APhA Immunization Self-Study Evaluation
Which of these vaccines is a live attenuated vaccine?
The live attenuated vaccines include cholera, herpes zoster, live attenuated influenza vaccine (LAIV), MMR, MMRV, rotavirus, tuberculosis (BCG), typhoid (Ty21a), vaccinia (smallpox), varicella, and yellow fever. All other vaccines are inactivated.
With the exception of rotavirus, the routinely recommended live vaccines are contraindicated in a patient who:
The majority of live vaccines are contraindicated in patients who are immunocompromised. Immunosuppression may reduce vaccine efficacy as well as pose a risk for disseminated infection with the normally attenuated pathogen in the live vaccine. However, some exceptions have been made depending on the level of immunosuppression. In the case of the rotavirus vaccine, severe combined immunodeficiency (SCID) is a contraindication but other immunocompromising conditions are precautions. The interval that should be observed between one or more live vaccines is four weeks. Ppsv2 Antibiotics can interfere with the oral typhoid and cholera vaccines but should be fine with all other vaccines.
Kimberly is a 34 year-old woman who is 30 weeks pregnant. She received a Td booster dose 1 year ago when she cut her hand while working in the kitchen. She has no documentation of receiving a Tdap vaccine. The most appropriate recommendation would be to administer:
According to the ACIP recommendations, pregnant women should receive 1 dose of Tdap during each pregnancy, preferably during the early part of gestational weeks 27-36, regardless of prior history of receiving Td or Tdap. In fact, earlier in this window maximizes antibody transfer to the infant. Waiting until after the child is born does not allow for this passive immunity to occur. DTaP contains higher amounts diphtheria toxoids and pertussis than Tdap. It is only used in children less than 7 years of age to avoid injection site reactions in adolescents and adults.
Why should refrigerated vaccines be stored in the middle of the refrigerator?
Feedback for both Full, Partial, and Incorrect Credit: LO 5.4; Module 5— Vaccine Storage and Handling Vaccines should be stored in the middle of the refrigerator, not in the door or on the bottom shelf, because the temperature in the middle does not fluctuate as much.
Emily is a 16-year-old high-school student with no chronic medical conditions. Emily's immunization record shows that she completed the primary series for IPV, HepA, Hib, DTaP, and MMR, and she had a physician-diagnosed case of chickenpox at 2 years of age. Which of the following would be the most appropriate recommendation for her today?
From 2015 childhood schedule: Upon reviewing the immunization schedule for children and adolescents, Emily was supposed to receive Tdap, MCV4, and HPV at ages 11 to 12. It also appears she did not receive her hepatitis B vaccines as an infant. Emily will need to get caught up on these four vaccines. Since influenza vaccine is universally recommended on an annual basis, she should receive that as well if it is during influenza season. We would refer to the catch-up schedule for dosing interval guidance.
John is a 46-year-old man with diabetes. He requests a refill of his diabetes testing supplies on October 21st. His immunization record indicates that he has completed the primary series of MMR, DTaP, HepA, and HepB vaccines. John has a documented history of chickenpox, and his last Td booster dose was 19 years ago. Which of the following vaccines should he receive?
From 2017 adult schedule: Because John has diabetes both the recommended immunization schedule for adults aged 19 years or older by age group and the recommended immunization schedule for adults aged 19 years or older by medical condition and other indications should be used to determine which vaccines he needs. Because Tdap is recommended for all adults who have not had that vaccine, he needs Tdap. Influenza vaccine is universally recommended and is important for John because his diabetes places him at high-risk for influenza complications. He is also a candidate for PPSV23, which is recommended for patients with diabetes. PCV13 is recommended for those with immunocompromising conditions, but is not currently recommended for patients with diabetes.
Kate is a 24-year-old woman with asthma. She requests a refill of her albuterol inhaler on November 1st. Kate's immunization record indicates that she completed the primary series of MMR, varicella, DTaP, HepA, and HepB vaccines, and she received a dose of Tdap 2 years ago. For complete coverage, which of the following vaccines should she receive?
From 2017 adult schedule: Because Kate has asthma, both the recommended immunization schedule for adults aged 19 years or older by age group and the recommended immunization schedule for adults aged 19 years or older by medical condition and other indications should be used to determine which vaccines she needs. PPSV23 is recommended for those ages 19 through 64 years of age with asthma. She did not receive HPV as an adolescent and is younger than 27 years of age so she would be a candidate for HPV vaccination. Influenza vaccine is universally recommended and is important for Kate because her asthma places her at high-risk for influenza complications. She will not need Td vaccination for another 8 years. PCV13 is recommended for those with immunocompromising conditions, but not asthma.
David is a healthy 5-year-old boy who is scheduled to see his pediatrician for a checkup in July prior to starting kindergarten. David's immunization record reveals that he has received the following vaccines: 3 doses of HepB 4 doses of PCV13 2 doses of HepA 3 doses of IPV 2 doses of rotavirus 1 dose of MMRV 4 doses of DTaP 4 doses of Hib Which vaccines should David receive at this visit?
From 2017 childhood schedule: Upon reviewing the immunization schedule for children and adolescents, David will need his 5th dose of DTaP, 4th dose of IPV, 2nd dose of MMR, and 2nd dose of varicella. His PCV13, Hib, hepatitis A and B series are complete. Depending on the rotavirus vaccine used, two doses may have completed the series. Regardless, David is too old to receive any additional rotavirus vaccine doses. He does not require the meningococcal vaccine (MCV4) until he is 11 to 12 years of age. Because he needs both MMR and varicella, he may receive the MMRV combination vaccine again.
In 2014, which vaccination rate was lowest among adolescents 13 through 17 years of age?
LO 1.1; Module 1—Current Vaccination Rates (Table 1.4) In 2014, the vaccination rate for 3 doses of HPV in females and males ages 13 through 17 years was 40% and 22%, respectively. This was drastically lower than other vaccines routinely recommended for adolescents. The rate of meningococcal (MenACWY) vaccination in this age group was 79%. The rate of Tdap vaccination was 88%. The rate of at least 2 doses of MMR vaccination was 91%.
