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Immunizations - PPT Presentation

Micah Pippin Lecture 8 National Vaccine Immunization Program One of the most successful examples of effective preventive care in the United States Example Since introduction of Hib conjugate vaccines in December 1987 the number of cases of invasive ID: 618662

dose vaccine hepatitis years vaccine dose years hepatitis tetanus receive influenza varicella age pneumococcal mmr pertussis received year recommended

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Slide1

Immunizations

Micah Pippin

Lecture #8Slide2

National Vaccine Immunization Program

One of the most successful examples of effective preventive care in the United States

Example: Since introduction of

Hib

conjugate vaccines in December 1987, the number of cases of invasive

Haemophilus

influenzae

type b in children younger than 5 has decreased 99 %

Immunization guidelines are revised and updated continuously by:

Center for Disease Control and Prevention (CDC)

Advisory Committee on Immunization Practices (ACIP)

Committee on Infectious Disease of the American Academy of Pediatrics (AAP)

American Academy of Family Physicians (AAFP)

American College of Obstetrics and Gynecology (ACOG)Slide3

Vaccination Coverage

In 2012 among individuals 19 to 35 in the United States

Diphtheria-tetanus-pertussis – 94 %

Poliovirus – 93 %

Hib

– 93 %

MMR – 91 %

Hepatitis B – 90 %

Varicella – 90 %

Pneumococcal conjugate vaccine – 92 %

Hepatitis A – 53 %

Rotavirus – 69 %Slide4

Thimerosal Controversy

In 1999, concern about

thimerosal

, a mercury based preservative in vaccines, led to the proposal that all childhood vaccines be produced without this preservative

Recommendation also made to delay Hepatitis B vaccine administration to 2-6 months of age

Despite availability of

thimerosal

free vaccines and recommendation to resume Hepatitis B vaccine administration to newborns, there has been a decline in its routine administrationSlide5

MMR And Autism

Andrew Wakefield study in the Lancet in 1998 began

controvery

10 of 13 authors have retracted the findings

In 2010, The Lancet retracted the study, citing ethical misconduct on the part of WakefieldSlide6

Adverse Event Reporting

Adverse events associated with vaccines should be reported to the United States Department of Health and Human Services via the Vaccine Adverse Events Reporting System (VAERS, telephone number 1-800-822-7967)

Vaccine specific reportable events include:

Tetanus – Brachial neuritis within 28 days

Pertussis – Encephalopathy or encephalitis within 7 days

MMR – Encephalopathy or encephalitis within 15 days

Rubella – Chronic arthritis within 6 weeks

Measles – Thrombocytopenic

purpura

within 7-30 days; vaccine-strain measles infection in an

immunodeficient

recipient within 6 months of measles vaccination

Oral Polio – Paralytic polio or vaccine-strain polio within 30 days to 6 months (this vaccine is no longer used for routine childhood immunizations

Rotavirus – Intussusception within 30 days of rotavirus immunizationSlide7

Pain Control

Several

nonpharmacologic

and pharmacologic options alone or in combination are effective in reducing injection pain

Infants

Oral sucrose

Breastfeeding during administration

Swaddling and Pacifiers

Small randomized trial suggests that the order of administration may affect pain in infants

DTaP

Hib

combination vaccine before PCV associated with less pain than administration in the reverse order

Older children

Nonpharmocologic

Breathing exercises

Distraction techniques

Stroking or rocking

“Blowing away the pain”

Pharmocologic

Topical anesthetics 30 to 60 minutes before injection

Oral analgesics before or after administration (acetaminophen, ibuprofen)Slide8

Prophylactic Acetaminophen

Pain and fever associated with vaccination can be attenuated by administration of acetaminophen; however, this practice may be associated with decreased vaccine response

Evaluated in multicenter, open-label trial with 459 infants randomly assigned to receive acetaminophen or no prophylaxis

Fewer children who received acetaminophen had fever >38 but no difference in children with fever >39.5 or requiring medical attention

