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Immunizations for Adults
Stephen J. Gluckman, M.D.
Immunizations
Where do the recommendations come from? Advisory Committee on Immunization
Practices Approved by:
American Academy of Family Physicians American College of Obstetricians and
Gynecologists American College of Physicians
Definitions
Active Toxoid Live, Attenuated Killed, Inactivated Recombinant
Pre-Exposure
Passive Immune Globulin Specific high titer
preparations
Post-Exposure
General Rules: Administration
Give it the way it is recommended. The buttock is generally not recommended. Recommended intervals between doses are
the minimal ones. Shorter may lead to decreased antibody levels Longer will not
Can administer most vaccines simultaneously.
General Rules:Contraindications and Precautions
The live vaccines are measles, mumps, rubella, yellow fever, oral polio, varicella, zoster, oral typhoid, BCG Pregnant woman Immunocompromised patients
Vaccines made in eggs are measles, mumps, influenza - both, yellow fever True egg allergy
Vaccines containing neomycin are measles, mumps, rubella, zoster None contain penicillin
General Rules:Misconceptions I
The following are not contraindications to vaccination
Local or mild-moderate reactions to previous vaccination
Mild acute URI or gastroenteritis Current antimicrobial therapy Breast Feeding
Personal history of “allergies” Family history of adverse reactions to an
immunization Pregnancy, unless live vaccine Pregnancy in a household member of
vaccinee
General Rules:Misconceptions II
General Rules:Misconceptions III
Mercury Thimerosal in vaccines since the 1930’s No evidence that it has caused any harm
Ethyl mercury not methyl mercury Essentially removed from all vaccines today
Trace amounts in some formulations of Influenza, Td, TDaP
Autism Fraudulent study Poorly supported anecdote
REPORT SEVERE REACTION TO PROPER AUTHORITIES
http://vaers.hhs.gov/index 1-800-822-7967
Immunization record
The patient’s chart should contain a notation including the: Date Type of Immunization Dose Site Lot number Manufacturer Identification of the person who administered
Pre-Exposure Immunization All Adults
Tetanus/Diphtheria (Td) Every 10 yearsOne of these should be: tetanus, diphtheria, acellular pertussis (Tdap) This should be given if no Td within 5 years
Many Adults Measles, Mumps, Rubella, Influenza, Pneumococcus,
Hepatitis B, Varicella, Hepatitis A, HPV, Zoster
Selected Groups Travelers, Health Care Workers, College Students, Nursing
Home Residents
Post-Exposure Immunizations
Hepatitis A
Hepatitis B
Tetanus
Rabies
Varicella
MMR Measles and Mumps
Made in Eggs, Live One dose indicated for all persons born after 1956 unless
One or more documented prior immunizations (+) serology HCW documented disease Medical contraindication
Second dose Recently exposed HCW International traveler College Student
Rubella
Rubella Live, no eggs One dose indicated for
All women of child bearing potential All HCW’s unless
History of vaccination (+) serology
» A history of rubella is not reliable
Rubella:Vaccine
Live attenuated virus is shed but there is no transmission
Adverse reactions: Arthralgias and arthritis Fever Rash
Rubella
What if pregnant at the time of immunization?
“The risk of vaccine associated with defects is so small as to be negligible and should not ordinarily be a reason to interrupt pregnancy”
- CDC Registry
Rubella
Can a breast feeding woman get Immunized?
Yes
Can a household member of a pregnant woman get immunized?
Yes
Influenza Two Types of Vaccines - equal efficacy
Live Vaccine (FluMist®) Advantages
No injection Disadvantages
Expensive Nasal stuffiness, rhinitis Shed virus Only approved for 18-49 year olds No contact with immunocompromised persons
Inactivated Vaccine Parenteral
Latex free» Fluzone®, Fluvirin®
Contains latex» Fluarix®
Influenza:Vaccine
Changes from year to year based on the “best guess” of which strains will be circulating
Patients need to know About 70% efficacy Prevents influenza, a bad disease, not URI’s
Influenza:Whom to Vaccinate with the Seasonal Vaccine?
All adults Particularly indicated for:
Otherwise healthy persons > 50 years of age Adults chronic cardiopulmonary disorders Adults with chronic metabolic diseases Pregnant women Health care workers Persons with HIV infection Residents of chronic care facilities
Pneumococcal Vaccine
PPV
23 capsular polyvalent polysaccharide antigens of 90% of bacteremic infections
Healthy adults respond to 80% of the serotypes
PCV
Conjugated vaccine for infants and children (Prevnar®)
Pneumococcal Vaccination
Whom to vaccinate? All adults 65 and over and those high risk groups
at any age CSF leaks and cochlear implants Asplenic Chronic cardiopulmonary, alcoholism or metabolic
diseases Revaccination?
