Vaccines / Travel Flashcards
What are vaccine resources and information for patients and providers?
- FDA: approves indication
- Advisory Committee on Immunization Practices (ACIP): recomendations for vaccine administration
-May differ from the FDA - CDC: approves ACIP’s recommendations and publishes Morbidity and Mortality Weekly Report (MMWR and The Pink Book (epidemiology and prevention of vaccine-preventable diseases)
- Immunize.org: provides vaccine info and education for HCPs
- Vaccine Information Statements (VIS): prepared by CDC for pt info on benefits and risks (federal law requires this to be handed to pt before administration)
Vaccine Types: Live Attenuated vs. Inactivated
-List live vaccines
Live attenuated: weakened (attenuated) via modifying a disease-producing (wild) virus or bacterium with ability to replicate and produce immunity, but usually will not cause illness (strong immune response, but CI: immunocompromised, pregnancy)
-COZY IV RM –> Cholera, Oral Typhoid, Zoster (Zostavax), Yellow Yever, Intranasal Influenza, Varicella, Rotavirus, MMR
Inactivated: either killed whole virus or bacterium or fractions (immunity can diminish w/ time and supplemental doses may be needed)
Types of Inactivated Vaccines and Provide Examples: mRNA, toxoid, recombinant, polysaccharide, and conjugate
mRNA: vaccine gives instructions to bdoy’s cells in form of mRNA to produce protein specific to prathogen (ex. COVID-19 vaccines)
Toxoid: vaccine targets a toxin produced by disease (ex. tetanus)
Recombinant: gene segment of protein from organism is inserted into gene of another cell (ex. yeast cell) where it replicates (ex. HHP - Gardasil 9, recombinant influenza - Flublock Quadrivalent)
Polysaccharide: sugar molecules taken from outside layer of encapsulated bacteria (do NOT produce a good repsonse in children <2 yo) - ex. Pneumovax 23
Conjugate: uses polysaccharide (sugar) molecules from outside layer of encapsulated bacteria and join molecules to carrier proteins (conjugation increases immune response in infants) - ex. Prevnar 20, Menveo
Timing of Vaccines:
1. Can vaccines be given simultaneously?
- Does increasing the interval between doses of vaccines diminish effectiveness?
- The minimum interval between an antibody-containing product and a MMR vaccine is __________ and can be up to ______ depending on the product OR give MMR ________ time before antibody-containing product.
- Most live and inactivated vaccines can be administered simultaneously on the same day or same visit
-Live vaccines can be given on same day, but IF NOT then space 4 weeks apart - No, but it delays complete protection and can interfere with antibody response
-do NOT shorten interval (inadequate antibody response) - 3 months; 11 months; 2 weeks
Timing of Vaccines
1. Why are most LIVE vaccines held until a child is 12 months of age?
- What is the issue with tuiberculin skin tests (TSTs) and live vaccines? What can be done to resolve this?
- When are antibody products recommended to give simulataneously to vaccines?
- Maternal antibodies reduce infant’s response to vaccines (exception: rotavarius - shown to be effective despite prescence of maternal antibodies) –> inactivated vaccines given at 2 months or older except HepB
- Live vaccines can give false negative TST results. Reduce risk by
-Giving live vaccine on same day as TST (antibodies won’t form quick enough)
-Waiting 4 weeks after live vaccine to perform TST
-Administer TST first and wait at least 24 hours after reading test to give live vaccine. - Postexposure prophylaxis of certain diseases (ex. hepatitis A and B, rabies, and tetanus)
Vaccine Adverse Reactions:
1. Patients should be screened for precautions and CIs pior to vaccine administration and then monitored for at least _____ minutes post vaccination. If an adverse event occurs, it should be reported to _________ and __________.
- Define: local vs. systemic reactions
- Allergic reaction management
- 15 minutes; pt’s HCP; FDA’s Vaccine Adverse Event Reporting System (VAERS)
2.
-Local rxns: common reactions that occur near injection site (pain, swelling, redness)
-Systemic rxns: fever, maliase, myalgia, HA, loss of appetite, or mild ilness similar to disease being prevented (live vaccines: mild systemic rxns can occur 3-21 days after; intranasal flu vaccine can replicated cold-like symptoms)
3.