Which of the following diseases has been successfully eradicated worldwide through vaccination efforts?
LO 1.1; Module 1—Impact of Vaccines In 1798, the smallpox vaccine became the first vaccine available to prevent disease. To date, smallpox has been completely eradicated and the vaccine is no longer routinely used. All other diseases for which vaccines are available still exist.
Federal law makes offering an annual influenza vaccination a requirement for continued federal funding in which setting?
LO 1.4; Module 1—Opportunities Based on Location Resident of long-term care facilities are at high-risk for influenza and pneumococcal disease. If a long-term care facility receives funding from Medicare, it must offer influenza vaccine annually to its residents. Pneumococcal vaccine must also be offered at least once during the resident's stay. The Centers for Medicare and Medicaid Services (CMS) began requiring this in 2005 as a condition of participation. This is not mandated for patient-centered medical homes, accountable care organizations, or home health care.
The childhood/adolescent and adult immunization schedules are updated and published annually during which months?
LO 1.6; Module 1—Vaccine Recommendation Sources The Advisory Committee on Immunization Practices (ACIP) meets at least three times a year to discuss vaccine recommendations and guidelines. Although new recommendations may result from these meetings, the comprehensive schedules for children, adolescents, and adults are published once per year. These are typically made available at the end of January or early February.
Vaccines as well as exposure to natural disease are both examples of which type of immunity?
LO 2.1; Module 2— Passive vs. Active Immunity There are two types of immunity—innate and acquired. Innate immunity is the first line of defense against pathogens and includes physical barriers (e.g., skin, mucus), physiologic factors (e.g., stomach acid, body temperature), processes (e.g., inflammation), and cells of the immune system (e.g., phagocytes, macrophages). These are defenses that are present at birth. Acquired immunity involves immunological memory. It is something the body develops upon exposure to pathogens or antigens and results in antigen-antibody complex formation. Acquired immunity can be active or passive. Passive immunity happens when antibodies are provided from another source, such as when maternal antibodies are transferred to the fetus or upon receipt of blood products or immunoglobulin. Passive immunity, which is short-lived, can be considered temporary. Temporary immunity happens when temporary protection is provided, as is the case when immunoglobulin is given following hepatitis B exposure. Active immunity occurs when an antigen from an invading pathogen or a vaccine triggers the immune system to respond. Active immunity has a prolonged effect.
A health care provider who has not been vaccinated against hepatitis B is stuck by a contaminated needle after administering an immunization to a hepatitis B-positive patient. In addition to hepatitis B vaccine, the health care provider also should receive hepatitis B Immunoglobulin (HBIG) as postexposure prophylaxis because the HBIG provides:
LO 2.1; Module 2—Passive and Active Immunity Can Be Complementary Giving both the hepatitis B vaccine and hepatitis B immunoglobulin (HBIG) allows for active and passive immunity. Active immunity occurs when the antigen from the vaccine triggers the immune system to respond. The vaccine will provide long-term protection but it takes the body about two weeks to develop immunity. Passive immunity happens when antibodies are provided from another source, such as immunoglobulin. Passive immunity is short-live, but it provides protection right away.
Jackie is a 34-year-old woman who received an influenza vaccine from you today. She wants to know how long it will take for the vaccine to begin working to protect her from getting the flu. What would be the most appropriate response to this patient?
LO 2.2; Module 2—Immunologic Memory.
Why are adjuvants added to vaccines?
LO 2.2; Module 2—Vaccine Adjuvants When an adjuvant is added to a vaccine, this results in an inflammatory response. This, in turn, strengthens the response to the antigen and the immune response is much greater. For instance, adjuvants are added to recombinant vaccines. When used alone, recombinant vaccines evoke a weak immune response. When adjuvants are added, the immune response is strong.
Herd immunity refers to which of the following situations?
LO 2.5; Module 2—Herd Immunity There are instances in which some individuals are not able to be vaccinated. For example, infants younger than 2 months of age are too you to receive DTaP and a child with a compromised immune system would not likely receive MMR. It is important to vaccinate those in the community who can receive the vaccine to avoid outbreaks and the transmission of disease to those unvaccinated. This is called herd immunity.
Which of the following is most likely to result in an influenza pandemic?
LO 3.1; Module 3—Influenza Viruses Influenza A is the main contributor to pandemic and epidemic outbreaks of disease. A pandemic is a worldwide outbreak. In the case of influenza, this is often due to an antigenic shift in which one or both of the surface antigens on the influenza A virus change. A new strain is created that can result in widespread infection. Antigenic drift occurs continuously and leads to minor changes in the structure of the virus, but does not result in new strains.
Aiden is a 6-month-old healthy boy with no known allergies. He has received vaccinations in the past with no reported adverse reactions. Aiden's father asks about having his son vaccinated against influenza. The most appropriate response would be to inform the father that Aiden:
LO 3.2 & 3.4; Module 3—Influenza. Vaccine Recommendations Influenza vaccination is universally recommended beginning at age 6 months. Children aged 6 months through 8 years who have not previously received at least two dose of the influenza vaccine should receive 2 doses, 4 weeks apart. Children aged 6 months can be given either the trivalent or quadrivalent inactivated influenza vaccine (IIV3 or IIV4), so long as the age indications for the product are appropriate. It is not recommended that LAIV be used for the current influenza season. Furthermore, LAIV is approved for healthy individuals 2 through 49 years of age. Even if it was recommended, Aiden would be too young.
If a patient with an egg allergy experiences hives following influenza vaccination, what is ACIP's recommendation for vaccinating this patient against influenza?
LO 3.2; Module 3— Non-Egg-Based Influenza Vaccines As recommended by the ACIP, persons with a history of egg allergy who have experienced only hives after exposure to egg should receive influenza vaccine. Any licensed and recommended influenza vaccine (i.e., any age-appropriate IIV or RIV3) that is otherwise appropriate for the recipient's age and health status may be used. Persons who report having had reactions to egg involving symptoms other than hives, such as angioedema, respiratory distress, lightheadedness, or recurrent emesis; or who required epinephrine or another emergency medical intervention, may similarly receive any licensed and recommended influenza vaccine. However, the selected vaccine should be administered in an inpatient or outpatient medical setting in which the administration should be supervised by a health care provider who is able to recognize and manage severe allergic conditions.