For most people only a single vaccination is recommended
Consider revaccination for: high risk groups Those immunized > 5 years ago and were < 65 at
the time
Hepatitis B
Why vaccinate?
200-300,000 new cases annually
10% chronic carrier
Immediate and late mortality
Hepatitis B
Recombinant >95% of healthy adults make antibody Schedule options
0,1,4 months With hepatitis A (Twinrix):
0,1,6 months 0,7,21 days and 12 months
High dose vaccine for dialysis and immunocompromised patients
Hepatitis B: Recommendations
All Newborns All Adolescents Selected (Almost all) Adults
Occupational, e.g. Health Care Workers Hemodialysis patients Injection drug users Sexually active, Non-monogamous Sexual partner of a known carrier Inmates of long-term correctional facility Recipients of blood products Persons with chronic liver disease Household contacts
Management of non-responder? 0.1 - 0.25 ml intradermal at 0,2,4 weeks* Revaccinate with dialysis dose (40 mcg)*
Need for booster? Not recommended
Pre and post immunization serological testing? Not recommended
*Not FDA approved but supported in the literature
Hepatitis BAreas of Concern
Hepatitis A
Vaccine Formalin inactivated No antibiotics Single dose is 99% protective; second dose at > 6 months
confers more long lasting immunity Indications
All children High risk adults
International travelers Persons living in areas of high endemicity Persons working in day care centers Persons with chronic liver disease
Post exposure prophylaxis (14 days)
Hepatitis A
Three equally effective options Hepatitis A alone (Vaqta or Havrix)
0, > 6 months
Twinrix (Combined with Hepatitis B) 0,1,6 months 0,7,21 days and 12 months
Varicella Vaccine
Live, attenuated, neomycin 99% seroconversion rate after two doses Protective for at least 10 years Breakthrough infections occur, but are mild Transmission rates of the vaccine to
susceptible contacts are very low.
Varicella
Who is Susceptible? A history of varicella is very reliable A negative history of varicella is not
Cost effective to measure antibodies in a person who says that they did not have varicella
Indications All susceptible
Varicella Vaccine
Dosage and administration Children 12 mos to 13 yrs - two doses at
> 3 months apart Greater than 13 yrs - two doses at 4-8 week
intervals
Routine testing for immunity after vaccination is unnecessary
Adverse effects: local discomfort
An 18 year old woman comes to your office for pre-college immunizations. If she does NOT already have known immunity, for which of the following should she be immunized?(select all that apply)
CASE
a. Measles, mumps, rubella
b. Hepatitis B
c. HPV
d. Meningococcus
Meningococcal Vaccine
Two types Conjugate (Menactra, Menveo)
Age 2-55
Polysaccharide (Menomune) > Age 55
Meningococcal Vaccine
Only effective against serogroups A,C,Y, W-135. About 30% caused by group B – not in the
vaccine
Meningococcal Vaccine
Recommended (1 dose) All children age 11-12 1st year college students living in dormitories and
military recruits (if not given earlier) Persons at increased risk ages 2-55 years
Travelers to endemic or epidemic areas Persons on a Hajj (required) Asplenic patients Persons with terminal complement deficiencies
Relative Risks for meningococcal disease (per 100,000) Endemic risk 1-1.5 All college students 0.6 Freshman 1.7 Freshman in dorm 5.4
Meningococcal Vaccine
Human Papillomavirus (HPV)Vaccine
Indicated for women and suggested for men, 9-26 years 99% make antibodies to the serotypes
ACIP: aim at 11-12 year olds with “catch-up” of older
Two vaccines Gardasil® HPV Types 16,18: 70% of types that cause
cervical cancer HPV Types 6,11: 90% of types that cause warts 3 doses: x, x+2m, x+6m
Cervarix®
Types 16,18 3 doses: x, x+1, x+6
Human Papillomavirus (HPV)Vaccine
FAQ Should woman be screened before being
vaccinated No
What about vaccinating men? Consider to prevent warts, not cancers or
transmission Should pregnant woman get vaccinated?
No, appears to be safe but….. How long does the protection lasts?
Unknown. At least 5 years
Herpes Zoster Vaccine
Single dose Live Neomycin
Studied in 60 years old and older Prevented disease in 50% Breakthrough infections were generally milder Decreased efficacy with increasing age History of zoster is not a contraindication
Pre-Exposure, Selected Groups
Nursing Home Patients
Influenza
Pneumococcus
Tetanus/Diphtheria (Tdap)
College Students
Measles, Mumps, Rubella
Tetanus/Diphtheria/Pertussis
Hepatitis B
Meningococcal
HPV
Health Care Workers
Hepatitis B
Influenza
Varicella
Measles, Mumps, Rubella
Questions?