-spasms continue for 3-4 weeks
If survive (25% mortality rate)-complete recovery may take months
Tetanus Complications (5)
- Laryngospasm
- Fractures
- Pulmonary Embolism
- Aspiration Pneumonia
- Death
Pertussis (whooping cough)
- highly contagious respiratory infection
- caused by Bordetella pertussis
- insidious onset
- similar to minor URI with nonspecific cough
- progresses –> severe coughing spells –>
- difficulty breathing
- vomiting
- disturbed sleep
- weight loss
- incontinence
- rib fractures
- passing out from violent coughing
-Up to 2/100 adolescents & 5/100 adults with pertussis
hospitalized/complications (including pneumonia and death)
- 2012: 48,277 cases in US exceeding levels observed since 1955
- most deaths are infants
Whole-cell & aCellular Pertussis Vaccine
- developed in the mid-30’s
- combined as DTP in the mid-40’s (DTP is not used in US)
- 70-90% efficacy after 3 doses
- Protection lasts for 5-10 yrs
- local adverse rxns are common in whole -cell
- whole cell is not used anymore because too many side effects
**acellular vaccine is safer to administer b/c it has about 90% fewer side effects (which include local pain, redness and/or fever)
-DTaP was developed in Japan in 1981
Diphtheria/Tetanus/Pertussis Combo: what the letters mean
uppercase letters = full strength (D, T, P)
lower case letters = “d” and “p” reduced doses of diphtheria and pertussis used in adolescent and adult formulations
“a” in DTaP = acellular, meaning pertussis component contains only a part of the pertussis organism
DTaP
- Diphtheria and Tetanus toxoids and acellular Pertussis vaccine
- given to infants/children ages 6 wks-6yrs
- kids should get 5 doses of DTaP
- 1 dose at each of the following ages
- 2, 4, 6 months
- 15-18 months
- 4-6 yrs
DT
-Diphtheria and Tetanus toxoids
(without pertussis component)
-given to infants and children ages 6 wks - 6 yrs
who have Contraindication to the pertussis component
Tdap
T=full dose, d and p =less than full dose
- Tetanus and diphtheria toxoids with acellular pertussis vaccine
- given as a 1-time dose to adolescents and adults
- women should receive Tdap with each pregnancy (preferably 3rd Trimester between 27th-36 weeks)
Td
-Tetanus & diphtheria toxoids
-Given to kids & adults ages 7 yrs and older
as booster shot or after exposure to tetanus
DTaP Vaccine
-Formalin-inactivated diphtheria toxins
-Schedule:
5 primary doses (2, 4, 6 months, 15-18 months, 4-6 yrs)
Booster shot every 10 years
Efficacy: about 98% (vaccine prevents disease 98% of the time)
Duration: about 10 years
Diphtheria & Tetanus Toxoids & Pertussis Vaccine:
Adverse reactions
-Local rxns (erythema, pain, induration)
-Systemic sx not common
(fever, headache, n/v, diarrhea, stomach ache, joint pain, rash)
-severe systemic rxns are rare
Diphtheria & Tetanus Toxoids & Pertussis Vaccine:
Contraindications
- severe allergic rxns to vaccine component or following a prior dose
- severe adverse effect to vaccine component or following a prior dose
Diphtheria & Tetanus Toxoids & Pertussis Vaccine:
Precautions
-mod/severe acute Illness
-Temp > 105 F (40.5 C) within 48 hours of previous dose
with no other identifiable cause
- collapse/shock-like state within 48 hours of previous dose
- persistent, inconsolable crying lasting > 3 hours occurring within 48 hours of previous dose
- convulsions with or without fever occurring within 3 days of previous dose
Routine DTaP Primary Vaccination Schedule
Dose Age Interval
Primary 1 6-8 wks ————
Primary 2 4 mths 4 wks
Primary 3 6 mths 4 wks
Primary 4 15-18 mths 6 mths
Primary 5 4-6 yrs 6 mths
Booster Schedule for DTaP
Booster Doses
-11 or 12 yrs of age if 5 years since last dose (Tdap)
- every 10 years thereafter (Td or Tdap)
- Pertussis is making a comeback it is recommended that all adults get at least from Tdap formulation
- pregnant women who have not received the primary tetanus vaccination series should begin this series during pregnancy after 20 weeks using Tdap
Haemophilus Influenzae Type B (HIB)