Vaccines were highly immunogenic in both groups

96 % of children achieved protective levels of antibody for all antigens

Acetaminophen was associated with lower geometric mean antibody titers (GMT) to:

Pneumococcus

Hib

Pertussis

Diphtheria

TetanusSlide9

Hepatitis B

250,000 people in the US contract Hepatitis B virus each year

More than one million have chronic liver disease and hepatocellular carcinoma

Incidence of contracting HBV increases during adolescence

Acquisition of HBV at a younger age is associated with an increased probability of developing:

Chronic HBV infection

Cirrhosis

Hepatocellular Carcinoma

Transmitted from exposure to contaminated blood, sexual intercourse, and vertically from mother to infant at the time of deliverSlide10

Hepatitis B

HBsAg

-negative mother

Administered in 3 doses at birth, at 1 to 2 months, and 6 to 18 months

Birth dose must be monovalent

If baby weighs more than 2000 grams can receive vaccine at 1 to 2 months, 4 months, and 6 to 18 months

Adults and

immunocompetent

children do not need booster or routine serologic testing

HBsAg

-positive mother

Should receive Hepatitis B immune globulin shortly after birth

Should be immunized with monovalent

Hep

B vaccine within 12 hours of age

Mother’s

HBsAg

status unknown

Should receive first dose of

Hep

B vaccine at birth

If mother is subsequently found to be positive, the infant must be given HBIG non later than one week after birthSlide11

MMR Vaccine

Measles

Acute infection characterized by fever, cough,

coryza

, conjunctivitis, rash, and

enanthem

that may be followed by severe complications including encephalitis

Mumps

Acute self limited viral syndrome

Principally in school children before the widespread use of vaccine

Rubella

German measles, a generally mild infection with a characteristic rash that can affect both children and adults

Can cause significant birth defects if occurs early in fetal lifeSlide12

MMR Vaccine

First dose at 12 to 15 months of age

Second dose at school entry and by 11 to 12 years of age if not previously administered

Children traveling outside the US should receive MMR vaccine earlier than it is routinely recommended

Women who are vaccinated with MMR should be advised to avoid pregnancy for at least 28 days after vaccination

HIV infection

Not severely

immunocompromised

Two doses should be administered

Severely

immunocompromised

Remains controversial

If at risk for measles exposure during an outbreak, the choice between measles vaccination and immune globulin prophylaxis should be consideredSlide13

Varicella Vaccine

Varicella-zoster virus is responsible for varicella (chickenpox) and herpes zoster (shingles)

Added to list of standard vaccines in 1995

Before its use, an estimated 37 million cases of chickenpox occurred in the US annually, resulting in nearly 9000 hospitalizations and 100 deathsSlide14

Varicella Vaccine

2 doses recommended at 12 to 15 months of age and at 4-6 years of age

Can be administered early if varicella outbreak

15 to 20 percent of children who have received one dose of VZV may develop chicken

pox

Evidence of immunity includes the following:

Documentation of age-appropriate vaccination with varicella vaccine

Laboratory evidence of immunity or laboratory confirmation of disease

Birth in the US before 1980

Diagnosis or history of varicella disease by a healthcare provider

Diagnosis or verification of history of herpes zoster by a healthcare providerSlide15

Varicella and Glucocorticoids

The recommended interval between discontinuation of high-dose systemic glucocorticoids and varicella vaccination depends on the duration of glucocorticoid therapy

If glucocorticoids have been administered for <14 days, do not need to delay varicella vaccine

If glucocorticoids have been administered for >14 days, the recommended interval is one month

Prospective open-label study of 274 children found no association between vaccine failure and asthma or the use of inhaled glucocorticoidsSlide16

Pneumococcal and Meningococcal

Pneumococcal

Leading cause of bacterial pneumonia worldwide and a principle cause of sepsis and meningitis, particularly in infants and children younger

The pneumococcal conjugate vaccine was added to recommended childhood immunization schedule in 2001