-Record all vital signs and administered medications
-Minor allergic rxn (swelling, pruritus): diphenhydramine, hydroxyzine
-Major allergic rxn (swelling of mouth/throat, difficulty breathing, wheezing, abdominal cramping, hypotension/shock): aqueous epinephrine 1mg/ML (1:1000 dilution) IM or 0.01mg/kg (max dose: 0.5mg) –> pharmacies should have at least three adult (0.3mg) auto-injectors administered Q5-15 minutes, call 911
-Place pt in supine position (flat on back) unless difficulty breathing (can elevate heard); if low BP, elevate legs only
CIs and Precautions to ALL vaccines
CIs: severe allergic rxn to vaccine or vaccine component after previous dose
Precautions: illness (mild: give vaccine and CAN when pt receiving ABXs; moderate/severe: delay vaccine until improvement)
CIs and Precautions to Live Vaccines
-CIs: pregnancy (do NOT attempt to become pregnant until 4 weeks after receiving vaccine), immunosuppression
-Precautions: recent administration of antibody-containing blood product
CI and Precautions to Diphtheria, tetanus, and pertusis vaccines
-CIs (pertussis-containing vaccines): encephalopathy that is NOT attributable to another cause within 7 days after receving a previous pertussis-containing vaccine
-Preacuations: guillain-barre syndrome (GBS) within 6 weeks of previous diphtheria, tetanus, and pertussis vaccine (for DTaP and Tdap only: infantile spasms, uncontrolled seizures)
CI to HepB / HPV Vaccines
hypersensitivity to yeast
CIs to Live Attenuated Influenza Vaccines (LAIV4)
- Pregnant
- Immunosuppressed
- Use of ASA-containing products (children and adolescents)
- Recent use of influenza antiviral medications (oseltamivir and zanamivir within past 48 hours, permaivir within 5 days, or baloxavir within last 17 days)
- Children age 2-4 yo w/ asthma or wheezing episode in past 12 months
- Close contact w/ immunocompromised person
Precautions to Influenza Vaccines
-ALL: hx of guillain-barre syndrome (GBS) within 6 weeks of previous influenza vaccination
-LAIV4: asthma in any pt >/= 5yo, underlying conditions that predispose to influenza complications (ex. chronic lung, heart, renal, hepatic, neurologic, hematologic, and metabolic disorders including DM)
Precautions to RSV Vaccine
pregnancy and breastfeeding - consider delaying vaccine
CIs and Precautions to Varicella Vaccine
-CIs: hx of severe allergic rxn to gelatin or neomycin
-Precaution: use of acyclovir, famiciclovir, or valacyclovir in past 24 hours before vaccination - avoid antivirals after 14 days of vaccination
CIs and Precautions to Rotavirus Vaccine
-Cis: hx of intussusception (part of intestine slides into adjacent intestine part, blocking fluids/food)
-Precautions: chronic GI disease
CI to Yellow Fever Vaccine
severe allergic rxn to eggs
What is a consideration of latex allergies with vaccines?
Latex on vial stoppers or prefilled syringes (CI): latex allergy that results in severe rxns (most sensitivities do NOT prohibit vaccine administration)
Recommended vaccinations/schedules for: Infants and Children
At birth: 3-dose hepatitis B, RSV (if mother NOT vaccinated during pregnancy)
Started at 2 months: PCV15 or PCV20, DTaP, Hib, polio, rotavirus
Start at 12 months or older: live vaccines
Polysaccharide vaccines: NONE before age 2 yo
Recommended vaccinations/schedules for: Adolescents and Young Adults
Tdap: first dose at 11-12 yo
HPV: recommended at age 11-12 yo, 2-3 doses depending on age at start
Meningococcal quadrivalent vaccine (MenACWY) - Menveo or MenQuadfi
-2 dsoes: 1 dose at age 11-12 yo and 1 dose at 16 yo
-First-year college students in residential housing (if NOT previously vaccinated): 1 dose
Recommended vaccinations/schedules for: Healthcare Providers
- Annual influenza vaccine - often required by employers
- HepB, varicella, and MMR - if NO demonstrated immunity (via vaccination hx or blood test)
Recommended vaccinations/schedules for: Sickle cell disease and other causes of asplenia
- H. influenzae type b (Hib) vaccine
- Age 19-64 yo: Pneumococcal either PCV20 x1 OR PCV15 then PPSV23 8 weeks later
- MenACWY and MenB
Recommended Vaccinations in Immunodeficiency
-Who counts as immunodeficient?
- Age 19-64 yo: PCV20 x1 OR PCV15 then PPSV23 8 weeks later
- Age 19 yo and older: Shingrix 2 doses 2-6 months apart
- HIV:
-MenACWY
-Hepatitis A and B
-Hib?