According to ACIP recommendations, HZV is indicated for the prevention of herpes zoster in adults aged:
LO 3.2; Module 3—Herpes Zoster, Target Groups for Vaccination Even though the herpes zoster vaccine (Zostavax) is FDA approved for individuals aged 50 and older, the ACIP recommends this vaccine for individuals aged 60 and older. There are concerns about waning immunity with this vaccine. If given too soon (before age 60), it may not afford protection in older individuals who are at higher risk of herpes zoster.
Which of the following statements is true regarding varicella-containing vaccines?
LO 3.2; Module 3—Herpes Zoster, Vaccine Herpes zoster vaccine (Zostavax) contains 14 times more antigen than varicella vaccine. This greater potency is necessary to elicit an adequate immune response in older patients who have immunity to varicella because they previously had chicken pox.
Which of these vaccines is an inactivated vaccine?
LO 3.2; Module 3—Table 2.2 Inactivated Vaccines The live attenuated vaccines include cholera, herpes zoster, live attenuated influenza vaccine (LAIV), MMR, MMRV, rotavirus, tuberculosis (BCG), typhoid (Ty21a), vaccinia (smallpox), varicella, and yellow fever. All other vaccines are inactivated.
How is the live, cholera vaccine administered?
LO 3.2; Module 3—Vaccines for International Travel The live cholera vaccine is administered as a single oral dose at least 10 days prior to potential exposure to V. cholera.Individuals should not eat or drink for 60 minutes before or after receipt of the vaccine.
According to ACIP, which of the following is a contraindication to receiving HZV?
LO 3.3, Herpes Zoster, Contraindications and Precautions The herpes zoster vaccine (Zostavax) is a live vaccine. It is contraindicated in individuals who are pregnant and those with compromised immune systems. This includes those with HIV and a CD4+ count less than 200, those receiving chemotherapy or radiation or other immunocompromising medications (e.g., corticosteroids), and cancer affecting the bone or lymphatic system (e.g., leukemia, lymphoma). It is also contraindicated in individuals who have experienced a severe allergic reaction to the vaccine components (e.g., gelatin, neomycin). Individuals with a history of a herpes zoster infection and those who have not received the varicella vaccine may still receive HZV. Although HZV can be administered to individuals younger than 60 years of age, this is not recommended by ACIP.
HZV should not be administered to a patient with a history of anaphylaxis to:
LO 3.3; Module 3— Herpes Zoster, Contraindications and Precautions Gelatin can be found in the MMR vaccine, rabies vaccine, typhoid vaccine, varicella vaccine, yellow fever vaccine, herpes zoster vaccine (HZV), and any combination vaccines that include these. A patient with a severe allergy to gelatin would have a contraindication to receiving these vaccines. HZV also contains neomycin, but does not contain egg protein, latex, or tree nuts.
A history of anaphylaxis caused by neomycin would be a contraindication to receiving which of the following vaccines?
LO 3.3; Module 3—Poliomyelitis, Contraindications and Precautions Neomycin can be found in hepatitis A vaccine, inactivated polio vaccine (IPV), MMR, rabies vaccine, smallpox vaccine, varicella vaccine, zoster vaccine, several influenza vaccines, and any combination vaccines that include these. A patient with a severe allergy to neomycin would have a contraindication to receiving these vaccines.
Arthus reactions, which are exaggerated local reactions that can occur if a patient is vaccinated too frequently, are most commonly reported after which vaccine?
LO 3.3; Module 3—Tetanus, Diphtheria, and Pertussis. Potential Adverse Reactions. The most common adverse reactions associated with tetanus and diphtheria toxoids-containing vaccines are local injection-site reactions. These injection-site reactions are usually mild and self-limiting. However, Arthus reactions have been reported after administration of these vaccines. An Arthus reaction after vaccination with tetanus and diphtheria toxoids is not an allergic reaction and is not common. However, these reactions may occur if a patient is immunized with tetanus or diphtheria toxoids too frequently. Patients with a history of Arthus reactions after vaccination should not receive doses of Td or Tdap any more frequently than every 10 years. Arthus-type reactions have not been associated with other types of vaccines.
Which vaccine does ACIP recommend for all college freshmen, aged 21 years or younger, living in dormitories, who have not been previously vaccinated?
LO 3.4; Module 3— Meningococcal Disease, Target Groups for Vaccination Routine vaccination with the quadrivalent meningococcal conjugate vaccine (MenACWY or MCV4) is one dose at ages 11 to 12 years and a booster dose at age 16 years. A first-year college student aged 21 years or younger living in residential housing who has not been previously vaccinated with MCV4 is considered high-risk for meningococcal disease. One dose should be administered. Living in dormitories on a college campus is not considered a risk factor for pneumococcal disease, HPV, or varicella.
Which of the following immunization strategies is preferred for adults under the age of 65 years with immunocompromising conditions who require both PCV13 and PPSV23?
LO 3.4; Module 3— Pneumococcal Disease, Vaccine Recommendations Ideally, when individuals require both PCV13 and PPSV23, PCV13 should be given first. For those with immunocompromising conditions at high-risk for pneumococcal disease, the interval between PCV13 and PPSV23 is at least 8 weeks. This 8-week interval also applies to those with asplenia, cochlear implants, and cerebrospinal fluid leaks. All others would wait at least one year between the two vaccines.
When Mary turned 64, she was diagnosed with type 2 diabetes. At that time, she received PPSV23. Which of the following represents appropriate pneumococcal coverage for Mary.
LO 3.4; Module 3— Pneumococcal Disease, Vaccine Recommendations Immunocompetent adults aged 65 years or older should receive 13-valent pneumococcal conjugate vaccine (PCV13) followed by 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least 1 year after PCV13. However, if an individual is a candidate for PPSV23 prior to age 65 due to high-risk conditions (in this case diabetes), then another dose of PPSV23 would be recommended after the individual turns 65, but should be given 5 years after the 1st dose. Since Mary received PPSV23 prior to PCV13, then PCV13 should be administered at least one year after PPSV23.
