Pink book: useful resource for detailed info on immunization and immunology.
Active immunity: Produced by the person's own immune system (Acquired through survive infection, or vaccination), permanent.
Passive immunity: Products transferred to another human by injection, the protection wanes over time. E.g: infant receives from mother; Blood antibody (IV immune globin and plasma products).
Polysaccharide vaccine: polysaccharides are taken from outside of bacteria, they do not provide good immunity in <2 y/o.
Conjugate vaccine: use polysaccharide molecules from outside of bacteria and join the molecules to carrier proteins. They increase immune response in infants and booster response.
Recombinant vaccine: gene segment of a protein from an organism is inserted into another cell (e.g yeast) to replicate. E.g: Gardasil 9.
Toxoid vaccine: targets a toxin produced by the disease. E.g: diphtheria, Tetanus.
Intervals of series of doses: Increasing the intervals does not diminish the effectiveness of a vaccine (a three-dose series 0,2,6 months can be administered at 0, 3, 8 months); Decrease the intervals may interfere with antibody response and protection, the body needs ample time to mount response to antigens and produce antibodies.
Live
MMR, varicella (chicken pox), zoster (Zostavax but NOT Shingrix!), yellow fever, oral typhoid (Vivotif), cholera, intranasal influenza, rotavirus (for all infant).
Administer two live vaccines on the same day; If not at the same visit, must separate by 4 weeks.
Wait at least 2 weeks before giving an antibody.
Do not give to immunocompromised patients, or pregnant women, as live vaccines can lower one’s immune system.
All other vaccines are inactivated virus (e.g: flu shots, Hep B, Tdap, Shingrix et)
Women should be vaccinated with Tdap during each pregnancy, it is recommended during 27 to 36 gestational weeks.
Give Td (tetanus-diphtheria) booster if 65 or older and had last tetanus shot > 10 years ago.
HPV (Gardasil, Cervarix)
Prevent cervix cancer.
3 doses: @0, 1-2 months, 6 months later.
2 doses: before age 15, 2nd dose 6-month later
Meningococcal
Prevent meningitis.
Meningococcal conjugate (Menactra, Menveo): for age 11 & 12, plus a booster @ age 16
Meningococcal B (Bexero, Trumenba): age 10 and up at increased risk: asplenia, sickle cell; for any 16-23 old for added protection
Bexero: 2 doses 1 month apart.
Trumenba: 3 doses.
Use same vaccine for all doses
MMR
Prevent measles, mumps, and rubella.
Increasing outbreaks in mumps recent years; Recommend booster dose in outbreak, which gives short term benefits (college dorm even if they had 2 doses MMR series as children); routine booster is not recommended.
Booster dose: single dose if had 1 or 2 doses in the past; 2nd dose 4-wks later if never had vaccine or history unknown
2 types available: MMR II & MMR-V (varicella), sub-Q.
Zostavax
Live attenuated shingle vaccine for age 60 and older. Store in freezer.
Do not give if allergic to gelatin, neomycin, immuno-compromised, history of bone cancer, untreated TB.
Shingrix
Non-live recombinant zoster vaccine with adjuvant, given at age 50 and older.
Immunity may last longer than Zostavax, preferred by CDC.
Two doses: Second dose given 2-6 months after the first dose.
It is safe to give Shingrix at the same time with other vaccines, such as flu, Tdap, pneumococcal.
Does a patient who’s had Zostavax before still need two doses of Shingrix? Yes, to boost immunity. Wait at least 2 months after Zostavax.
Give Shingrix even if the patient has already had shingles because shingles can recur, however, wait until the acute symptoms go away.
Vaccination is recommended regardless of shingles or chickenpox history.
Two doses of the RZV (zoster vaccine recombinant) are necessary to complete the series regardless of previous zoster vaccine status, assuming at least 2 months have elapsed since zoster. A dose of zoster should not be substituted for RZV to complete the series.
Pneumonia
2 types: PCV Prevnar 13 (conjugated) and PPSV, Pneumovax 23
Old guideline recommends give 13 first followed by 23 one year later, new CDC guideline is leaning away from Prevnar 13 (due to very low risk reduction), seniors are mainly protected from strains by herd immunity, so focus on giving Pneumovax 23 to healthy seniors >65 yo for the additional 12 serotypes.
Continue to give 2 doses to immunocompromised patients (chronic renal failure, weak immune system, or if spleen has been removed), space out at least 8 weeks (instead of 1 year) to reduce unprotected time.
CDC also recommends Pneumovax 23 for age under 65 with risk factors (smokers and chronic illnesses).
Vivotif (Typhoid Vaccine)
Protect against typhoid feverthat is caused by bacteria called Salmonella Typhi (S. typhi).
Refrigerated capsule, dosed every other day for a total of 4 capsules
Neuraminidase inhibitor
For influenza type A &B, used commonly in community setting.
Oseltamivir (Tamiflu): reduce dose in renal impairment.
Treatment: 75mg BID x 5 days; prevention 75mg QD x 10 days.