Immunodeficiency:
-Chemotherapy/bone marrow transplants drugs
-Strong immunosuppressant drugs for autoimmune conditions or cancer
-HIV w/ CD4 count <200cells/mm3 (AIDS)
-Transplant pts taking immunosuppressant drugs
-Systemic steroids >/=14 days (does NOT include inhaled, topicals, or intrarticular) at >/=20mg or 2mg/kg predinisone daily or equivalent
Recommended Vaccines in Pregnancy
- Inactivated influenza vaccine in any trimester
- RSV vaccine at weeks 32-36 during RSV season
- Tdap x1 with each pregnancy during weeks 27-36
Recommended Vaccines in Older Adults
- Age 50 yo and older: Shringrix 2 doses 2-6 months apart
- Age 65 yo and older: PCV20 x1 OR PCV15 then PPSV23 12 months at least later
Recommended Vaccines in DM
- Age 19-64 yo: PCV20 x1 OR PCV15 then PPSCV23 12 months or later (>/=8 weeks if immunocompromised)
- Age 60 and older: hepatitis B if not previously vaccinated
Route Vaccination schedule for Adults: Influenza and Tetanus
Influenza: annually
Tetanus: Tdap Q10 years
Routine Vaccination Schedule for Adults: Shingles
Age 50 yo and older (immunosupressed or expected to be immnosupressed: 19 yo and older)
-Two doses 2-6 months apart (can shorten to 1-2 months if immunocompromised)
-Vaccine even if hx of chickenpox or shingles or received Zostavax (wait at least 8 weeks)
Routine Vaccination Schedule for Adults: HPV
26 yo or younger who did NOT complete series (up to 45 yo w/ clinical decision making)
Routine Vaccination Schedule for Adults: Meningococcal
-Serogroup B (MenB: Bexsero, Trumenba): give if complement component deficiency, taking eculiziumab or ravulizumab, asplenia, microbiologist w/ exposure to N. meningitidis, serogroup B meningococcal disease outbreak exposure
-Quadrivalent conjugate (MenACWY: Menveo, MenQuadfi): same groups as MenB + HIV, travelers/residents to countries in which disease is common, military recruits, first-year colege students in living in residential housing, if NOT up-to-date
Routine Vaccination Schedule for Adults: Pneumocococcal
Age 65 yo and older (specific medical condition: age 19-64 yo)
-If never received: PCV20 x1 OR PCV15 then PPSV23 12 months or more later (>/=8 weeks if immunocompromised)
Routine Vaccination Schedule for Adults: Hepatitis B
If NOT previously vaccinated, all adults 19-59 yo (risk factors: 60 yo and older)
-Risk factors: chronic liver disease, HIV, exposure via sexual activitiy, IV drug use, incarcerated, travel to an endemic area, blood exposure (healthcare personnel, DM, dialysi)
-Give alone or with hepatitis A (Twinrix)
Routine Vaccination Schedule for Adults: Hepatitis A
Adults traveling to endemic area, household members or close contacts of adopted children newly arriving from countries w/ moderate-high infection risk, liver disease, hemophilia, men who have sex with men, illict drug use. homeless, HIV
COVID-19 Vaccine:
-Available formulations
-Storage requirements
-Administration (IM or SQ?)
-Vaccine schedule
Available as:
-mRNA vaccines: Comirnaty (Pfizer-BioNtech), Spikevax (Moderna)
-protein subunit vaccine: Novavax COVID-19
Storage: varies per product
Administration: IM
Schedule: age 12 yo and older (immunocompromised: <12 yo –> for schedule, see CDC)
-If previously unvaccinated: 1 dose of Moderna or Pfizer or 2-dose series of Novavax (given at 0 and 3-8 weeks)
-If previously vaccinated: 1 dose of any vaccine at least 8 weeks after most recent vaccine
-Pts should receive the updated formulations of the vaccine designed to protect aginst most likely circulating variants
Diphtheria Toxoid, Tetanus-toxoid, and acellular Pertussis-containing Vaccines:
-Available formulations
-Difference between DTaP and Tdap or Td
-Storage requirements
-Preparation requirements
Available formulations:
-DTaP: Daptacel, Infanrix
-DTaP-IPV: Kinrix, Quadracel
-DTaP-HepB-IPV: Pediatrix
-DTaP-IPV / Hib: Pentacel
-DTaP-IPV-Hib-HepB: Vaxelis
-Td: Tenivac, TDVax
-Tdap: Adacel, Boostrix
Differences:
-DTaP: pediatric formulations with 3-5 times more diphtheria than adult formulations
-Tdap or Td: adult formulations with lower-case d
Storage: refrigerator
Preparation: shake vial or prefilled syringe before use
Diphtheria Toxoid, Tetanus-toxoid, and acellular Pertussis-containing Vaccines:
-Administration (IM or SQ?)
-Routine Vaccine schedule
-When to give additional doses of tetanus
Administration: IM
Schedule:
-DTaP (for under 7 yo): routine series of 5 doses at age 2, 4, 6, 15-18 months and 4-6 years
-Td or Tdap: booster given at age 11-12 yo; adults: routine booster Q10 years
Additional doses:
1. Each pregnancy to prevent pertussis in infants <2 months
2. Close contacts of infants younger than age 12 months if NOT up-to-date
3. Healthcare personnel with direct pt contact if NOT up-to-date
4.* Wound prophylaxis if deep or dirty wounds that it has been more than 5 years since last dose –> tetanus immunoglobulin (TIG) may be required if NO previous tetatnus vaccines have been given)*
Haemophilus influenza Type B (Hib)-containing vaccines:
-Available formulations
-Storage requirements
-Preparation requirements
-Administration (IM or SQ?)
-Vaccine schedule
Available as:
-Hib: ActHIB, Hiberix, PedvaxHIB
-DTaP-IPV / Hib: Pentacel
-DTaP-IPV-Hib-HepB: Vaxelis
Storage: refrigerator –> do NOT freeze
Preparation: shake vial or prefilled syringe before use
Administration: IM
Schedule:
-Hib: routine childhood vaccine given between ages 2-15 months
-AcHIB and Hiberix are a 4-dose series, PedvaxHIB is a 3 dose series
-Given to adults with asplenia
Hepatitis-containing vaccines:
-Available formulations
-Storage requirements
-Preparation requirements
-Administration (IM or SQ?)