Discussed further in review questions

Meningococcal

Meningococcal vaccines protect against one or more

serogroups

of Neisseria

Meningitidis

Discussed further in review questionsSlide17

Hepatitis A Vaccine

Nearly 60 % of viral hepatitis cases in the US are caused by hepatitis A virus

Pediatric

Daycare settings where fecal-oral transmission is common

Manifestation in children younger than 5 tend to be relatively mild

Adult

Manifest more significant signs and symptoms of illness than children

Advantage to immunizing children is the reduction of transmission to adult household contacts

Universal HAV immunization of all children 12 to 23 months of age is recommended by the CDC and AAP

Dosing 1-18 years: two doses at least six months apart

Dosing >19 years: two doses administered 6 to 18 months apart

Also recommended for specific high risk groups including:

International travelers

Close contacts of newly arriving international adoptees

Persons with clotting factor disorders

Patients with chronic liver disease

Males with homosexual activity

Injecting/non-injecting drug users

People living in communities with HAV outbreaksSlide18

HPV Vaccine

Recommended for:

Girls beginning at 11-12 years of age

Girls and women ages 13-26 years of age who have not received or completed the vaccine series

Boys beginning at 11-12 years of age

Boys and men ages 13-21 years of age who have not received or completed the vaccine series

May be given to men up to 26 years of age

Reduces the likelihood of acquiring anal/genital warts and may reduce the risk of anal cancer in malesSlide19

Question 1

Julie

is a nineteen year old first-year college student who will be living in a dormitory this fall. She presents to you in August. In the state where she lives, colleges require that her vaccinations are "up to date." You review her medical record and find that she had 5 doses of DTP, 5 doses of oral poliomyelitis vaccine, and 1 dose of MMR prior to age 5 years. Her medical history also includes Chlamydia cervicitis that she contracted from her boyfriend last year. Although it is not noted in her medical history, she states that her mother told her she had chickenpox when she was 3 years old.

What vaccine(s), if any, should Julie receive

?

Hepatitis A

Hepatitis B

Human Papilloma Virus

Meningococcal

Varicella

Zoster

Pneumococcal

MMR

Tetanus/Diphtheria/Pertussis

Influenza

Tetanus/

Diptheria

Slide20

Answer 1

MMR

Two doses, on or after the first birthday

A second dose of measles containing vaccine is recommended for persons entering college

Tetanus/Diphtheria/Pertussis

Single booster dose. Later booster doses with Td, every 10 years

Adults 19-64 years of age should receive a single dose of

Tdap

to replace single dose of Td for booster immunizations against tetanus, diphtheria, and pertussis if it has been 10 or more years since they received their last dose of tetanus toxoid-containing vaccine.

Tdap

may be given at an interval as short as 2 years since the last Td dose if protection against pertussis is needed. Shorter intervals may be used

Hepatitis B

Three dose series

Timing - 0,1,6 months, 0,2,4 months, 0,1,4 months

Recommended for persons who have recently acquired an STI

Meningococcal

One dose

First-year college students who live in dormitories are at a higher risk of meningococcal disease than other college students and should be vaccinated with one dose of meningococcal vaccine

HPV

3 dose given over 6 months

HPV vaccine is recommended for females 13-26 years of age who previously have not received vaccine. HPV vaccine protects against infection that could lead to cervical cancerSlide21

Question 2

James

is a 40 year old heterosexual African-American social worker who comes to your office in November for a check up. He is beginning a new job at a medical clinic that cares primarily for HIV infected patients. He does not expect to be exposed to blood or body fluids, but he will be working closely with patients. His medical record shows that he has had 1 dose of MMR, 5 doses oral polio, and received his most recent Td booster 5 years ago. He reports that he has never had chickenpox. He has no current medical problems.

What vaccine(s), if any, should James receive?