- severe bacterial infections particularly among infants
- organism colonizes nasopharynx
-prior to intro of vaccination
HIB was the leading cause of childhood meningitis, pneumonia, epiglottitis which is a true medical emergency (we hardly see epiglottitis any more)
-Incidence has fallen more than 99% since revaccination era
Haemophilus Influenzae Type B Vaccine (HbOC)
- polysaccharide-based conjugate vaccine
- dose 0.5 ml via IM route
- efficacy = 95%
- recommended interval = 8 weeks for primary series doses
- minimum age = 6 weeks
Haemophilus Influenzae Type B Vaccine (HbOC):
when to administer
-not routinely given to kids age 5 yrs or older
why? already exposed –> created ABs
- Indications to administer HIB vaccine to adults and kids > 5 yrs old include…
- Sickle cell disease
- HIV/AIDS
- removal of the spleen (asplenia)
- bone marrow transplant
- certain cancer pts on immune compromising chemo
Haemophilus Influenzae Type B Vaccine (HbOC): Adverse Rxns (local and systemic)
Local
- injection site pain
- erythema
- induration
- swelling
Systemic
- Rash
- Fever
- Anorexia
- Diarrhea
- Vomiting
Haemophilus Influenzae Type B Vaccine (HbOC):
Precautions & Contraindications
Precautions
-mod/severe acute illness
Contraindications
-severe allergic reaction to vaccine component or following a previous dose
- severe adverse rxn to vaccine component or following a previous dose
- kids should NOT get the vaccine
Routine HIB Primary Vaccine Schedule
Dose Age Interval
Primary 1 6-8 wks ——–
Primary 2 4 mths 4 wks
Primary 3 6 mths 4 wks
Booster 15-18 mths 6 mths
Measles
- highly contagious viral illness
- respiratory transmission of virus
- replication in nasopharynx and regional lymph nodes
- near universal infection of childhood in pre-vaccination era
- common and often fatal in developing areas
Measles: clinical features
Incubation period = 10-12 days
-Prodrome
stepwise increase in fever to 103 F or higher
cough, coryza, conjunctivitis
Koplik spots
-1-3 mm whitish, grayish, bluish, elevations on an erythematous base
-seen on the buccal mucosa typically opposite the molar teeth
-pathognomonic for measles infection
Measles: Clinical Features: Rash
Rash
- 2-4 days after prodrome, 14 days after exposure
- maculopapular rash –> becomes confluent
- begins on face and head
- persists 5-6 days
- fades in order of appearance
Measles: Complications
- otitis media
- pneumonia
- encephalitis
- Laryngotracheobronchitis (croup)
- Death
Mumps
virus –> headache, fever, muscle pain, loss of appetite, and swollen glands (parotitis)
Complications include…
- deafness
- meningitis
- painful swelling of the testicles/ovaries (orchitis)
- rarely sterility
Rubella (German Measles)
Rubella virus –> rash, arthritis (mostly in females) and mild fever
Rubella in and of itself = generally mild, self-limiting disease
but if a female gets rubella while pregnant can cause…
- miscarriage
- serious birth defects (congenital rubella syndrome)
Congenital Rubella Syndrome
- Infection may affect all organs
- deafness
- cataracts
- heart defects
- microcephaly (abnormal brain development)
- mental retardation
- bone deformities
- liver & spleen damage - may lead to fetal death or premature delivery
- severity of damage to fetus depends on gestational age
- up to 85% of infants affected if infected during 1st Trimester
Measles, Mumps, Rubella Vaccine (MMR)
-live virus attenuated vaccine of 0.5 ml dose via SubQ route
1st dose of MMR at 12-19 months
2nd dose of MMR at 4-6 yrs (before kindergarten)
-2nd dose may be given any time (at least 4 wks after 1st dose)
-susceptible adolescents and adults without documented evidence of rubella immunity
emphasis on non-pregnant females of childbearing age
-particularly if born outside of US
Measles, Mumps, Rubella Vaccine (MMR):
Contraindications & Precautions
- pregnancy
- immunosuppression
- severe allergic reaction to vaccine component or following a prior dose
- severe allergic reaction to neomycin
Precaution: moderate/severe acute illness