-Vaccine for dialysis pts
Available as:
-Hepatitis A: Havrix, Vaqta
-Hepatitis B: Engerix-B (adults and pediatrics), Heplisav-B (adults), Recombivax HB (adults and pediatrics), PreHevbrio (adults)
-DTaP-HepB-IPV: Pediarix
-DTaP-IPV-Hib-HepB: Vaxelis
-Hepatitis A and B: Twinrix
Storage: refrigerator –> do NOT freeze
Preparation: shake vial or prefilled syringe before use
Administration: IM
Dialysis pts: high-dose Recombivax HB (40mcg/mL)
Hepatitis A: Vaccine Schedule
-Children: routine schedule of 2 doses at age 12-23 months with iminimal interval between doses of 6 months
-Adults: men who have sex with men, illicit drug use, chronic liver disease, homeless, HIV, travelers to endemic area, anyone who wants
Hepatitis B: Vaccine Schedule
-Children: routine schedule of 3 doses at age 0 (starting within 24 hours after birth) 1-2, and 6-18 months
-Adults (if NOT previously vaccinated): age 19-59 yo or 60 yo and older w/ risk factors (chronic liver disease, HIV, blood exposure - healthcare workers, DM, dialysis), IV drug use, sexual exposure risk (men who have sex with men, multiple partners), incarcerated, traveling to endemic area
-Energix-B, Recombivax HB, and PreHevbrio: 3 dose series given at months 0, 1, and 6 (can be completed in 4 months if necessary, but may require booster at 1 year)
-Heplisav-B: 2 dose series given at months 0 and 1
Combined Hepatitis A and B: Vaccine Schedule
3 dose series at months 0, 1, and 6 (can be completed faster if needing tro travel to high-risk area)
Human Papillomavirus Vaccine:
-Available formulations
-Storage requirements
-Preparation requirements
-Administration (IM or SQ?)
-Vaccine schedule
-Cautions/CIs
-Purpose of vaccine
Available as: HPV9 (9-Valent) - Garasil 9
Storage: refrigerator –> do NOT freeze
Preparation: shake vial or prefilled syringe before use
Administration: IM
Schedule:
-Routine vaccination at age 11-12 yo (may be started at 9 yo - hx of sexual abuse and up to 26 yo - immunocompromised, men who have sex with men)
-If started before age 15 yo, 2 doses at months 0 and 6-12
-If started at age 15 yo and older or immunocompromised: 3 doses at months 0, 1-2, and 6
Cautions/CIs:
-Caution: fainting (though incidence is similar to other vaccines) –> administered to seated pt and monitor after vaccination
-CI: severe yeast allergy
Purpose: prevents cervical, vulvar, vaginal, oropharyngeal, penile, and anal cancers and genital warts
Influenza Vaccines:
1. Annually for all pts ________ and older
- Give two doses if age _____ to ______ and NOT previously vaccinated. Give these two doses ________ days apart.
- Recommendations in pts with egg allergy
- 6 months
- 6 months-8 yo; 28 days
- Even in severe allergy, can receive any age-appropriate vaccine –> no additional observation period required beyond the 15 minutes
-Egg-free products: Flublok (18 yo and older) and Flucelvax (age 6 months and older)
Influenza Vaccines:
1. Recommendations in pregnancy
- Recommendations in pts 65 yo and older
- Influenza A subtype vaccines are based on ________.
- Can receive any age-appropriate inactivated influenza vaccine –> do NOT aminister live vaccine (FluMist)
- Preferred: Fluzone High-Dose, Fluad, or Flublok
- Surface antigens (hemagglutinin, neuraminidase)
Quadrivalent Inactivated Influenza Vaccines (IIV4):
Vaccines for 6 months and older
-Which ones are egg-free?
Afluria, Fluarix, FluLaval, Fluzone
Egg-free: Flucelvax (grown in cell culture, ccIIV4)
Quadrivalent Inactivated Influenza Vaccines (IIV4):
Vaccines for age 18 years and older and 65 years and older
-Which ones are egg-free?
-Age 18 yo and older, egg-free: Flublok (recombinant, RIV4)
-Age 65 yo and older: Fluzone High-Dose, Fluad
Quadrivalent Inactivated Influenza Vaccines (IIV4):
-Storage requirements
-Preparation requirements
-Administration (IM or SQ?)
-Vaccine schedule
-What does quadrivalent cover?
Storage: refrigerator –> do NOT freeze
Preparation (Afluria): can be given w/ a needle-free jet injector
Administration: IM
Schedule: annually given as soon as available (prefereably before October, but can be vaccinated later –> outbreaks usually peak in February)
Covers: two different influenza As and two different Influenza Bs
Quadrivalent Live Attenuated Influenza Vaccine (LAIV4):
-Available formulations (age indicated)
-Storage requirements
-Administration
-CIs
Available as: FluMist for healthy individuals 2-49 yo
Storage: refrigerator –> do NOT freeze
Administration: intranasal as 0.2mL divided between two nostrils
CIs:
-Pregnancy
-Immunocompromised
-Recently taken influenza medications (oseltamivir or zanamivir within 48 hours, peramavir in past 5 days, or baloxavir in past 17 days)
Measles, Mumps, and Rubella-Containing Vaccines:
-Available formulations (type)
-Storage requirements
-Administration (IM or SQ?)