Hepatitis A

Hepatitis B

Human Papilloma Virus

Meningococcal

Varicella

Zoster

Pneumococcal

MMR

Tetanus/Diphtheria/Pertussis

Influenza

Tetanus/

Diptheria

Slide22

Answer 2

MMR

2 doses for at risk adults

A second dose of measles containing vaccine is recommended for individuals who work in healthcare facilities. Persons with HIV are at particular risk for complications from measles, so one additional dose of MMR is indicated for healthcare personnel working with HIV infected persons

Hepatitis B

Three doses

Recommended for persons with occupational risk of exposure to blood or blood-containing body fluids

Influenza

One dose annually in the fall

Seasonal influenza vaccine should be offered to persons working with patients, such as

immunodeficient

persons, who are at risk for serious complications from influenza

Tdap

Single booster dose. Later booster doses with Td, every 10 years

Health-care personnel who work in hospitals or ambulatory care settings and have direct patient contact should receive a single dose of

Tdap

as soon as feasible if they have not previously received

Tdap

. The interval can be as short as 2 years from the last Td. Shorter intervals may be used

Varicella

2 doses, 4-8 weeks apart

Healthcare worker who lack evidence of immunity should receive the varicella vaccine. Evidence of immunity includes:

Documentation of vaccine

History of disease

Laboratory evidence of immunity

Laboratory confirmation of disease

History of herpes zosterSlide23

Question 3

Kim is a 65 year old Asian man presenting for his annual physical in October. He reminds you that it is the five year anniversary of his kidney transplant. His medical record shows that he received Td and pneumococcal vaccine 5 years ago, just prior to his transplant operation, and influenza vaccine last year

.

What vaccine(s), if any, should Kim

receive?

Hepatitis A

Hepatitis B

Human Papilloma Virus

Meningococcal

Varicella

Zoster

Pneumococcal

MMR

Tetanus/Diphtheria/Pertussis

Influenza

Tetanus/

Diptheria

Slide24

Answer 3

Pneumococcal

1 dose. Revaccination once is recommended for persons at high risk provided 5 years have elapsed since receipt of the first dose

Immunocompromised

adults who are at highest risk of pneumococcal disease or its complications (i.e., patients with

nephrotic

syndrome, renal failure, or organ transplants) should receive a second dose of the vaccine 5 years after receiving the first dose. Also, all persons 65 years of age and older should receive pneumococcal vaccine if unvaccinated. Those who receive pneumococcal vaccine prior to age 65 should receive a one-time revaccination at least 5 years after the first dose

Influenza

One dose annually in fall

Seasonal influenza vaccine should be given to all adults

Zoster

One dose

The herpes zoster (shingles) vaccine is recommended for adults 60 years of age and olderSlide25

Question 4

Marguerite, a 58 year old Caucasian woman, presents to your office in November complaining of a persistent cough. As you take a history from her, you learn that she smokes 1 ½ to 2 packs of cigarettes per day and reports a history of alcoholism. She remembers having received a shot 3 years ago during a visit to the emergency room when her "pancreas was acting up," but cannot remember what the shot was.

What vaccine(s), if any, should Marguerite receive

?

Hepatitis A

Hepatitis B

Human Papilloma Virus

Meningococcal

Varicella

Zoster

Pneumococcal

MMR

Tetanus/Diphtheria/Pertussis

Influenza

Tetanus/

Diptheria

Slide26

Answer 4

Influenza

1 dose, annually in fall

Immunocompetent

adults with chronic illnesses are at increased risk for influenza and its complications. All adults should receive a seasonal influenza vaccine each year in the fall

Cardiovascular

Pulmonary

Kidney

DM

Cirrhosis

Asthma

CSF leak

Tdap

Single booster dose. Later booster doses with Td, every 10 years

Adults, 19-64 years of age should receive a single dose of

Tdap

to replace a single dose of Td for booster immunization against tetanus, diphtheria, and pertussis if it has been 10 or more years since the last dose of tetanus toxoid containing vaccine.