Varicella Zoster Virus (VZV)
-herpes virus (DNA)
primary infection –> varicella (chicken pox)
secondary infection –> herpes zoster (shingles)
Varicella (chicken pox)
-respiratory transmission of virus
Incubation period: 14-16 days (range 10-21 days)
mild prodrome: for 1-2 days
Rash: characterized by vesicular lesions
generally appears on head 1st
most concentrated on trunk
successive crops over several days with lesions
present in several stages of development
Varicella Complications
- bacterial infection of skin lesions
- pneumonia (viral/bacterial)
- CNS manifestations
- Reye’s syndrome
- hospitalization: 2-3 per 1000 cases
- Death: in 2013 the disease resulted in 7000 deaths worldwide
- postherpatic neuralgia (complication of zoster)
Herpes Zoster (Shingles): Prevalence
-1 million episodes occur annually in US
-about 1/3 of US population –> shingles
risk increases after 50 years of age
-50% of persons living until 85 yrs will develop zoster
Herpes Zoster (Shingles):
-reactivation of varicella zoster virus
- characterized by…
- painful, unilateral vesicular eruptions
- which usually occurs in a restricted dermatomal distribution
- associated with…
- aging
- immunosuppression
- varicella at younger than 18 months of age
Herpes Zoster: Complications
- postherpetic neuralgia (PHN)
- ophthalmic zoster (effects eye –> blindness)
- dissemination with generalized skin eruptions and involvement of CNS, lungs, liver, pancreas
- can cause systemic complications
Congenital Varicella Syndrome
- results from maternal infection during pregnancy
- period of risk may extend thru 1st 20 wks of pregnancy
- low birth weight
- atrophy of extremity with skin scarring
- eye & neurologic abnormalities
-risk appears to be small (
Varicella-containing Vaccines
- Varicella Vaccine (Varivax)
- Herpes Zoster vaccine (Zostavax)
- MMRV (ProQuad)
Varicella Vaccine (Varivax): Describe vaccine, Pediatric and Adult Dosing
- Live attenuated vaccine
- Prevents primary varicella infection (chicken pox)
- does not prevent shingles
Pediatric dosing: 0.5 ml SubQ
ACIP recommends that routine childhood vaccines should be given with 2 doses
-1st dose at 15-18 months of age
-2nd dose at 4-6 yrs of age, but it may be given earlier provided >/= 3 months has elapsed since 1st dose
Adult dosing: 0.5 ml SubQ
ACIP recommends that all kids and adults who received only 1 dose of vaccine receive a 2nd dose at least 4 wks apart
Varicella Vaccine (Varivax): Precautions
-mod/severe acute illness
-varicella vaccine and AB-containing products
(immune globulin, blood products) should NOT be administered simultaneously
-avoid salicylates (aspirin and aspirin-containing products) for 6 weeks: varicella may increase the risk for Reye’s Syndrome
Varicella Vaccine (Varivax): Contraindications
- pregnancy
- immunosuppression
- severe allergic reaction to vaccine component or following a prior dose
Herpes Zoster Vaccine: (Zostavax)
- live attenuated vaccine
- approved for persons >/= 50 yrs of age
- SubQ 0.65 ml administered as a single dose
- ACIP recommends routine vaccination of all pt >/= 60 yrs of age
- including pt who report previous episodes of zoster
Herpes Zoster Vaccine (Zostavax): Precautions
-mod/severe acute illness
- postherpetic neuropathy (PHN)
- not for use in tx of PHN
-TB: defer tx of pt with active untreated TB
- VZV infection:
- not for prevention of primary varicella virus infection (chicken pox)
- or tx of active zoster outbreak
- may be used in pt with previous hx of zoster (at least 6 months after zoster outbreak)
-Antiviral drugs: meds active against the herpes virus family (acyclovir, famciclovir, valacyclovir) may interfere with zoster vaccine
Herpes Zoster Vaccine (Zostavax): Contraindications
- pregnancy
- Immunosuppression
- severe allergic reaction to vaccine component or following a prior dose
Varicella/Zoster Vaccine: Adverse Rxns
-local rxns (pain, erythema)
- rash- 3-4%
- may be maculopapular rather than vesicular
- avg 5 lesions