-Vaccine schedule
-CIs
Available as: LIVE attenuated
-MMR: M-M-R II, Priorix
-MMRV (MMR + Varicella): ProQuad
Storage:
-Refrigerator: Priorix, diluents (or at room temp)
-Freezer: ProQuad (due to varciella component)
-M-M-R II: refrigerator or freezer
Administration: SQ (M-M-R II and ProQuad may be given IM)
Schedule:
-Children: routine 2 dose series at 12-15 months and 4-6 years (ProQuad: for age 12 months - 12 years)
-Adults: 1 dose if NO evidence of immunity (adults born before 1957 are considered immune generally)
-Give 1-2 doses 4 weeks apart if NO evidence of immunity in: healthcare workers, HIV w/ CD4 count >/=200 cells/mm3 for at least 6 months, nonpregnant pts of childbearing age w/ no evidence of immunity to rubella, international travelers, household contacts of immunocompromised people and students in postsecondary educational institutions
Is: pregnancy or immunocompromised
MenACWY (Quadrivalent Meningococcal) Vaccines:
-Available formulations
-Storage requirements
-Preparation requirements
-Administration (IM or SQ?)
Available as:
-Age 2 yo and older: MenQaudfi
-Age 2 months - 55 yo (can be 56 yo and older if needed): Menveo
Storage: refrigerator –> do NOT freeze
Preparation (Menveo):* both vials (powder and liquid) contain vaccine –> use only the supplied liquid for reconstitution*
Admnistration: IM
MenACWY (Quadrivalent Meningococcal) Vaccines:
-Routine Vaccine schedule
-Special populations to vaccinate
Routine vaccination: 2 doses at 11-12 years and 16 years
Special populations to vaccinate:
1. Travelers to certain countries (ex. African meningitis belt); proof of vaccination required for: Saudi Arabia for Haji and Umrah pilgrimages
- Two months and older w/ asplenia or sickle cell disease, HIV infection, complement component deficiencies, or use of eculizumab or ravalizumab
- Lab workers with N. meningitidis exposure
- First-year college students living in residential housing if not up-to-date
- Military recruits
*Number of dosease and timing will depend on age and specific risk –> ongoing risk should be revaccinated Q5 years
MenB Vaccines:
-Available formulations
-Storage requirements
-Preparation requirements
-Administration (IM or SQ?)
-Vaccine schedule
Available as:
-MenB: Bexsero, Trumenba
-MenABCWY: Penbraya (for age 10-25 yo when all serogroups indicated)
Storage: refrigerator –> do NOT freeze
Preparation (Penbraya):prefilled syringe contains MenB and vial contains MenACWY - use of both components required
Administration: IM
Schedule:
-Age 10 yo or older and high risk (asplenia/sickle cell disease, complement component deficiences or use of eculizumab or revalizumab, lab workers w/ N. meninigitidis exposure, during an outbreak):
-Bexsero or Penbraya 2 doses given 1 month apart
-Trumenba: 2 doses given 6 months apart (if high risk or during outbreak): 3 doses at 0, 1-2, and 6 months
-NOT at high risk: optional for those 16-23 yo who want vaccine (preferred in age 16-18 yo)
Pneumococcal Vaccines:
-Purpose
-Available formulations
-Storage requirements
-Preparation requirements
-Administration (IM or SQ?)
Purpose:
-Children: risk of common infections w/ S. pnuemoniae (ottitis media, pneumonia, meningitidis, and bloodstream infections)
-Also at risk: chronic conditions of altered immunocompetence
Available as:
-Conjugate vaccines: Prevnar 20 (PCV20), Vaxneuvance (PCV15)
-Polysaccharide vaccine: Pneuomovax 23 (PPSV23)
Storage: refrigerator –> do NOT freeze
Preparation: shake vial or prefilled syringe before use
Administration:
-PCV15, PCV20: IM
-PPSV23: IM or SC
Pneumococcal Vaccine Schedule
Children < 5 yo: PCV15 or PCV20 as 4 doses at 2, 4, 6, and 12-15 months
-PPSV23: <2 yo will NOT produce adequate antibody response, indicated in 2-18 yo after PCV15 or PCV20 series completion with select medical conditions
Adults age 19-64 yo with specific medical conditions OR 65 yo and older routinely
-Specific medical conditions: alcohol use disorder; cigarrette smoking; DM; chronic heart, lung, or liver disease; immunocompromised - chronic renal failure, asplenia/sickle cell disease, HIV, malignancy, solid organ trasnplant, immunosuppressive drugs
-PCV20 x 1 OR PCV15 followed by PPSV23 12 months later (>/=8 weeks if immunocompromised)
-Previously had PCV13 or PPSV23: consult CDC recommendatoins
Poliovirus-containing vaccines:
-Available formulations
-Storage requirements
-Preparation requirements
-Administration (IM or SQ?)
