Immunizations, Screening test guidelines,

HIGHLY RECOMMENDED PREVENTIVE SERVICES

"A" grade preventive healthcare services - Bacteriuria screening in pregnant women: via urine culture for pregnant women at first prenatal visit or 12-16 weeks' gestation - Blood pressure screening in adults: >18 - Cervical cancer screening: 21-65 y/o, in sexually active women with a cervix - Colorectal cancer screening: adults 50-75, fecal occult blood testing/sigmoidoscopy/colonoscopy - Folic acid supplementation: daily, 0.4-0.8 mg for all women planning to or capable of becoming pregnant - Gonorrhea prophylactic medication in newborns: prophylactic ocular topical medication against gonococcal ophthalmia neonatorum - HBV screening in pregnant women: first prenatal visit - Hemoglobinopathies screening in newborns: sickle cell disease screening - HIV screening: all adolescents and adults at increased risk - Hypothyroidism screening in newborns: congenital hypothyroidism screening - Rh incompatibility screening in pregnant women: Rh (D) blood typing and antibody testing, first prenatal visit - Syphilis screening in non-pregnant women and persons at high risk, pregnant women - Tobacco use counseling and interventions in adults, pregnant women

HIGHLY RECOMMENDED PREVENTIVE SERVICES

"B" grade preventive healthcare services - Abdominal aortic aneurysm screening in men: one-time ultrasound in men 65-75 who have ever smoked - Alcohol misuse counseling: screening and behavioral counseling in primary care settings - Aspirin to prevent cardiovascular disease in adults age 50-59 who have greater than 10 year life expectancy. - BRCA screening: women with positive family history for BRCA 1/BRCA 2 gene mutation, genetic counseling and evaluation - Breast cancer chemoprevention: women at high risk for breast cancer and low risk for chemoprevention adverse effects (inform patient of benefits and risks) - Breast cancer screening: mammography for women > 50, every 1-2 years - Breastfeeding counseling: interventions pre and postpartum to promote and support breastfeeding - Chlamydial infection screening in nonpregnant women: in sexually active women < 24, in high risk women > 24 - Hypercholesterolemia screening for men 20-35 y/o if at increased risk for coronary heart disease - Hypercholesterolemia screening for women 20-45 y/o if at increased risk for coronary heart disease - Dental caries chemoprevention in preschool children: children > 6 months, oral fluoride supplements - Depression screening in adolescents: 12-18 y/o, used if accurate diagnosis, psychotherapy and follow-up are possible - Depression screening in adults: when staff-assisted depression care supports are in place to ensure accurate diagnosis, treatment and follow-up - Diabetes screening: T2DM screening in asymptomatic adults 40-70 overweight or obese - Fall prevention in high risk adults: exercise, physical therapy and Vitamin D supplements - Gonorrhea screening in women: sexually active/pregnant women if at high risk for infection - Healthy-diet counseling: intensive behavioral dietary counseling for adults with hyperlipidemia and other known risk factors for cardiovascular/diet-related chronic disease; counseling by primary care clinician/nutritionist/dietitian - Hearing loss screening in newborns - Obesity screening and counseling in adults: for adults with BMI > 30 - Obesity screening and counseling in children: > 6 y/o - Osteoporosis screening in women: > 65 y/o, also in women whose fracture risk equals/exceeds that of 65 y/o white woman with no other risk factors - PKU screening in newborns - Rh incompatibility screening at 24-28 weeks'gestation: repeat Rh(D) antibody testing for all unsensitized Rh(D) negative women, unless father is known to be Rh(D) negative as well - STI counseling: all sexually active adolescents and adults at increased risk - Visual acuity screening in children: 3-5 y/o; amblyopia, strabismus, defects in visual acuity

COMMUNITY SCREENING: OBJECTIVES - Screening Programs targeting Risk Factors

- Behavioral: change in lifestyle (eg. smoking, unsafe sexual practices) - Environmental: change in occupation (eg. COPD) - Metabolic: treat/change in diet and lifestyle (eg. hyperlipidemia)

PASSIVE IMMUNIZATION: ANTITOXINS

- Botulinum antitoxin: treat botulism - Diphtheria antitoxin: treat respiratory diphtheria PASSIVE IMMUNIZATION: IMMUNE GLOBULIN: - Cytomegalovirus immune globulin, IV (CMV-IGIV): prophylaxis for hematopoietic stem cell and kidney transplant recipients - Hep B Immune Globulin (HBIG): Prophylaxis for HBV post exposure - Immune Globulin (IG): prophylaxis for HAV pre/pro exposure, measles post exposure, immunoglobulin deficiency, rubella during pregnancy first trimester, varicella. - IV immune globulin (IVIG): prophylaxis for bacterial/viral infections (HIV), primary immunodeficiency disorders, autoimmune thrombocytopenic purpura, chronic B-cell lymphocytic leukemia, Kawasaki disease, several autoimmune disorders (myasthenia gravis, guillan barre syndrome), graft-vs-host disease. - Subcutaneous immune globulin (SCIG): treat primary immunodeficiency disorders - Rabies immune globulin (HRIG): rabies postexposure in those not immunized with rabies vaccine - Respiratory syncytial virus immune globulin, intravenous (RSV-IVIG): prevent RSV in premature infants or children with chronic lung disorders - Tetanus immune globulin (TIG): treat tetanus, postexposure prophylaxis in those not immunized with tetanus toxoid - Varicella-zoster immune globulin (VZIG): postexposure prophylaxis in immunocompromised, susceptible pregnant women, perinatally exposed neonates