-systemic rxns: not common
MMRV (ProQuad)
Combo: Measles, Mumps, Rubella, and Varicella vaccine
-approved for kids 12 months - 12 yrs of age (up to 13 yrs)
ACIP guidelines: 2 doses of MMRV vaccine recommended
- 1st dose at 12-15 months of age
- 2nd dose at 4-6 yrs of age
These are recommended ages, but kids can get 2nd dose up thru 12 yrs (as long as given at least 3 maths after 1st dose)
Hepatitis A Virus (HAV)
- picornavirus (RNA)
- humans are only natural hosts
- entry into mouth via fecal-oral route
- viral replication in the liver
- virus present in blood and feces 10-12 days after infection
- virus excretion may continue for up to 3 weeks after onset of sx
Hep A: Clinical Features
Incubation period: 30 days (range from 15-49 days)
-manifestations vary with age
-usually silent/subclinical in kids
-infxn in adults varies with severity
(mild flu-like illness –> fulminant hep)
- Abrupt onset of prodromal sx
- fatigue
- malaise
- n/v
- anorexia
- fever
- RUQ pain
- progresses to dark urine, acholic stool (light colored stools, lacking bilirubin pigment), jaundice and pruritis (liver disease sx)
- any type of hepatitis - hard to say what type unless have lab results (similar presentations)
Hep A Vaccines
- inactivated whole virus vaccine
- Pediatric and Adult Formulations
- Pediatric Formulation approved for 12 mths -18 yrs
(0. 5 ml IM)
-Adult Formulation approved for 19 yrs and older
(1 ml IM)
Hep A Vaccine Recommendations: Indications
-all kids b/n 1st & 2nd birthdays
(12-23 months of age)
- international travelers
- men who have sex with men
- illegal drug users
- pt has occupational risk
- pt has chronic liver disease
ACIP recommendations for routine Hep A vaccination of kids
- all kids should receive Hep A vaccine at 12-23 months of age
- kids who are not vaccinated by 2 yrs can be vaccinated at later visits
- administered with a 2 dose series
- 1st dose: given at 12-23 months
- 2 doses should be separated by 6-18 months
Typical Schedule
- 1st dose: 12 months
- 2nd dose: 24 months
Hep A Post-exposure Prophylaxis
- For healthy persons 12 months - 40 years of age
- single antigen Hep A vaccine should be administered as soon as possible after exposure
- For persons older than 40 yrs
- immune globulin is performed
- vaccine can be used if IG cannot be obtained
Hep A Vaccine: Adverse Rxns
- local rxn (pain/erythema)
- systemic rxn (malaise, fever, fatigue)
Hep A Vaccine: Contraindications & Precautions
- severe allergic rxns to vaccine component or following a prior dose
- severe adverse rxn to previous dose
Precaution: mod/severe acute illness
Hep B Virus (HBV)
- epidemic jaundice described by Hippocrates in 5th century BC
- Hepadnaviridae family (DNA)
- humans are only known host
- may retain infectivity for more than 7 days at room temp
Hep B Virus (HBV): Clinical Features
Incubation period = 60-150 days (avg 90 days)
- nonspecific prodrome: malaise, fever, headache, myalgias
- illness nonspecific for Hep B
- at least 50% of infections are asymptomatic
Hep B Virus (HBV): Complications
- chronic infections
- fulminant hepatitis
- hospitalizations
- cirrhosis
- hepatocellular carcinoma
- death
Adults at risk for HBV Infections: Sexual exposure
- sexual exposure
- sex partners of HBsAg-positive persons
- sexually active persons NOT in a long-term mutually monogamous relationship
- persons seeking evaluation/treatment for a sexually transmitted disease
- men who have sex with men
- persons with more than 1 sexual partner during the previous 6 months
Adults at risk for HBV Infections:
Percutaneous/mucosal exposure to blood
Percutaneous/mucosal exposure to blood
- current/recent IVDU (IV drug user)
- household contacts of HBsAg-positive persons
- residents & staff of facilities for developmentally disabled persons
- healthcare & public safety workers with risk for exposure to blood or blood-containing body fluids
- persons with end-stage renal disease
Adults at risk for HBV Infections: Other Groups
