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“What Family Physicians Need to Know”
Dr. Marie Andrades
Senior Instructor
Family Medicine
ADULT IMMUNIZATION
Under emphasized and under appreciated
Under utilized
Important preventive strategy to decrease morbidity and mortality
ADULT IMMUNIZATION
ROUTINE
Tetanus and Diptheria ( Td )
Pneumococcal ( Age >65 )
Influenza ( Age >50 )
Hepatitis B
MISSED CHILDHOOD VACCINES
Mumps, Measles and Rubella ( MMR )
Varicella
ADULT IMMUNIZATION Recommendation
Hepatitis A vaccine
Polio
BCG
Meningococcal
Typhoid
Rabies
Yellow fever
Anthrax
Plague
Hib
ADULT IMMUNIZATION Other vaccines when indicated
Pregnancy
Lactation
Health care workers
Animal handlers
HIV positive patients
Immunocompromised states
ADULT IMMUNIZATION In Special Cases
Administration of multiple vaccines
Immunoglobulins combined with
ToxoidsInactivated vaccinesPolysaccharide vaccines
Live virus vaccines
ADULT IMMUNIZATION General Guidelines
History of previous immunization
Hypersensitivity reactions to vaccine or their component
Specific allergies
Acute febrile illness
Contraindications to live vaccine
AssessmentADULT IMMUNIZATION
Correct
A 22 year old patient comes to the clinic for advice. He has missed his last dose of Hepatitis B vaccination which was due 4 months back.
Should he repeat the series?
ADULT IMMUNIZATION Hepatitis B Vaccine
Case Study
Recombinant DNA vaccine
Dose. 1 ml I/M in deltoid at 0, 1 and 6 months
Booster dosing and serological testing
High risk group: Test for AntiHBs 1-4 months after completion of series
Poor responders: AntiHBs 10-100mIU/ml
Non responders: Anti HBs < 10mIU/ml
ADULT IMMUNIZATION Hepatitis B Vaccine
Health care professionals
Homosexuals
Family member or sexual partner of chronic hepatitis B carrier
Prostitutes
Drug abusers
Patient frequently receiving blood or its products
Patients with chronic renal failure
Travelers
ADULT IMMUNIZATION Hepatitis B
High Risk Group
If given in the gluteus muscle (needle length important)
Immunodeficient
Chronic renal failure
Smokers
Elderly
Obese
ADULT IMMUNIZATIONHepatitis B
Decreased Immunological Response
Pain
Rash
Fever > 37.7 C
Influenza like syndrome
Arthritis, arthralgia, myalgia
ADULT IMMUNIZATIONHepatitis B
Adverse Effects
• Correct
A final year medical student presents with a history of needle stick injury a few hours ago while giving an injection to a patient.
The patient’s Hep B status is not known.
What advise would you give to this student who is not vaccinated?
ADULT IMMUNIZATIONCase Study
Source Unvaccinated Vaccinated
ADULT IMMUNIZATIONHepatitis B
Percutaneous Exposure
Source Unvaccinated Vaccinated
HBs Ag+HBIG 0.06ml/kgBegin HB vaccine
series
Test for Anti HBsIf inadequate
HBIG + Vaccineseries
ADULT IMMUNIZATIONHepatitis B
Percutaneous Exposure
Source Unvaccinated Vaccinated
HBs Ag+HBIG 0.06ml/kg
Begin HB vaccineseries
Test for Anti HBsIf inadequate
HBIG + Vaccineseries
Unknownsource
Begin HB vaccineseries
Nothing required
ADULT IMMUNIZATIONHepatitis B
Percutaneous Exposure
Toxoids
Dose: 0.5 ml I/M at 0, 1 and 6-12 months
Seroconversion 100%
Booster 10 yearly
ADULT IMMUNIZATIONTetanus Diphtheria (Td) Vaccine
Persistent nodule
Pain, redness swelling
Headache, lethargy, malaise, myalgia
Urticaria, anaphylaxis
ADULT IMMUNIZATIONTetanus Diphtheria (Td) Vaccine
Adverse Effects
• Correct
A 30 year old is brought to the clinic after a road traffic accident in which he has sustained laceration of his leg. On questioning he says that he has received all his childhood immunizations.
How would you manage this patient?