According to ACIP recommendations, what is the maximum number of doses of PPSV23 a patient should receive in his or her lifetime?
LO 3.4; Module 3— Pneumococcal Disease, Vaccine Recommendations Immunocompromised individuals and those with asplenia should receive two doses of PPSV23 five years apart. If the second dose was administered prior to age 65, then a third dose would be given after the individual turns 65 (and five years after the previous dose). It is possible for these individuals to receive up to three doses of PPSV23. However, there are no circumstances in which more than three doses would be recommended.
If a patient is a candidate for revaccination with PPSV23, what is the ACIP-recommended interval between doses of this vaccine?
LO 3.4; Module 3— Pneumococcal Disease, Vaccine Recommendations Individuals at high-risk for pneumococcal disease may require one to three doses of PPSV23, depending on age and condition. When multiple doses are required, the interval between doses should be 5 years. For example, individuals under the age of 65 who are immunocompromised or have asplenia should receive two doses of PPSV23 five years apart. If the second dose was administered prior to age 65, then a third dose would be given after the individual turns 65 (and five years after the previous dose).
Barbara is a 60-year-old woman who presents to the pharmacy for two vaccines: HZV and IIV. Which of the following are the appropriate doses and routes for administering these vaccines to this patient?
LO 3.4; Module 3— Storage and Administration of Herpes Zoster Vaccine and Table 3.2 The dose of the herpes zoster vaccine (Zostavax) is 0.65 mL. It is administered subcutaneously in the outer aspect of the upper arm. Inactivated influenza vaccines are administered intramuscularly into the deltoid muscle. The dose for individuals aged 3 years and older is 0.5 mL.
Alan is a 47-year-old man who has no documentation of a primary series of tetanus-containing vaccine. Which of the following would be an appropriate primary series for Alan?
LO 3.4; Module 3— Target Groups for Vaccination. DTaP Vaccine DTaP contains higher amounts diphtheria toxoid and pertussis than Tdap. It is only used in children less than 7 years of age to avoid injection site reactions in adolescents and adults. Individuals 7 years of age and older who need protection against tetanus, diphtheria, and pertussis should receive Tdap, not DTaP. Adults with an unknown or incomplete history of a 3-dose primary series with tetanus and diphtheria toxoid-containing vaccines should complete the primary series. The initial dose in this series should be Tdap. The second dose should be Td given at least 4 weeks later. The third dose, also using Td, should be 6-12 months after the second dose. A booster of Td is then given every 10 years after the third dose.
After completion of a primary vaccine series and documentation of a one-time dose of Tdap, Td booster doses are recommended every:
LO 3.4; Module 3— Target Groups for Vaccination. Td Vaccine Following the one-time dose of Tdap that is given after the primary series has been completed, a Td booster should be given every 10 years.
Tom is a 9-year old boy who has never had an influenza vaccine. Tom's mother shows you his up-to-date immunization record and reports that he has never had any adverse reactions to vaccinations. What dose and schedule of IIV should be administered to Tom?
LO 3.4; Module 3— answer in table 3.4. Influenza vaccination is universally recommended beginning at age 6 months. Children aged 6 months through 8 years who have not previously received at least two dose of the influenza vaccine should receive 2 doses, 4 weeks apart. Beginning at age 9, children only need one dose during an influenza season. The dose of influenza vaccine is 0.25 mL for children aged 6 months through 2 years. Children 3 years of age and older would get 0.5 mL.
Alex is a 32-year-old man who is scheduled to travel to a country where hepatitis A is endemic. He leaves in 3 weeks and will be gone a month. He received his first dose of hepatitis A vaccine today. Alex should be counseled to return for his second dose of hepatitis A vaccine:
LO 3.4; Module 3—Hepatitis A, Vaccine Recommendations Adults needing protection from the hepatitis A virus should receive a two-dose series. The second dose should be given at least 6 months after the first dose.
Which of the following vaccines may be administered to boys and young men aged 9 through 26 years to reduce the likelihood of acquiring genital warts?
LO 3.4; Module 3—Human Papillomavirus, Target Groups for Vaccination The human papillomavirus (HPV) is a sexually transmitted disease. High-risk strains are known to cause a variety of cancers. However, other low-risk HPV strains also cause the majority of cases of genital warts. The 9-valent HPV vaccine provides protection against two of the strains known to cause genital warts (6 and 11). 9vHPV may be given to both males and females ages 9 through 26 years and is routinely recommended at ages 11 or 12 years.
HPV vaccine is recommended for which of the following individuals?
LO 3.4; Module 3—Human Papillomavirus, Vaccine Recommendations According to ACIP, both males and females between ages 9 through 26 years may receive the HPV vaccine. It is routinely recommended at 11 or 12 years of age.
Which of the following patients should receive the MMR vaccine?
LO 3.4; Module 3—Measles, Mumps, Rubella, Vaccine Recommendations MMR is a live vaccine and is not generally recommended until 12 months of age. A 2-dose series should be administered at 12 through 15 months and 4 through 6 years. No additional doses are needed. Adults who do not have evidence of immunity should receive one dose. Evidence of immunity includes being born before 1957, documentation of MMR vaccination, or laboratory evidence of disease. However, health care personnel should receive two doses.
Which of the following patients is a candidate for both MenACWY and MenB vaccines?
LO 3.4; Module 3—Meningococcal Disease, Target Groups for Vaccination Even though the quadrivalent meningococcal conjugate vaccine (MenACWY or MCV4) and the serogroup B meningococcal vaccine both provide protection against meningococcal disease, the risk of infection for the various strains and age indications of vaccines differ. Both are recommended during outbreaks of the respective serogroup(s) as well as for individuals with functional or anatomic asplenia and persistent complement component deficiencies. While MenACWY can be used beginning at age 2 months, MenB is not recommended for use until age 10 years. HIV infection and being in the military are considered risk factors for the serogroups in MenACWY, but not serogroup B.