International travelers to regions with high/intermediate levels (HBsAg prevalence of 2% or higher) or endemic HBV infection
*persons with HIV infection
Hep B Vaccine Formulations
*inactivated viral vaccine
Recombivax HB (Merck) IM
- 5 mcg/0.5 ml (pediatric)
- 10 mcg/1ml (adult)
- 40 mcg/1 ml (dialysis)
Engerix-B (GSK) IM
- 10 mcg/0.5 ml (pediatric)
- 20 mcg/1 ml (adult)
***do not memorize dosing
Hep B Vaccine: Routine Infant Schedule
Babies normally get 3 doses of Hep B vaccine
- 1st dose = birth
- 2nd dose = 6-8 wks of age
- 3rd dose = 6-18 months of age
- some babies might get 4 doses
- ex if a combo vaccine containing Hep B is used (single shot, containing several vaccines)
-the extra dose is not harmful
Hep B Vaccine: High Risk Infants
- infants born to HBsAg-positive females
- administer Hep B vaccine & 0.5 ml of Hep B Immune globulin (HBIG) within 12 hours of birth
-infants should be tested for HBsAg and AB to HBsAg (anti-HBs) 1-2 months after completion of Hep B series
Hep B Vaccine: Adult and Adolescent Schedule
Dose Usual Interval Minimal Interval
Primary 1 0 ——————-
Primary 2 1 month 4 weeks
Primary 3 6 months 8 weeks
*3rd dose must be separated by 1st dose by at least 16 weeks
Influenza
- commonly called the flu
- caused by RNA viruses of the family Orthomyxoviridae
- transmitted thru air or by direct contact with nasal secretions (coughing, sneezing, close contact)
Influenza: Clinical Features
- sx commonly confused with common cold although generally more severe including
- fever/chills
- sore throat
- Arthralgias (muscle aches)
- headache
- coughing
- weakness and fatigue
Influenza: Complications
-pneumonia
-severe diarrhea & dehydrations
-myositis & rhabdomyolysis
-seizures
-encephalitis
-each yr thousands of people in US die from the flu
& many more are hospitalized
*most at risk for complications are young kids, people 65 years and older, pregnant females, immunocompromised
Types of Influenza Vaccines: Injectable
- Injectable - inactivated vaccine
- approved for use in pt older than 6 months including healthy pt and also those with chronic medical conditions
3 types available
-standard flu shot: approved for people ages 6 months and older (0.5 ml dose IM)
-High-dose flu shot: approved for 65 and older
(60 mug of hemagglutinin per strain vs 15 mug of hemagglutinin per strain in the standard vaccine)
- Intradermal flu shot: approved for 18-64 years of age
(0. 1 ml/dose)
Types of Influenza Vaccines: Intranasal
Intranasal
-live vaccine
- only approved for use in healthy pt ages 2-49 who are NOT pregnant
- sometimes called LAIV (live attenuated influenza virus)
- viruses in nasal spray vaccine do NOT cause the flu
Influenza Vaccine
- flu vaccine is recommended every year
- kids 6 months - 8 yrs of age should get 2 doses the 1st yr they get vaccine
- inactivated flu vaccine - protects against 3-4 different influenza strains
- it takes about 2 weeks for protection to develop after vaccination and protection lasts several months to a yr
- seasonal flu vaccines protect agains 3-4 influenza viruses that research indicates will be most common during the upcoming season
- viruses in the vaccine can change each year based on the international surveillance and scientists’ estimations about which types and strains of viruses will circulate in a given yr
Timing of Influenza Vaccine Programs
- influenza activity can occur as early as October
- in more than 80% of seasons since 1976 peak influenza activity has not occurred until January or later
- in more than 60% of seasons the peak was in February or later
- providers should begin offering vaccine as soon as it becomes available (if possible by October)
- to avoid missed opportunities for vaccination: providers should offer vaccine during routine healthcare visits or during hospitalizations whenever vaccine is available
- providers should continue to vaccinate thru out influenza season
Influenza Vaccination: Healthcare Workers (HCW)
- educate HCW about benefits for themselves, their families and their pt