PREVENT DEFICIENCY STATES (Another type of specific protection):

- Food and H2O has been fortified with specific nutrients - Iodine in salt to reduce goiter - Vit D in milk to reduce rickets - Fluoridated H2O to reduce dental caries - Folic acid in cereal grains to reduce fetal defects - Breakfast cereals: many vitamins and minerals

COMMUNITY SCREENING PROGRAMS - Involve four conditions

- Hypertension: sphygmomanometer reading of blood pressure - Hypercholesterolemia: blood screening - Cervical cancer: Papanicolaou smear - Ovarian cancer: CT screening considered but rejected (did not meet minimum requirements of community screening programs)

Types of vaccines

- Inactivated/Killed: Influenza, inactivated polio - Live attenuated/Altered: TB vaccine, measles, oral polio - Toxoids: inactivated/altered bacterial exotoxins: Diphtheria, tetanus. Newer vaccines use genomic methods to identify and replicate antigenic sequences of base pairs that are recognized by T/B cells to then stimulate antibody production. Trivalent: against 3 dif organisms. Quadrivalent: Against 4 dif.

Screening Breast CA

- Majority of mammograms yield false positive results - Majority of mammograms result in unnecessary diagnosis/treatment of harmless lesions such as ductal carcinoma in situ (DCIS: may or may not progress to invasive carcinoma, but are always treated as though they will progress, which is costly and traumatic) ** Many true positive mammograms detect cancers too late for cure of patient >> For every 2000 women screened over 10 years: - 1 will have prolonged life - 10 otherwise healthy women will have unnecessary tests/treatment as a result of screening. - > 200 women will experience months of psych distress due to false positives. TEST RATING: B for women 50-74 C: 40-49 y/o

Prostate CA

- PSA tests often yield false positives - PSA tests can lead to unnecessary invasive testing (biopsy etc.) - Serious harm caused by dx and tx of lesions found due to PSA test in otherwise non-problematic pt's (most men die w/ prostate CA, not of prostate CA) > TEST RATING: D in gen pop. - necessary to personalize screening decisions

COMMUNITY SCREENING: OBJECTIVES - Screening Programs targeting Disease

- Reduce mortality via treatment (eg. cancer) - Prevent complications via treatment (eg. hypertension) - Eradicate infection and prevent spread via treatment (eg. gonorrhea, syphilis, tuberculosis) - Change diet and lifestyle (eg. CAD, T2DM)

ADULT VACCINATION GUIDELINES: IMMUNOCOMPROMISED

- Required: * Influenza: 1 dose annually * Tetanus, diphtheria, pertussis (Td): 1 time dose Td booster, then boost every 10 years * HPV male and female: 3 doses through age 26 * Pneumococcal 13-valent conjugate: 1 dose * Pneumococcal polysaccharide: 1 or 2 doses - Recommended: * Meningococcal: >1 dose * HAV: 2 doses * HBV: 3 doses - Contraindicated * Varicella, Zoster, MMR

ADULT VACCINATION GUIDELINES: HEALTHCARE PERSONNEL

- Required: * Influenza: 1 dose annually * Tetanus, diphtheria, pertussis (Td): 1 time dose Td booster, then boost every 10 years * Varicella: 2 doses * HPV: 3 doses through age 21 (male) or 26 (female) * Zoster: 1 dose * MMR: 1 or 2 doses * HBV: 3 doses - Recommended: * Pneumococcal 13-valent conjugate: 1 dose * Pneumococcal polysaccharide: 1 or 2 doses * Meningococcal: >1 dose * HAV: 2 doses * HiB: 1 or 3 doses

ADULT VACCINATION GUIDELINES: PREGNANCY

- Required: * Influenza: 1 dose annually * Tetanus, diphtheria, pertussis (Tdap): 1 dose each pregnancy - Recommended: * Pneumococcal polysaccharide: 1 or 2 doses * Meningococcal: > 1 dose * HAV: 2 doses * HBV: 3 doses - Contraindicated: * Varicella, Zoster, MMR

ADULT VACCINATION GUIDELINES: DIABETES

- Required: * Influenza: 1 dose annually * Tetanus, diphtheria, pertussis (Td): 1 time dose Td booster, then boost every 10 years * Varicella: 2 doses * HPV: 3 doses through age 21 (male) or 26 (female) * Zoster: 1 dose * MMR: 1 or 2 doses * Pneumococcal polysaccharide: 1 or 2 doses * HBV: 3 doses - Recommended: * Pneumococcal 13-valent conjugate: 1 dose * Meningococcal: >1 dose * HAV: 2 doses * HiB: 1 or 3 doses