-Vaccine schedule
Available as: ONLY inactivated in US (other countries provide live oral vius)
-IPV: IPOL
-DTaP-IPV: Quadracel
-DTaP-HepB-IPV: Pediarix
-DTaP-IPV / Hib: Pentacel
-DTaP-IPV-Hib-HepB: Vaxelis
Storage: refrigerator –> do NOT freeze
Preparation: shake vial or prefilled syringe before use
Administration (IPV): IM or SC
Schedule: routine childhood vaccine series (4 doses at age 2, 4, 6-18 months and 4-6 yo)
Rotavirus Vaccines:
-Available formulations
-Storage requirements
-Administration
-Vaccine schedule
Available as: LIVE attenuated
-RSV1: Rotarix
-RSV2: RotaTeq
Storage: refrigerator –> do NOT freeze
Administration: PO
Schedule:
-Routine infant series: do NOT initiate after 15 weeks
-Rotarix: 2 doses at age 2 and 4 months
-RotaTeq: 3 doses at age 2, 4, and 6 months
Respiratory Syncytial Virus (RSV) Vaccines and Antibodies:
-Purpose
-Available formulations
-Storage requirements
-Preparation requirements
-Administration
Purpose: prevent RSV-associated lower respiratory tract disease during RSV season in high risk populations
Available as:
-RSV Vaccines: Abrysvo, Arexvy
-RSV Monoclonal Antibodies: nirsevimab (Beyfortus), palivizumab (Synagis)
Storage: refrigerator –> do NOT freeze
Administration: IM
Schedule (RSV Vaccines):
-Pregnant pts 32-36 weeks during RSV season (September-January): 1 dose of Abrsyvo to prevent RSV in infant <6 months old
-Adults 60 yo and older (double check CDC: lots of changes) at increased risk ((COPD< asthma, heart failure, kidney or liver disease, DM, immunocompromised, residence in long-term care facility 1 dose of Abrsyvo or Arexvy
Schedule (RSV Monoclonal Antibodies):
-Neonates and infants <8 months born during or entering first RSV season: 1 dose of nirsevimab (if mother NOT vaccinated during pregnancy)
-Palivizumab: reserved for premature infants and infants at highest risk of hospitalization due to RSV infection
Varicella Virus containing vaccines
-Available formulations
-Storage requirements
-Preparation requirements
-Administration (IM or SQ?)
-Vaccine schedule
-Cautions/CIs
Available as:
-Varicella (for chickenpox): Varivax –> LIVE vaccine
-MMRV: ProQuad
Storage (Varivax): freezer –> store diluent in refrigerator or rom temperature
Preparation (Varivax): reconstitute immediately upon removal from freezer and administer within 30 minutes
Administration: SC or IM
Schedule:
-Routine childhood vaccine of 2 doses at age 12-15 months and 4-6 yo
-Any adolescent or adult w/o evidence of immunity to varicella: give 2 doses four weeks apart
Cautions/CIs:
-CI: pregnancy, immunocompromised, hypersensitivity to gelatin or neomycin
-Some antivirals (ex. acyclovir, valacyclovir, famciclovir) can interfere w/ Varivax (live) –> stop 24 hours before vaccine administration and do NOT take for 14 days after vaccination
Zoster Virus Vaccine: Shingrix
-Storage requirements
-Administration (IM or SQ?)
-Vaccine schedule
Storage: refrigerator (along w/ adjuvant liquid) –> do NOT freeze
Administration: IM
Schedule:
-All adults 50 yo and older or adults 18 yo and odler who are or will be immunocompromised: 2 doses at 0 and 2-6 months (if immunocompromised: 2nd dose can be given at 1-2 months)
-Vaccinate even if pt has had received Varivax or Zostavax (wait at least 8 weeks - live vaccine no longer available) or hx of zoster infection since recurrence is possible
Miscellaneous vaccines:
1. The rabies vaccine, __________, may be given with post-exposure w/o previous vaccination along with one dose of __________.
- _________ is the oral live vaccine for typhoid which prevents typhoid fever caused by __________. The capsules should be stored _____________, and the dose should be finished at least ________ prior to travel. _________ is the inactivated polysacharide vaccine given IM.
- What is the main consideration with the Bacille Calmette-Guerin (BCG) vaccine?
- RabAvert; rabies immune globulin (RIG)
- Vivotif; Salmonella typhi; in the refrigerator; one week; Typhim Vi
- It is a live TB vaccine that can cause a positive rxn to the TB skin test.
Miscellaneous Vaccines:
1. Yellow fever vaccine (YF-VAX) is a _______(inactivated/live) vaccine that should be given ______(IM/SQ). How is the vaccine prepared?
- What is the main CI to YF-VAX? What is given after vaccination?
- Cholera vaccine (Vaxchora) is an oral _________(inactivated/live) vaccine that is for patients traveling to an active area of toxigenic __________.