Adolescents should be routinely vaccinated with MCV4 on the following schedule:
LO 3.4; Module 3—Meningococcal Disease, Target Groups for Vaccination Routine vaccination with the quadrivalent meningococcal conjugate vaccine (MenACWY or MCV4) is one dose at ages 11 to 12 years and a booster dose at age 16 years. According to ACIP, adding this booster dose substantially reduces the number of cases and deaths due to meningococcal disease while the initial dose serves to protect the younger adolescents.
A 69 year-old man received Td vaccination 4 years ago. He is preparing to travel to see his newborn granddaughter next month. Which of the following vaccines containing tetanus, diphtheria, and/or pertussis would be most appropriate for him?
LO 3.4; Module 3—Pertussis. Target Groups for Vaccination. Tdap Vaccine. According the the ACIP recommendations, all adults who have not received tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap) or for whom pertussis vaccination status is unknown should receive 1 dose of Tdap followed by a tetanus and diphtheria toxoids (Td) booster every 10 years. Tdap should be administered regardless of when a tetanus or diphtheria toxoid-containing vaccine was last received.
RotaTeq (RV5) should be administered as a
LO 3.4; Module 3—Rotavirus, Vaccine Recommendations There are two live, oral vaccines available to prevent rotavirus. However, the dosing differs between the two. RotaTeq (RV5) is administered orally in a 3-dose series, with doses administered at ages 2, 4, and 6 months. Rotarix (RV1) is administered orally in a 2-dose series, with doses administered at ages 2 and 4 months.
Justin is a healthy 16-year-old boy who has no documentation of varicella vaccine or history of the disease. He should receive:
LO 3.4; Module 3—Varicella Vaccine Recommendations Anyone aged 7 years and older without evidence of immunity to varicella should receive 2 doses of varicella vaccine. Children aged 7 through 12 years should receive 2 doses 3 months apart. However, if the second dose was administered at least 4 weeks after the first dose, it can be considered valid. Individuals aged 13 years and older should receive 2 doses at least 4 weeks apart.
According to the Advisory Committee on Immunization Practices (ACIP), which of the following would be considered adequate evidence of immunity to varicella, indicating that administration of varicella vaccine is unnecessary?
LO 3.4; Module 3—Varicella. Target Groups for Vaccination. According to ACIP, evidence of immunity to varicella is documentation of 2 doses of varicella vaccine at least 4 weeks apart; history of varicella or herpes zoster diagnosis or verification of varicella or herpes zoster disease by a health care provider; laboratory evidence of immunity or disease; or for women who are not pregnant, immunocompetent individuals, and individuals who are not health care providers, born in the U.S. before 1980. Given the likelihood of false positive reports, self-reporting is no longer considered evidence of immunity
Which of the following best describes how to administer MMR vaccine to an adult patient weighing 210 lb?
LO 4.10; Module 4— General Injection Principles The MMR vaccine is administered subcutaneously at a 45 degree angle into the outer aspect of the upper arm. Vaccines that are given intramuscularly are administered into the deltoid muscle at a 90 degree angle. The weight of the patient does not matter with regard to route of administration.
Which of the following best describes how to administer Tdap vaccine to an adult patient weighing 185 lb?
LO 4.10; Module 4— General Injection Principles The Tdap vaccine is administered intramuscularly into the deltoid muscle. Intramuscular injections should be administered at a 90 degree angle. Vaccines that are given subcutaneously are administered at a 45 degree angle into the outer aspect of the upper arm. The weight of the patient does not matter with regard to route of administration.
What is the minimum needle length recommended for administering HepB vaccine to an adult patient weighing 130 lb?
LO 4.10; Module 4— General Injection Principles The hepatitis B vaccine is administered intramuscularly into the deltoid muscle in individuals three years of age and older. The needle must be long enough to reach deep into the muscle. Fixed 1-inch needles are acceptable for patients weighing 60 kg (132 lb) or less.
What is the standard dose of epinephrine for managing anaphylaxis?
LO 4.11; Module 4—Anaphylaxis Preferably, epinephrine is dosed on the basis of the patient's body weight. Aqueous epinephrine (1 mg/mL preparation) should be administered at a dose of 0.01 mg/kg/dose, up to a maximum of 0.5 mg per dose. The dose of epinephrine can be repeated every 5-15 minutes (according to the patient's response), up to three doses.
Even though state laws may have specific mandates, how long should pharmacists maintain records of immunizations?
LO 4.12; Module 4—Keeping Immunization Records Immunizations should become part of the patient's permanent record and should be kept for the patient's lifetime.
Which of the following best describes an opportunity for pharmacists to use diagnosis-based screening to identify people at risk for vaccine-preventable diseases?
LO 4.2; Module 4—Identifying People at Risk for Vaccine-Preventable Disease There are two main approaches for determining who needs a vaccine: universal immunization and high-risk targeting. Three screening strategies can be used to identify people at high-risk: diagnosis-based screening, procedure-based screening, and occurrence-based screening. Diagnosis-based screening identifies patients in need of vaccines based on the presence of a particular diagnosis (in this case, diabetes). Procedure-based screening involves assessing vaccine needs based on a patient's receipt of a surgical, medical, or pharmacy-based procedure (in this case, a splenectomy). Occurrence-based screening takes advantage of an event, such as a hospital admission, clinic visit, or emergency department visit to identify people who need to be vaccinated (in this case, discharge counseling).
When looking at the schedule for vaccines that might be indicated for children and adolescents aged 18 years or younger based on medical indications, what does the orange bar represent?
LO 4.3, answer from 2017 childhood schedule The schedule for vaccines that might be indicated for children and adolescents aged 18 years or younger based on medical indications includes six different color-coded bars. Yellow indicates that vaccination according to the routine schedule is recommended. Purple is for vaccines that are recommended for persons with an additional risk factor for which the vaccine would be indicated. The yellow and black checkered bar indicates that vaccination is recommended, and additional doses may be necessary based on medical condition. The footnotes will need to be used for further guidance. A white bar means that there is no recommendation. Red means the vaccine is contraindicated and orange indicates there is a precaution for vaccination.