- educate staff about vaccine adverse rxns
- provide free vaccinations at work site to all employees (including night and weekend staff)
Inactivated Influenza Vaccine: Adverse Rxns
- local rxns = 15-20%
- fever/malaise - not common
- allergic rxns - rare
- neurological - very rare rxns
Inactivated Influenza Vaccine:
Contraindications & Precautions
-severe allergic rxn to vaccine component (ex eggs) or following a prior dose of vaccine
Precautions
- mod/severe acute illness
- hx of Guillian Barre within 6 weeks following previous dose
Recombinant flu vaccine
- does not use chicken eggs
- safe for pt with egg allergies
Live attenuated Influenza Vaccine: Adverse Rxns
Minor
- rhinorrhea
- nasal congestion
- headache
- sore throat
Out of 2.5 million people the following adverse rxns were reported
- anaphylaxis (7)
- Guillian Barre (2)
- Bells Palsy (1)
- Asthma exacerbation among pt with hx of asthma (8)
Live Attenuated Influenza Vaccine: Precautions
- kids younger than 5 yrs with asthma/recurrent wheezing (ex hx of RSV) *
- mod/severe acute illness
- pt with chronic medical conditions*
- kids/adolescents receiving long-term aspirin therapy*
- pt should receive inactivated flu vaccine
Live Attenuated Influenza Vaccine: Contraindications
- immunosuppression from any cause *
- pregnant women *
- kids younger than 2 yrs of age *
- pt 50 yrs or older *
- severe (anaphylactic) allergy to eggs or other vaccine components
- hx of Guillian Barre
- pt should receive inactivated influenza vaccine
Pneumococcal Disease
- Streptococcus pneumoniae: 1st isolated by Pasteur in 1881 gram-positive bacteria
- 90 known serotypes
- 2nd most common cause of vaccine-preventable death in the US (after influenza)
- major clinical syndromes include
- pneumonia
- bacteremia
- meningitis
- very young and very elderly = highest death rates
- 100K-135K hospitalizations per yr
- 4000 deaths/yr
- common bacterial complication of influenza and measles
Pneumococcal Vaccination Types
Pneumococcal conjugate vaccine (PCV13 or Prevnar 13)
- protects against 13 types of pneumococcal bacteria
- IM route 0.5 ml per dose
Pneumococcal poly-saccharide Vaccine (PPSV)
- protects against 23 types of pneumococcal bacteria
- IM/SubQ 0.5 ml per dose
Pneumococcal Conjugate Vaccine (PCV13):
Recommended Immunization Schedule
Dose Age Primary 1 6-8 wks Primary 2 4 months Primary 3 6 months Booster 12-15 months
Pneumococcal Polysaccharide Vaccine (PPSV)
-all adults 65 yrs of age or older
- anyone 2-64 yrs of age who is immunosuppressed or has a chronic medical condition such as
- heart/lung disease
- sickle cell
- diabetes
- alcoholism
- cirrhosis
-any adult 19-64 yrs of age who is a smoker or has asthma
Pneumococcal Polysaccharide Vaccine (PPSV) Dosage
PPSV is usually given as a single dose per lifetime
However 2nd dose is recommended for people…
-65 yrs of age or older who got their 1st dose before 65 and it has been 5 or more yrs since 1st dose
- for people 2-64 yrs of age who are immunocompromised
- when a 2nd dose is given it should be given 5 yrs after the 1st dose
Pneumococcal Vaccines: Adverse Rxns
- Local Rxns
- polysaccharide 30-50%
- conjugate 10-20%
- Fever/myalgia
- polysaccharide
Pneumococcal Vaccines: Contraindications & Precautions
- severe allergic rxn to vaccine components or following a prior dose of vaccine
- moderate/severe acute illness
Meningococcal disease
- serious bacterial illness
- caused by Neisseria meningitidis
- organism colonizes nasopharynx and can invade blood stream –> infunction at distant site
- it is the leading cause of bacterial meningitis in kids 2-8 yrs old in US
- about 1000 people get meningococcal disease per year in US and even when treated with antibiotics 10-15% of these people die
Meningococcal Meningitis
- most common pathologic presentation of meningitis
- result of hematogenesis dissemination
- clinical findings
- fever
- headache
- stiff neck
Meningococcemia
- bloodstream infection (sepsis)
- may occur with or without meningitis