ADULT IMMUNIZATIONCase Study
TTImmunization
CleanMinor Wound
LargeDirty Wounds
T.T TIG T.T TIG
ADULT IMMUNIZATIONTetanus prophylaxis in
wound management
T.T Tetanus Toxoid
TIG Tetanus Immunoglobulin
TTImmunization
CleanMinor Wound
LargeDirty Wounds
T.T TIG T.T TIGNone,incomplete,Unknown
BeginPre ExpSeries
No Yes Yes
ADULT IMMUNIZATIONTetanus prophylaxis in
wound management
T.T Tetanus Toxoid
TIG Tetanus Immunoglobulin
TTImmunization
CleanMinor Wound
LargeDirty Wounds
T.T TIG T.T TIGNone,incomplete,Unknown
BeginPre ExpSeries
No Yes Yes
Last booster>5 years Booster No Yes Yes
ADULT IMMUNIZATIONTetanus prophylaxis in
wound management
T.T Tetanus Toxoid
TIG Tetanus Immunoglobulin
TTImmunization
CleanMinor Wound
LargeDirty Wounds
T.T TIG T.T TIGNone,incomplete,Unknown
BeginPre ExpSeries
No Yes Yes
Last booster>5 years Booster No Yes Yes
CompleteLast boosterwithin 5 years
No No No No
ADULT IMMUNIZATIONTetanus prophylaxis in
wound management
Live attenuated vaccine
Dosage: 0.5 ml subcutaneous
Seroconversion 95%
Lifelong immunity
ADULT IMMUNIZATIONMumps, Measles & Rubella
Vaccine
Fever
Rash
Arthralgia
Lymphadenopathy
ADULT IMMUNIZATIONMumps, Measles & Rubella Vaccine
Adverse Effects
Correct
A 32 year old lady, 8 weeks pregnant presents with a history of recent exposure to German Measles. On inquiring she reveals that she was immunized with MMR after the birth of her first child.
What would you advise this patient?
ADULT IMMUNIZATIONCase Study
All pregnant women with suspected rubella or exposure to rubella must be investigated serologically irrespective of a history of rubella immunization, clinical rubella or previous positive
rubella antibody result
ADULT IMMUNIZATION Rubella Exposure
What immunization would you recommendfor a 55 year old patient with congestive cardiac failure and no previous immunization?
Correct
ADULT IMMUNIZATION Case Study
Inactivated trivalent vaccine
Dosage: 0.5 ml I/M yearly usually October
Efficacy: 70-90% in healthy subjects <65
In elderly, prevents disease in 30-40% and death in 80%
ADULT IMMUNIZATIONInfluenza Vaccine
Healthy adults > 50
Residents of nursing homes
Chronic respiratory, heart and renal disease
Immunosuppressed including diabetics
Health care workers
Travelers
ADULT IMMUNIZATIONInfluenza Vaccine
Indications
Polyvalent vaccine
Dosage: 0.5 ml I/M
Single booster after 5 years
Efficacy: Prevents disease in 70% of immunized adults
ADULT IMMUNIZATIONPneumococcal Vaccine
Healthy adults >65
Asplenia or splenic dysfunction
Chronic heart, lung or liver disease
Chronic renal disease including nephrotic syndrome
Immunosuppressed states including DM and HIV positive individuals
ADULT IMMUNIZATIONPneumococcal Vaccine
Indications
Comorbids
Monovalent whole cell Typhoid vaccine
2 doses 4-6 weeks apart
Booster 3 yearly
Typhoid Vi polysaccharide antigen vaccine
Single dose
Booster 3 yearly
Live attenuated oral Typhoid vaccine
4 doses, 1 capsule on alternate days Booster 3 yearly
ADULT IMMUNIZATION Typhoid Vaccine
Whole cell vaccine
Pain, swelling, redness, malaise, fever, headache
Vi polysaccharide vaccine
Mild local and systemic symptoms
Oral vaccine
nausea, vomiting, abdominal cramps, diarrhea, urticaria
ADULT IMMUNIZATIONTyphoid Vaccine Adverse Effects
Live attenuated vaccine
Dosage: 0.5 ml s/c. 2 doses 4-6 weeks apart
Seroconversion in 97%
Health care workers
Workers at day care centers
Non pregnant women
ADULT IMMUNIZATION Varicella Vaccine
Indications
Immunosuppressed
Neonates whose mother develops chicken pox 7 days before to 28 days after delivery
Pregnant women with significant exposure to chicken pox or herpes zoster
Dosage: 1000mcg (4 vials) within 10 days of exposure
ADULT IMMUNIZATIONPost Exposure Varicella Zoster
Immunoglobulin
Vaccination is an important tool in disease prevention
Adult immunization should be given priority
Vaccination needs based on occupation, lifestyle, and health condition should be considered
ADULT IMMUNIZATION Conclusion