Tdap

may be given at an interval as short as 2 years since the last Td does if protection against pertussis is needed. Shorter intervals may be used

Pneumococcal

One dose. Revaccination once is recommended for persons at higher risk provided 5 years have elapsed since receipt of the first dose

Immunocompetent

adults 64 years of age or younger with chronic illnesses or adults 19-64 years of age who have asthma or smoke cigarettes are at increased risk of pneumococcal disease and its complications and should receive a pneumococcal vaccine if they have not received one in the past. If history is unknown, they should be vaccinated. Slide27

Question 5

Dianne, a 35 year old African American woman with diabetes mellitus, comes to your office in October. She has just secured a job working at a pre-school. Her medical records show that she received MMR once and a complete series of diphtheria-tetanus-pertussis and polio vaccines as a child. The only vaccine she received since she was 5 was a Td booster at age 18. She could not remember whether she had chickenpox as a child, so you tested her sera for varicella antibodies: the results were negative. Although not pregnant now, she and her husband are planning on having a second child in a year.

What vaccine(s), if any, should Dianne receive?

Hepatitis A

Hepatitis B

Human Papilloma Virus

Meningococcal

Varicella

Zoster

Pneumococcal

MMR

Tetanus/Diphtheria/Pertussis

Influenza

Tetanus/

DiptheriaSlide28

Answer 5

Influenza

1 dose, annually in fall

Immunocompetent

adults with chronic illnesses are at increased risk for influenza and its complications. All adults should receive a seasonal influenza vaccine each year in the fall

Cardiovascular

Pulmonary

Kidney

DM

Cirrhosis

Asthma

CSF leak

Tdap

Single booster dose. Later booster doses with Td, every 10 years

Adults, 19-64 years of age should receive a single dose of

Tdap

to replace a single dose of Td for booster immunization against tetanus, diphtheria, and pertussis if it has been 10 or more years since the last dose of tetanus toxoid containing vaccine.

Tdap

may be given at an interval as short as 2 years since the last Td does if protection against pertussis is needed. Shorter intervals may be used

Pneumococcal

One dose. Revaccination once is recommended for persons at higher risk provided 5 years have elapsed since receipt of the first dose

Immunocompetent

adults 64 years of age or younger with chronic illnesses or adults 19-64 years of age who have asthma or smoke cigarettes are at increased risk of pneumococcal disease and its complications and should receive a pneumococcal vaccine if they have not received one in the past. If history is unknown, they should be vaccinated.

Varicella

2 doses, 4-8 weeks apart

U.S. birth before 1980 is considered evidence of immunity to varicella except for healthcare workers, pregnant women, and

immunocompromised

individuals. Since Dianne is a woman of childbearing age and has already had a serology test, which was negative for varicella, she should receive this vaccine. Slide29

Question 6

Sue, a 19 year old nursing assistant, comes to your office in October for a pre-employment physical, as required by the hospital where she will be employed. Sue’s medical history shows that she has diabetes mellitus. She received MMR once, and a complete childhood series of diphtheria-tetanus-pertussis,

Haemophilus

influenzae

type b, and polio vaccines. She received her last Td when she broke her arm at age 7. She states that she has never had chickenpox.

What vaccine(s), if any, should Sue receive

?

Hepatitis A

Hepatitis B

Human Papilloma Virus

Meningococcal

Varicella

Zoster

Pneumococcal

MMR

Tetanus/Diphtheria/Pertussis

Influenza

Tetanus/

Diptheria

Slide30

Answer 6

Influenza

Tdap

Pneumococcal

Has Diabetes

Hepatitis B

Occupational exposure to blood or blood-contaminated body fluids

MMR

Second dose of measles containing vaccine for individuals who work in healthcare facilities

Varicella

No evidence of immunity

HPV

13-26 years oldSlide31

Question 7

Juan

, a 71 year old Hispanic man, presents in October for an annual physical. You find him in good health. His medical record shows that he received Td and pneumococcal vaccine at age 65. He reports to you that he once had what sounds like an anaphylactic reaction to eggs.

What vaccine(s), if any, should Juan receive?