- clinical findings
- fever
- petechial/purpuric rash
- hypotension
- multiorgan failure
Meningococcal Vaccine
2 types
- meningococcal conjugate vaccine (MCV4, Menatra)
- preferred vaccine for people 55 and younger
- meningococcal polysaccharide vaccine (MPSV4) licensed for people 55 and older
- Both vaccines –> prevent 4 strains
- Route IM 0.5 ml dose
MCV4 Recommendations
2 doses of MCV4 recommended for adolescents 11-18 yrs of age
- 1st dose at 11-12 yrs of age - with booster dose at age 16
- Adolescents in this age group with HIV should get 3 doses
- 2 doses 2 months apart at 11 or 12 yrs
- plus booster at age 16
Meningococcal Vaccine: Adverse Rxns
Local = 11-50%
Systemic (headache, malaise, fatigue) = 4-22%
Meningococcal Vaccine: Contraindications & Precautions
- severe allergic rxns to vaccine component or following prior dose of vaccine
- mod/severe acute illness
Human Papillomavirus (HPV)
- DNA virus
- more than 100 types identified based on the genetic sequence of the outer capsid protein L1
- 40 types infect the mucosal epithelium
- most common sexually transmitted virus in US
- more than half of sexually active men and women infected with HPV at some time in their lives
HPV: Clinical Findings
most HPV infections are asymptomatic and result in no clinical disease
clinical manifestations of HPV infections include
- anogenital warts
- cervical cancer precursors (cervical intraepithelial neoplasia)
- cancer (cervical, anal, vaginal, vulvar, penile, oropharyngeal cancer)
HPV Vaccine Types
3 types of HPV Vaccines
-nonavalent vaccine HPV9 (Gardasil-9)
indicated for males and females
(6, 11, 16, 18, 31, 33, 45, 52, 58)
-quadrivalent vaccine HPV4 (Gardasil)
indicated for males and females
-bivalent vaccine HPV2 (Cervarix)
only indicated for females
Routine HPV Vaccination Recommendations
ACIP recommends routine vaccination of all adolescents
11-12 years of age
- the vaccine series can be started as young as 9 years of age (at clinician’s discretion)
- “catch up” vaccine recommended for adolescents 13-26 years of age
HPV Vaccine Efficacy
-high efficacy among females without evidence of infection
with vaccine HPV types
- Prior infection with 1 HPV type did not diminish efficacy of vaccine against other HPV types
- Clinical trials of HPV vaccine in males has demonstrated similar immunogenicity with a favorable side effect profile
HPV Vaccine Schedule
Routine Schedule = 0, 2, 6 months
- 3rd dose should follow 1st dose by at least 24 weeks
- an accelerated schedule using minimal intervals is NOT recommended
- series does NOT need to be re-started if the schedule is interrupted
HPV Vaccine: Special Situations*
- equivocal/abnormal Pap test
- positive HPV DNA test
- genital warts
- immunosuppression
- breastfeeding
- vaccine can be administered
HPV Vaccine: Adverse Rxns
- Local Rxns (pain/swelling) = 84%
- Fever = 10%*
- no serious adverse rxns reported
- similar to reports in placebo recipients (9%)
HPV Vaccine: Contraindications & Precautions
- CI
- severe allergic reaction to vaccine component or following a prior dose
- Precaution
- mod/severe acute illness (defer until sx improve)
HPV Vaccine: During Pregnancy
- initiation of vaccine series should be delayed until after completion of pregnancy
- if female found to be pregnant after initiating vaccination series –> remaining dose(s) should be delayed until after pregnancy
- if vaccine dose has been administered during pregnancy there is no indication for intervention
- any female vaccinated during pregnancy should be reported to Merck registry
Rotavirus: Prevalence
- 1st ID as cause of diarrhea in 1973
- most common cause of severe diarrhea in infants/kids
- nearly universal infection by age 5 yrs
- responsible for up to 400K diarrheal deaths each year worldwide
Rotavirus
- Reovirus (RNA)
- 5 predominant strains (G1-G4, G9) and accounts for 90% of isolates
- G1 strain accounts for 75% of infections
- very stable and may remain viable for weeks/months if not disinfected