- Live; SQ; reconstitute with provided diluent
- CI: severe allergy to eggs or gelatin; International Certificate of Vaccination (yellow card)
3 Live; Vibrio cholerae
Storage considerations with vaccines
- Keep earliest expiration date first to use
- Keep vaccines in original packaging until use
- Never place vaccines the in the doors of the freezer or refrigerator where temperature is unstable
- Measure refrigerator and freezer temperatures w/ buffered temperature probe and document at least twice each workday. Keep temperature log for three years (or longer as required by individual states).
Overview of vaccine storage:
-Most are stored in refrigerator –> 35F-46F (2C -8C)
-Freezer: varicella –> -58F - +5F (-50C - -15C)
-Diluents kept at room temp or in refrigerator
Vaccine Administration Technique
Never mix vaccines in syringe
IM: use 22-25 guage needle at 90 degree angle
-Needle length: 1 inch for most adults, males >260lb or females >200lbs: 1.5 inch
-Adults: inject into deltoid muscle above level of armpit and below shoulder joint
-Infants: inject into anterolateral mid-thigh muscle
SC: 23-25 guage needle, 5/8’’ in length at 45 degree angle
-Adults: inject into fatty tissue over triceps, pinch skin to prevent injection into muscle
-Infants: inject into thigh
Intradermal: also 90 degree angle, but given with autoinjector that has very small needle
General Traveler Considerations
- Travelers should have list of medical conditions and medications (Rx and OTC)
- Travel vaccinations should be documented on International Certificate of Vaccination or Prophylaxis (ICVP) sometimes called the “yellow card”
- Medications and medical supplies should be packed in carry-on luggage
- Assess need for disease prevention and vaccines though CDC on the yellow book (considerations: does disease spread through water and food, insects, or blood/bodily fluids?)
- Increased risk for DVT and PE from limited movement with long air travel - consider compression stockings, performing lower leg exercises when sitting, and standing up and walking
- Prevention of altitude sickness - acetazolamide started the day before in moving up high altitudes (AVEs: photosensitivity and polyuria, CI: sulfa allergy, recommend sun protection and hydration)
-Acute cases: oxygen, inhaled beta-agonists, dexamethasone - See healthcare provider after return from traveling
Traveler’s Diarrhea (TD):
-Transmission
-Primary pathogen
-What is dysentery TD?
-Prophylaxis (non-pharm)
-Treatment (non-pharm)
Transmission: through food and water
Primary pathogen: bacterial (E. coli)
Dysentery: blood is mixed in with stool often accompanied with systemic symptoms (classified as severe)
0rophylaxis (non-pharm):
-General rule of “boil it, cook it, peel it, or forget it”
-Eat food that is cooked and served hot; avoid food that has been sitting on a buffet
-Eat raw fruits and vegetables if washed in clean water or peeled
-Use bottled water or boil for approximately one minute before drinking or using to brush teeth; avoid ice
-Keep hands clean and out of mouth, water hands often or alcohol hand-sanitizer
Treatment (non-pharm):
-Hydration with increased fluid and salt intake (oral rehydration solution)
Traveler’s Diarrhea (TD): Pharmacological Therapy (Prophylaxis)
-Bismuth subsalicylate (BSS) in 13 yo and older (have been used in >3 yo w/ no recent or current viral infections): 524-1050mg PO QID with meals and at bedtime
-Avoid BSS in ASA allergy, pregnancy, renal insufficiency, gout, ulcer, or anyone taking anticoagulants, probenacid, or methotrexate
-Antibiotics: should NOT be used by most travelers except those at very high risk of complications or for performance reasons (ex. proferssional athelete) –> rifaximin preferred (alternative: azithromycin and rifamycin)
Traveler’s Diarrhea (TD): TX
-Mild TD: loperamide 4mg after first loose stool then 2mg after each (max: 16mg/day by Rx or 8mg/day by OTC for up to 2 days - if symptoms do NOT resolve, contact HCP) or BSS (loperamide preferred)
-Moderate TD: loperamide +/- antibiotics (low resistance: azithromycin or quinolone, alternative: rifaximin)
-Severe TD (including dysentery) antibiotics +/- loperamide (preferred: aztihromycin, alternative: quinolones or rifaximin)
-Rifaximin and rifamycin: cannot use when invasive pathogen suspected
Typhoid Fever:
-Transmission
-Pathogen
-Prophylaxis
Transmission: food or water contaminated by feces of someone with acute infectionor chronic asymptomatic carrier
Pathogen: Salmonella typhi
Prophylaxis:
-Safe food and water precautions
-Wash hands frequently
-Typhoid vaccines: only about 50-80% effective
-Vivotif (PO, live vaccine): complete 1 week or more before travel for 6 yo and older, revaccinated Q5 years
-Typhim Vi (IM, inactivated): complete 2 weeks or more before expected exposure for 2 yo and older, revaccinated Q2 years
Travel Dieases transmitted from water and food:
1. Cholera caused by ___________ often results in __________ (symptom) that is typically mild, but can be vaccinated against with __________ which is a single dose oral live vaccine that should be done at least ____ days before travel.
- Though most people in the US are vaccinated with polio in childhood, what are CDC recommendations for travel?
- _________ is a disease that has the highest risk of people traveling from developed countries to developing countries and can be vaccinated prior (though some experts advise against regardless of destination).