If a patient received the first dose of HepB but did not return for the remaining doses in the series, under what circumstances should the HepB series be restarted?
LO 4.3; Module 4—Immunization Catch-Up Schedule for Children and Adolescents If patients fall behind with vaccinations given in a multi-dose series, it usually is not necessary to start the series over; oral typhoid is the one exception. Increasing the interval between doses of a multi-dose vaccine series does not diminish the ultimate effectiveness of the vaccine, but it does delay protection for the patient.
For a patient who needs to receive IIV and HZV, which of the following best describes appropriate administration of these vaccines?
LO 4.4; Module 4— Timing and Spacing of Vaccine Doses and General Injection Principles. IIV is the inactivated influenza vaccine and HZV is the live, attenuated herpes zoster vaccine. Inactivated vaccines do not interfere with the immune response to other vaccines, live or inactivated. There is no need to observe any minimum interval between doses of two different inactivated vaccines, nor between combinations of inactivated and live vaccines. The concern is when two live vaccines are not administered at the same clinic visit. If two live vaccines are not given simultaneously, at least 4 weeks must pass before giving the other live vaccine.
Which of the following key questions is important to ask a patient before administering IIV?
LO 4.5; Module 4— Screening for All Vaccines When screening patients prior to vaccination, there are a variety of questions to ask depending on the vaccines to be administered. The purpose of screening is to determine if there are any precautions or contraindications to the respective vaccines. Before giving any vaccine, it is important to determine how the patient is feeling. It is okay to administer vaccines if the patient has a mild illness, such as low-grade fever, mild respiratory tract infection, mild diarrhea, or otitis media. However, if the patient has moderate to severe acute illness that requires additional care, it is advised to defer vaccination until the illness resolves. Antibodies and blood products may interfere with the replication needed by live vaccines to elicit an immune response. This is an important question for all live vaccines. If any live vaccines were administered within the past 4 weeks, no additional live vaccines can be administered until at least 4 weeks have passed. If a patient's immune system is suppressed due to certain cancers, HIV, immunosuppressive medications, or other immune-suppressing conditions, then live vaccines are usually contraindicated because immunosuppression may reduce vaccine efficacy as well as pose a risk for disseminated infection with the normally attenuated pathogen in the live vaccine. On the other hand, immunosuppression may indicate the need for certain inactivated vaccines (e.g., influenza, pneumococcal). Because the inactivated influenza vaccine (IIV) is not a live vaccine, the questions pertaining to live vaccines do not need to be asked.
Which of the following statements would be accurate when responding to a patient's concerns about the safety of vaccines?
LO 4.7; Module 4— Countering Myths and Misperceptions About Vaccines Injectable influenza vaccine is inactivated (i.e., killed), thus it is impossible for this vaccine to cause influenza. The intranasal influenza vaccine is a live vaccine, but the virus has been modified so that it cannot cause disease. No vaccine is 100% effective and efficacy varies depending on the vaccine. Furthermore, if illness does occur in someone vaccinated, it is often less severe. Thimerosal is a mercury-containing compound that has been used for decades as a preservative in vaccines to prevent bacterial contamination. There is no scientific evidence showing any short- or long-term harm from exposure to thimerosal in vaccines. One myth that has circulated about vaccines is that some manufacturer lots are associated with higher incidences of adverse events reported to VAERS (i.e., hot lots). To date, no vaccine lot in the modern era has been found to be unsafe on the basis of VAERS reports. There is a misperception that giving several vaccines on the same day overloads the patient's immune system. In immunocompetent people of any age, the immune system is fully capable of eliciting an appropriate immune response to multiple antigens administered on the same day through vaccination. In fact, a person's immune system is exposed to more antigens every day from food or bacteria in the mouth and nose than from some vaccines.
In the event that a young child is fussy following the receipt of a vaccine, pharmacists should advise parents to:
LO 4.8; Module 4—Common Adverse Events Young children may experience drowsiness, fretfulness, or poor appetite following vaccination. Parents should be advised to plan quiet activities and comfort their children as needed. Children's formulations of acetaminophen or ibuprofen can be used to relieve local discomfort, if needed. Aspirin is not recommended for use in children. If more serious adverse reactions occur, parents should be instructed to seek emergency care and to follow up with the pediatrician as necessary.
There should be a flat hard surface in the area where vaccines will be administered to ensure:
LO 5.2; Module 5—The Immunization Area The location for vaccine administration should have space for the patient to faint without being injured, and a flat surface for the patient to lie on if fainting occurs or if the pharmacist needs to perform CPR.
Which of the following is a requirement of the Occupational Safety and Health Administration's (OSHA's) Bloodborne Pathogens Standard?
LO 5.3; Module 5—Occupational Safety and Health Administration. The Needlestick Safety and Prevention Act of 2000 directed OSHA to redesign its Bloodborne Pathogens Standard to provide more detail in the OSHA guidelines for employers to identify, evaluate, and implement safer medical devices.This Act mandates the use of safety devices and health care employers must provide safety devices to employees to reduce the risk of occupational exposure to bloodborne pathogens. Following injection, the safety device on the syringe should be immediately activated. Used needles should never be clipped nor recapped. Preexposure vaccination with hepatitis B vaccine must be offered by the employer to all employees with job responsibilities with potential exposure to bloodborne pathogens. There is no such requirement for hepatitis A since this is not considered a bloodborne pathogen. The OSHA Bloodborne Pathogens Standard requires the employer to provide training for all personnel with potential exposure to bloodborne pathogens. OSHA training must be repeated at least annually.
If a vial of influenza vaccine is left out of the refrigerator on the pharmacy counter overnight, what should be done with the vaccine?
LO 5.4; Module 5— Vaccine Storage and Handling. If a vaccine has been exposed to temperatures outside the recommended range, the vaccine should be quarantined and stored in the refrigerator or freezer (as appropriate based on where the vaccine should usually be stored). In the case, the IIV should be placed back in the refrigerator. This quarantined vaccine should be clearly marked "do not use" and the manufacturer should be contacted for further guidance. Pharmacists should document each of these steps any time there is a break in the cold chain.
Which of the following statements about establishing clinics for administering vaccines is true?