Rotavirus Pathogenesis
- entry thru mouth
- replication in epithelium of small intestine
- replication outside intestine & viremia uncommon
- infection –> mod/severe diarrhea
Rotavirus: Clinical Features
-short incubation period (usually could die from dehydration)
Rotavirus: complications
- severe diarrhea
- dehydration
- electrolyte imbalance
- metabolic acidosis
- immunodeficient kids may have more severe or persistent disease
Rotavirus Vaccines
- RV5 (RotaTeq)
- live attenuated vaccine
- route: oral 2 ml dose/3 doses
- Pentavalent human-bovine rotavirus reassortant vaccine
- RV1 (Rotarix)
- live attenuated vaccine
- route: oral 2 ml dose/2 doses
- monovalent vaccine derived from the most common human rotavirus serotype
Rotavirus Vaccine Recommendations
Schedule
1st dose = 6 wks of age
2nd dose = 4 months of age
3rd dose = 6 months of age (only for RotaTeq)
For both rotavirus vaccines
- max age for 1st dose = 14 wks 6 days
- min interval b/n doses = 4 wks
- max age for any dose = 8 months 0 days
Rotavirus Vaccine: Adverse Rxns
- vomiting = 15-18%
- diarrhea = 9-24%
- irritability = 13-62%
- fever = 40-43%
- serious adverse rxns = none
Rotavirus vaccine & intussusception
#infants vaccine recip Placebo recip RV1 63,255 7 cases 7 cases RV5 69,625 6 cases 5 cases
*RV1: 0-30 days after either dose
RV5: 0-42 days after any dose
Rotavirus Vaccination: Precautions
- Immunosuppression
- Acute, moderate/severe gastroenteritis or other acute illness
- hx of intussusception
- decision to vaccinate (if precaution present) should be made on a case-by-case risk vs benefit basis
Polio
- caused by a virus
- enters the body thru mouth
- causes paralysis, meningitis and death
1916 Polio epidemic in US –> killed 6000 and paralyzed 27000 more
early 50’s > 25,000 cases of polio reported each year
Polio vaccine was started in 1955
By 1960 # of reported cases dropped to about 3000
1979 there were only about 10 cases
Today Polio eliminated from US, but still common in other parts of the world.
It would only take one person coming from another country to bring the disease back here if we were not protected from the disease
if the effort to eliminate the disease is successful –> then someday we might not need the polio vaccine
until then we need to keep getting our kids vaccinated
Polio Vaccine (IPV)
kids get 4 doses of IPV at these ages
- A dose at 6-8 weeks - A dose at 4 months - A dose at 6-18 months - Booster at 4-6 yrs
Combo Vaccines
idea with combo vaccines is to cut down on # of injections
some parents will state that they are only willing to have their child get x amount of vaccinations per visit and sometimes it is difficult to succeed at 100% recommended immunization
combo shots allow for significantly fewer shots that what was previously required
Combo Vaccines: List of approved formulas
- DTaP, DT, Tdap, Td
- MMR
- MMRV (ProQuad)
- DTaP + Hep B + IPV (Pediarix)
- Hep A + Hep B (Twinrix)-only approved > 18 yo
- HIB + Hep B (Comvax)-can only be used as 4th dose
Combo Vaccine Schedule
Birth = Hep B 6 wks = PCV, HIB, Prediarix 4 mths =PCV, HIB, Prediarix 6 mths =PCV, HIB, Prediarix 9mths = nothing 12 mths= PCV, HIB, ProQuad (MMRV), Hep A 15-18 mths = Hep A 4-6 yrs = DTaP, IPV, ProQuad (MMRV)
Other Combo Vaccines being studied
Pentavac: combo DTaP, IPV, HIB
Hexavac: DTaP, IPV, HIB, Hep B
(allow only Hexavac and PCV during infancy)
DTaP, HIB, IPV, Hep A and Hep B
Pediarix
DTaP-Hep B-IPV combo
minimum age = 6 wks
approved for 3 doses (2, 4, 6 months)
not approved for booster doses
licensed for kids 6 wks - 7 years of age
may be used interchangeably with other pertussis-containing vaccines if necessary
-can be given at 2, 4, 6, months in infants who received a birth dose of Hep B vaccine (4 total doses)
may be used in infants whose mothers are HBsAg-positive or status unknown
Twinrix
-combo Hep A vaccine (peds dose) and Hep B (adult dose)
schedules
-0, 1, 6 months
or
-0, 7, and booster at 12 months
approved for persons 18 yrs of age and older