Hepatitis A

Hepatitis B

Human Papilloma Virus

Meningococcal

Varicella

Zoster

Pneumococcal

MMR

Tetanus/Diphtheria/Pertussis

Influenza

Tetanus/

DiptheriaSlide32

Answer 7

Zoster

One dose

Recommended for adults 60 years of age and older

Influenza?

Recommend consultation with allergist if have previous life threatening reaction to eggs. Otherwise administer vaccine if mild reaction.

Juan

has no medical conditions indicating the need for a second dose of pneumococcal vaccine. Since Juan received his Td shot within the last ten years, another dose is not indicated now.Slide33

Question 8

Hank is a 51 year old white male with history of cardiac arrest, arteriosclerosis, and congestive heart failure presenting to your office in October. His vaccination history shows that he received influenza vaccine last September (one year ago) and Td 6 years ago. He believes he had chickenpox as a child.

What vaccine(s), if any, should Hank receive?

Hepatitis A

Hepatitis B

Human Papilloma Virus

Meningococcal

Varicella

Zoster

Pneumococcal

MMR

Tetanus/Diphtheria/Pertussis

Influenza

Tetanus/

Diptheria

Slide34

Answer 8

Influenza

Pneumonia

Chronic diseaseSlide35

Question 9

Michael is a 28 year old HIV(+) gay male presently in good health presenting to your office in November. He is employed at a computer software agency, but spends 10 or more hours per week volunteering at an AIDS hospice. According to his medical record, Michael received Td 6 years ago, MMR as a child and again prior to college entry, three doses of hepatitis B vaccine three years ago, and had chickenpox as a child.

What vaccine(s), if any, should Michael receive?

Hepatitis A

Hepatitis B

Human Papilloma Virus

Meningococcal

Varicella

Zoster

Pneumococcal

MMR

Tetanus/Diphtheria/Pertussis

Influenza

Tetanus/

DiptheriaSlide36

Answer 9

Influenza

Everyone

Pneumococcal

Adults with symptomatic or asymptomatic HIV disease should be vaccinated

Hepatitis A

Sexually active men who have sex with men should receive Hepatitis A vaccine

Tdap

Health-care

personnnel

who work in hospitals or ambulatory care settings and have direct patient contact should receive a single dose of

Tdap

as soon as feasible if they have not previously received

Tdap

. The interval can be as short as 2 years from the last dose of Td. Slide37

Question 10

Jenny is a 35 year old woman in good health and in her third trimester of her first pregnancy. She presents to your office in October for a routine prenatal visit after just moving to town from out of state. You review her medical record and note that she received a Td booster 3 years ago and that at her first prenatal visit, she tested negative for varicella and rubella antibodies.

What vaccine(s), if any, should Jenny receive?

Hepatitis A

Hepatitis B

Human Papilloma Virus

Meningococcal

Varicella

Zoster

Pneumococcal

MMR

Tetanus/Diphtheria/Pertussis

Influenza

Tetanus/

Diptheria

Slide38

Answer 10

Influenza

Because of the increased risk for influenza-related complications, women who will be pregnant during the influenza season should be vaccinated with inactivated seasonal influenza vaccine. Vaccination can occur in any trimester. (Live attenuated influenza vaccine, i.e., the intranasal spray, is not recommended for pregnant women.)

Rubella and varicella vaccines are live virus vaccines and, therefore, contraindicated during pregnancy.

Jenny should receive rubella vaccine, given as MMR, prior to leaving the hospital after she delivers this baby to protect her and any future pregnancies she may have against rubella.

Since Jenny is pregnant, the varicella vaccine is not indicated for her. She should receive this vaccine during the postpartum period.

Jenny received her Td booster 3 years ago, so she should be given tetanus, diphtheria, pertussis (

Tdap

) vaccine in the immediate postpartum period to protect her and her infant against pertussis. A one-time dose of

Tdap

with an interval as short as 2 years from the previous Td vaccination is recommended for postpartum women.Slide39

Sources

http://www.uptodate.com/contents/standard-immunizations-for-children-and-adolescents

http://www.cdc.gov