LO 5.5; Module 5— Workflow Processes and Options Year-round vaccine programs more readily lend themselves to being managed as prescriptions within the usual pharmacy workflow, whereas seasonal or high-demand vaccines may be better suited for clinics during which additional resources and time can be devoted. Immunization clinics can be held in pharmacies as well as other venues, such as businesses (including health care organizations which have a need to immunize providers), schools, houses of worship, community centers, and other community gathering areas. Pharmacy technicians can serve an important role during clinics to help manage workflow, such as providing paperwork (e.g., VISs, screening questionnaires). Each state dictates the duties a student pharmacist may perform, which may or may not include vaccine administration.
HealthMap Vaccine Finder is a free online tool that allows pharmacists to:
LO 5.6; Module 5—Marketing Materials Pharmacists also can list their vaccine service with the HealthMap Vaccine Finder, which is a free marketing tool. To participate in HealthMap Vaccine Finder, vaccine providers create an account at flushot.healthmap.org/admin/signup and enter information on their immunization services regarding several kinds of influenza vaccines and other adult vaccines. People wanting to be vaccinated can go to the website, flushot.healthmap.org, and enter their zip code to locate vaccine providers in their area.
What is the type of immunity that occurs when a pregnant woman is vaccinated with Tdap to protect the infant from pertussis after birth?
LO2. 1; Module 2—Passive vs. Active Immunity Acquired immunity involves immunological memory. It is something the body develops upon exposure to pathogens or antigens and results in antigen-antibody complex formation. Cell-mediated immunity is a component of acquired immunity and destroys pathogens that have entered cells. Acquired immunity can be active or passive. Active immunity occurs when an antigen from an invading pathogen or a vaccine triggers the immune system to respond. Passive immunity happens when antibodies are provided from another source, such as or upon receipt of blood products or immunoglobulin when maternal antibodies are transferred to the fetus. This is the reason Tdap is given with every pregnancy—the maternal antibodies passed to the fetus protect the newborn from pertussis.
Robert is a 48-year-old pharmacist who is preparing to provide immunizations in his pharmacy for the first time next fall. He has no documentation of receiving the hepatitis B vaccine and would like to be vaccinated before administering vaccines in his practice. What is the recommended routine schedule for vaccination against hepatitis B?
LO3 .4; Module 3—Hepatitis B, Vaccine Recommendations Hepatitis B vaccine is routinely given as a 3-dose series. For adults seeking protection against the hepatitis B virus, the routine schedule is 0, 1, and 6 months.
During which step of the Pharmacists' Patient Care Process would a pharmacist analyze a patient's need for certain vaccines?
LO4.1; Module 4— Applying the Pharmacists' Patient Care Process to Immunization Services The Pharmacists' Patient Care Process incorporates five steps to providing patient-centered care (collect, assess, plan, implement, and follow-up). Each of these can be applied to immunization services. Collect: the pharmacist collects the information that is necessary to determine which vaccinations may be indicated. Assess: the pharmacist assesses the information collected and analyzes the need for vaccines in accordance with the ACIP recommendations. Plan: the plan should include an offer to immunize, as appropriate, as well as pertinent areas of education for the patient, including education about vaccine-preventable diseases, vaccines, and how vaccines can help the patient. Implement: The pharmacist implements the care plan in collaboration with a patient or caregiver and physician or other health care professional, as appropriate. Follow-up: includes appropriate monitoring and management of possible adverse reactions, which may range from injection-site reactions to more severe reactions such as syncope and anaphylaxis. A follow-up plan should be created for patients who initially decline a vaccine recommendation, who may have temporary contraindications, or precautions, or those referred to another immunization provider. In addition, follow-up plans are required for patients who require additional immunizations to complete a vaccine series.
What is meant by the term "immunization neighborhood"?
Module 1—Collaborating to Improve Vaccination Rates. The immunization neighborhood is a term coined by the American Pharmacists Association to describe the "collaboration, coordination, and communication among immunization stakeholders dedicated to meeting the immunization needs of the patient and protecting the community from vaccine-preventable diseases."
Which entity determines the specific vaccines that a pharmacist may administer?
Module 1—Expanding Vaccination Offerings A pharmacist's scope of practice and immunization authority are determined by the pharmacist's state practice act. As such the laws and regulations for pharmacists as immunizers vary by state. The U.S. Food and Drug Administration provides the regulatory oversight for the approval of vaccines. The Advisory Committee on Immunization Practices is the leading authority in the U.S. that provides comprehensive vaccination recommendations and guidelines. These recommendations are reviewed and approved by the CDC. The local health departments do not have any oversight regarding a pharmacist's immunization practices. However, pharmacists often work with their local health departments to provide vaccines and public health services.
Which type of vaccine involves stimulation of B cells without the assistance of T helper cells?
Module 2—Polysaccharide and Conjugated Vaccines A pure polysaccharide vaccine does not require T-helper cells to produce an immune response. It is mediated solely through B cells. As such, they are T cell-independent. The immune systems in children younger than 2 years of age are too immature to mount an immune response by this method. In addition, there is no booster effect and any immunity developed is relatively short-lived. When a polysaccharide vaccine is altered by adding a protein, it is considered conjugated. The immune response changes to one that is T cell-mediated. This mechanism allows children younger than 2 years of age to form an immune response. Conjugated vaccines provide longer-lasting protection. A recombinant vaccine is made by using recombinant DNA technology. Both live attenuated vaccines and recombinant vaccines mimic natural infection and involve T cells in the immune response.
What is the most common complication of pertussis?
Module 3 - Pertussis Pertussis, which is is caused by Bordetella pertussis, infects the respiratory tract and produces toxins that interfere with the function of the respiratory tract, ultimately causing the characteristic symptoms of pertussis. Symptoms begin as they would for the common cold but then transition to the paroxysmal (whooping) cough. Given the impact on the respiratory tract, pneumonia is the most common complication. Poor oxygenation during the coughing episodes can lead to hypoxemia and seizures, but these are less common. Colic is inconsolable crying, which has been attributed to abdominal pain. This is unrelated to pertussis.