Started 1-2 weeks before travel, during and taken for 4 weeks post-travel.
May causeVISUAL problems (chloroquine).
Avoid in pregnancy and renal impairment.
Do not use in area with high chloroquine or mefloquine resistance.
Special groups
All groups should receive annual inactivated influenza vaccine.
Pregnancy: each pregnancy requires a Tdap during week 27-36. Live flu vaccine is contraindicated.
Asplenia (spleen is damaged or has been removed): spleen contains T cells and B cells, asplenia causes immunodeficiency; Pneumococcal vaccine, Meningococcal vaccine.
Immunodeficiency: Live vaccine is contraindicated. Pneumococcal vaccine, Meningococcal vaccine, hepatitis B.
Older adults: >50 yo Shingrix, > 65 Pneumococcal vaccine.
Diabetes: Pneumococcal vaccine, hepatitis B.
Vaccines require to be stored in freezer (-50 to -15 degrees C):
· Varicella, Zostavax, MMR-V (Measles, mumps, rubella, varicella), MMR is either in the refrigerator or freezer.
Quiz
1. Which of the following is a correct statement regarding the recommendation of pneumonia vaccine?
A 45-year-old man with a diagnosis of hypertension should receive one dose of PPSV23 now and a second dose of PPSV23 at age 65 years.
A 19-year-old woman who has sickle cell anemia should receive one dose of PCV13 now and one dose of PPSV23 at age 65 years.
A 38-year-old health care provider should receive one dose of PCV13 and one dose of PPSV23 at the same visit.
A 52-year-old man who smokes one pack of cigarettes per day should receive one dose of PPSV23 now, one dose of PCV13 at age 65 years, and a second dose of PPSV23 at 66 years.
2. Which of the following information regarding Pneumovax 23 is TRUE?
a. Pneumococcal vaccine is administered intradermally as one 0.5-mL dose. b. Pneumococcal vaccine MUST NOT be administered at the same time as influenza vaccine. c. For any person who has received a dose of pneumococcal vaccine at age greater than 65 years, revaccination is not indicated. d. PNEUMOVAX 23 is approved for use in children older than 1 year of age.
3: Which of the following statements is true regarding recommendations for human papillomavirus vaccination (HPV)?
The HPV vaccine should be routinely administered to all females and males younger than 26 years of age.
All females should be given a pregnancy test prior to the administration of HPV vaccine.
If HPV vaccine is administered to females or males 15 to 26 years of age, three doses are required.
The HPV vaccine is contraindicated in patients with HIV infection with CD4+ count less than 200 cells/mL.
Which of the following statements is NOT TRUE about vaccines or immunizations? (Select ALL that apply)
parenteral or intranasal administration of a live vaccine is not thought to affect the immune response of a subsequently administered oral live vaccine.
Two live vaccines may be given at the same visit.
A live vaccine and an inactivated vaccine can be administered regardless of the timing of the other.
Two live vaccines may be separated by two weeks.
All of the following vaccines can be stored in a refrigerator EXCEPT:
HZV
Influenza
Hep B
Rotavirus
D. Person with risk factors (smoking) should receive a dose of PPSV23 before turning to age 65.
C. Pneumovax 23 is a vaccine indicated for active immunization for the prevention of pneumococcal disease caused by the 23 serotypes contained in the vaccine. It is NOT approved for use in children younger than 2 years of age because children in this age group do not develop an effective immune response to types contained in the polysaccharide vaccine. Recommendations exist for revaccination against pneumococcal disease for persons at high risk who were previously vaccinated with pneumovax 23. Routine revaccination of immunocompetent persons previously vaccinated with a23-valent vaccine, is not recommended. All persons in this category should receive the pneumococcal vaccine, including previously unvaccinated persons and persons who have not received vaccine within 5 years (and were <65 years of age at the time of vaccination). For any person who has received a dose of pneumococcal vaccine at age greater than 65 years, revaccination is not indicated. Canadian and U.S. product labeling do say to consider separating administration of Zostavax and Pneumovax 23 by at least four weeks, since concurrent administration of these vaccines can reduce patients’ immune responses to Zostavax.
A. The HPV vaccine should be routinely administered to all females and males younger than 26 years of age.
(D) If more than one non-oral live vaccine (e.g., live attenuated influenza vaccine [LAIV], varicella, mumps) are administered, it is recommended that the vaccines be given on the same day, or be separated by at least four weeks. The four-week interval reduces the interference of immune response to the first vaccine by the second vaccine.
This rule for separation does not apply to oral live vaccines not given on the same day (typhoid and rotavirus). These vaccines can be given less than four weeks apart. However, this scenario is not likely to occur. Parental or intranasal administration of a live vaccine is not thought to affect the immune response of a subsequently administered oral live vaccine. A live vaccine and an inactivated vaccine can be administered without regard to the timing of the other.
(A). HZV Herpes Zoster Vaccine is a live vaccine, it should be stored in a freezer.