- Vibrio cholerae; rice-water stools; Vaxchora; 10 days
- Single lifetime booster dose of IPV at least 4 weeks prior to travel for adults have previously completed a poliovirus series and are traveling to a region where poliovirus is circulating
- Hepatitis A
*Which diseases are transmitted through bodily fluids and blood that should be considered with international travel? What the general recommendations for vaccine prophylaxis? *
Hepatitis B:
-Low risk in travelers that do not participate in high-risk behaviors
-Vaccination extremely important when traveler plans to receive medical care, volunteer to provide medical work, or have unprotected sexual encounters (also: obtaining piercings and tattoos)
-3-dose vaccine series can take 6 months to complete (if unable to obtain all three: receive as many doses before and complete upon return, high risk: accelerated series can be done and booster required in a year)
Meningococcal meningitis:
-Transmitted through respiratory secretions
-Vaccination recommended when traveling to area where N. meningitidis is hyperendemic or epidemic, particularly if spending a long time (high risk: meningitis belt of Africa during December-June)
-Saudi Arabia requires vaccine for traveling along Haji and Umrah pilgrimages
-Current recommendations with only Menveo and MenQuadfi; no recommendations for MenB use
Diseases transmitted via insect bites:
1. Insects that transmit disease are _______. What are the primary insects tha transmit disease?
- What are some strategies to avoid insect bites?
- _________ is a disease from mosquito bites often in the timeframe where populations are high during rainfall that can cause severe bleeding and organ failure, and treatment is mostly supportive.
- Japanese encephalitis is an often asymptomatic disease that causes swelling around the brain. The ______ vaccine is recommended when travelers are planning exposure to outdoors or spending at least one month in endemic area during transmission season.
- Vectors; mosquitoes (transmit: Japenese encaphalitis, yellow fever, dengue, malaria, and Zika virus)
- -Stay and sleep in screened or air-conditioned rooms and use bed net which can be pre-treated w/ mosquito repllent
-Cover exposed skin with long-sleeved shirts, long pants, and hats
-Use mosquito repellant consisting of DEET on exposed skin which also covers ticks (covers only mosquitos: picaridin, oil of lemon, eucaltyptus, or IR3535) –> apply sunscreen then repellant
-Use permethrin to treat clothing, gear, and bed nets, but do NOT apply directly to skin
- Dengue
- Ixiaro
*Malaria: *
-Transmission
-Primary pathogen and most deadly pathogen
-Prophylaxis options and key considerations
Transmission: Anopheles mosquito
Primary pathogen: Plasmodium vivax
Most deadly pathogen: P. falciparum
Prophylaxis: QD regimens initiated 1-2 days prior to travel
-ALL: avoid in pregnancy, and causes nausea (take CF, milk, or water)
-Doyxycline (Doryx, Vibramycin): also prevents rickettsial infections and leptospirosis (preferred in hiking/camping), avoid in children <8 yo
-Atovaquone/proguanil (Molarone): avoid in breastfeeding, severe renal impairment
-Primaquine: most effective for P. vivax, strop 1 week after travel, avoid in G6PD deficiency (required screening before) and breastfeeding (unless infant tested for G6PD deficiency)
Prophylaxis: weekly regimens initiated 1-2 weeks prior to travel
-ALL: safe in children and pregnancy, choice depends on resistance in region
-Chloroquine: resistance issues w/ P. falciparum and P. vivax, stop 4 weeks after travel, AVEs of retinal toxicity and visual changes, avoid in areas of chloroquine or mefloquine resistance
-Mefloquine: start >2 weeks before travel; stop 4 weeks after travel, avoid in underlying psychiatric conditions, seizures, arrhythmias, and areas of mefloquine resistance
-Tafenoquine: may be used for up to 6 months; avoid use in G6PD deficiency (requires testing prior), breastfeeding (unless infant tested negative for G6PD), or underlying psychiatric conditions
Yellow Fever:
-Transmission
-Prophylaxis
-Treatment
Transmission: mosquitoes
Prophylaxis:
-Reducing mosquito exposure
-YF-VAX (live attenuated vaccine) prior to travel for high risk (due to serious side effects: yellow-fever vaccine-associated neurological disease)–> pt should receive ICVP (“yellow card”) which is valid 10 days after date of vaccination; single dose provides lifetime protection; CI in severely immunocompromised or hypersensitivity to egg
Treatment:
-No specific TX except symptomatic relief with fluids, analgesics, and antipyretics
-NSAIDs ans ASA cannot be used due to increased risk of bleeding (in severe cases, yellow fever can cause hemorrhage)
Zika Virus:
-Transmission
-Main concerns
-Prophylaxis
Transmission: mosquitos, possibly sexual and blood transfusion-associated
Main concern: disease itself usually asymptomatic or mild –> infants can be born with microcephaly causing significant disability and many birth defects of brain, eyes, hearing, and impaired growth
Prophylaxis:
-NO vaccine
-Avoiding mosquito bites
-Condoms during sexual contact
-CDC recommends pregnant women NOT traveling to any area with ongoing Zika Virus