Which disease is characterized by the development of a membrane on the tonsils, pharynx, or larynx, leading to respiratory obstruction?
Module 3—Diphtheria Diphtheria is caused by Corynebacterium diphtheriae, which enters the body through the respiratory tract. C. diphtheriae can infect any mucous membrane in the body, with the most common sites being the tonsils, pharynx, larynx, and nasal mucosa. The infection can cause tissue destruction and usually results in the formation of a pseudomembrane, which is a characteristic sign of diphtheria infection. This bluish-white membrane develops on the tonsils and pharynx within 2 to 3 days. As the membrane extends into the airway, it can lead to respiratory obstruction. Bordetella pertussis, infects the respiratory tract and produces toxins that interfere with the function of the respiratory tract, ultimately causing the characteristic symptoms of pertussis. Symptoms begin as they would for the common cold but then transition to a paroxysmal (whooping) cough. Haemophilus influenza type b (Hib) is spread by respiratory transmission and most commonly causes pneumonia, bacteremia, and meningitis. Meningitis is an infection of the brain and spinal cord, which can lead to a variety of complications including brain damage and deafness.
Prior to the introduction of a vaccine, what was the leading cause of bacterial meningitis in children younger than 5 years of age?
Module 3—Haemophilus influenzae type b, Clinical Features and Potential Complications H. influenzae type b (Hib) is an aerobic gram-negative coccobacillus spread by respiratory transmission from asymptomatic carriers.Before the availability of vaccines, Hib affected 1 of every 200 children in the United States, accounting for more than 20,000 cases each year.It was the leading cause of bacterial meningitis in children younger than 5 years of age. Hib vaccines have been highly effective—disease incidence was reduced from 20,000 cases in 1985 to 17 cases reported in 2010.
Which viruses are associated with the development of cancer?
Module 3—Human Papillomavirus and Hepatitis B Human papillomavirus (HPV) is a sexually transmitted disease that infects epithelial cells. It is known to cause a variety of cancers, including cervical cancer. Hepatitis B is a bloodborne pathogen that replicates in the liver. It can cause a variety of complications, including liver cancer. Up to 80% of hepatocellular cancers are caused by hepatitis B. Hepatitis A is spread by the fecal-oral route. While it can cause a variety of liver problems, including inflammation, jaundice, dark urine, and, rarely, liver failure, it does not cause chronic infection or cancer. Neither the varicella virus, which includes herpes zoster, nor rubella have been linked with the development of cancer.
The presence of fever, diffuse maculopapular rash, and Koplik spots are characteristic of which of the following diseases?
Module 3—Measles, Mumps, Rubella. Measles The classic symptoms of measles include fever, cough, coryza (runny nose), conjunctivitis, Koplik spots (a bluish-white rash on mucous membranes, especially the mouth), followed by the development of a maculopapular rash approximately 14 days after exposure. Individuals infected with mumps may not have symptoms. Others may have nonspecific symptoms, such as headache, fever, myalgia, and malaise. About 30% to 40% of individuals may experience inflammation of the parotid glands. Rubella symptoms tend to be relatively mild and may present as a maculopapular rash that occurs approximately 14 days after exposure. Others may experience arthritis and arthralgia. Varicella presents as a generalized vesicular rash.
Which disease is almost certain to cause death if infected patients do not receive postexposure prophylaxis?
Module 3—Rabies Rabies is caused by a rhabdovirus, a group of RNA viruses. It is transmitted to humans via animal bites. Once the virus enters the body, it affects the central nervous system, causing acute encephalitis and neurologic dysfunction. While very few cases occur in the US each year, rabies is almost always fatal if not treated with rabies immune globulin for post-exposure management. Even though hepatitis B immune globulin (HBIG) is given as post-exposure prophylaxis to prevent hepatitis B infection, the case-fatality rate from acute hepatitis B is extremely low. Post-exposure prophylaxis is also available for measles and meningitis, but the mortality rate is also low for these infections.
Which of the following diseases are transmitted through mosquito bites?
Module 3—Vaccines for International Travel Mosquito-borne infections for which vaccines are available include yellow fever and Japanese encephalitis. Typhoid fever is spread by Salmonella typhi in food and water. Hepatitis A is spread via the fecal-oral route. Haemophilus influenzae type b and measles are spread by respiratory transmission.
Which of the following documents must be given to every patient or patient's caregiver before administration of a vaccine covered under the National Childhood Vaccine Injury Act (NCVIA)?
Module 4— Providing Vaccine Information Statements Vaccine information statemetns (VISs) are standardized forms that provide an overview of the risks and benefits of vaccines. Health care providers who administer vaccines are required by law to provide patients with the most up-to-date version of the VIS for any vaccine covered under the National Childhood Vaccine Injury Act (NCVIA). The CMS-1500 and CMS-855B are forms required by the Centers for Medicare and Medicaid Services (CMS) for billing and enrolling as a Medicare provider, respectively. The PHS-731 is now the CDC 731 form and is the International Certificate of Vaccination or Prophylaxis as Approved by the World Health Organization (the Yellow Card).
Which of the following is recognized by sociologists as a factor in a patient's decision whether to be vaccinated?
Module 4—Educating Patients About Vaccines. Sociologists have identified five key factors in a person's decision to be vaccinated: 1) perceived susceptibility to a disease, 2) perceived seriousness of a disease, 3) perceived vaccine benefits, 4) perceived vaccine barriers (e.g., adverse effects, access), and 5) social influence (e.g., recommendation from a health care provider)
Which of the following statements about pharmacy-based vaccination programs is true?
Module 5—Consider Community Needs. The vaccines that pharmacists are permitted to administer vary from state to state. Some states allow pharmacists to administer vaccines under protocol or collaborative practice agreement, while others require a prescription to administer a vaccine. Many pharmacists have initially implemented immunization services with influenza vaccine, due in part to the general high demand for the vaccine, as well as state laws that have supported this approach. Because pharmacists have the infrastructure to bill Medicare Part D prescription drug plans, it may be easier for them to offer these services for older patients and pharmacists could partner with other providers to increase immunization rates.
