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
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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