CLINICAL PREVENTIVE SERVICE: RANKING ACCORDING TO COST-EFFECTIVENESS

-> 10- most cost effective; 2- least cost effective 10: * daily aspirin use discussion: men > 40, women > 50 * child immunizations 9: * Smoking cessation and help to quit in adults. * alcohol screening and brief counseling in adults 8: * Colo rectal CA: >50 * HTN screening and treatment: > 18 Influenza immunizations: > 50 * Vision screening: > 65 7: * Cervical CA screening in women * Cholesterol screening and treatment: men > 35, women >45 * Pneumococcal immunizations: > 65 6: * Breast CA screening: >40 * Chlamydia screening: in sexually active women < 25 5 * Discuss folic acid use in women of childbearing age * Obesity screening in adults 4: * Depression screening in adults * Hearing screening: > 65 * Injury prevention counseling: parents w/ children < 4 * Osteoporosis screening: Women > 65 2: * Cholesterol screening: Men < 35, women < 45 at high risk * DM screening: adults at risk * Diet and counseling: adults at risk * Tentanus-diphteria booster: adults

ADULT VACCINATION GUIDELINES:

-Many adult immunizations build on the foundation immunity provided by childhood vaccinations- boosters - If adult was never immunized, the vaccinations need to be administered immediately - All significant post-vaccination reactions need to be reported to the Vaccine Adverse Event Reporting: http://www.vaers.hhs.gov/ - Pneumococcal vaccines should be admin once to pt's with chronic disease at increased risk for severe pneumococcal infection outcomes: smokers, pt's in long- term care facilities. - Flu vaccines should be given to ALL individuals > 6 months old, each yr in late autumn - HAV: recommended for individuals that travel, have significant occupational exposure, engage in homosexual activities and use illicit drugs. - Traveling to underdeveloped countries: HAV, HBV, Typhoid, Cholera, Yellow fever, Polio etc.

1) Vaccine: 2) Vaccination: 3) Immunization:

1) Substance that creates immunity against a disease; inject-able/oral/aerosolized. 2) Injection consisting of killed/weakened organism creating immunity against organism 3) Process by which individual becomes protected against disease.

1) Passive immunity

1) circulating antibodies that protect against infectious disease. Antibodies bind to antigen and mark it for destruction. - Incomplete, short term immunity - individual becomes immune very fast. (useful for immuno-compromised pt's) > i.e. Fetus, newborns: maternal antibodies transferred through the placenta and milk > Recent Hep B virus (HBV): exposure in those not immunized with HBV: give victim human immune globulin, confers passive immunity to the person receiving the vaccine > Emergency situations: Specific antitoxins.

ADULT VACCINATION GUIDELINES: REQUIRED to be Up-to-date

> 19 y/o: * pneumococcal: 1 dose * Meningococcal: > 1 dose * HAV: 2 * HBV: 3 * HiB: 1 or 3 - 19 y/o * Influenza: 1 dose annually * Td (tetanus, diphtheria, pertussis): 1 time dose of Td booster, then boost every 10 years * Varicella: 2 doses - 19-26 y/o: * HPV - fem: 3 doses male: 3 doses required only until 22 y/o - 19-55 y/o: * MMR: 1 or 2 doses > 60 y/o: *Zoster: 1 dose > 65 y/o: * Pneumococcal polysaccharide: 1 dose

ANTIMICROBIAL PROPHYLAXIS:

Another form of specific protection - Oral chemoprophylaxis for endemic malaria regions, Plasmodium - Chloroquine phosphate/mefloquine before and during travel, followed by primaquine for some weeks after returning home - Tuberculosis: * Latent TB diagnosed via PPD test, should be treated to prevent active PPD * Prophylaxis: Isoniazid daily for 6-9 months Criteria for positivity: - > 5mm * HIV + pt's * recent contact with TB + patients * Fibrotic changes on CXR consistent with prior TBn * Organ transplant/immunosuppressed pt's (> 15 mg/day prednisone for > 1 month) - > 10 mm: * Recent immigrants (last 5 years) * IV drug users * High risk residents/employees: prisons/jails, nursing homes/ long term facilities for elderly, hospitals/ HC facilities, residental facilities for AIDS pt's, homeless shelters, mycobacteriology lab personnel. * High risk conditions: Silicosis, DM, Renal failure, hematologic disorders, weight loss > 10% ideal weight. * Infants/children < 4 y/o, children/adolescents exposed to high risk adults > 15mm: * Pt without TB risk factors - SEVERE structural heart disease * Prophylaxis: Short term antibiotics before dental or invasive medical procedures. ' - Exposure to meningitis or meningococcal sepsis: * Prophylaxis: antibiotics (rifampin, ciprofloxacin, ceftriaxone), tetravalent meningococcal vaccine (control serogroup C meningococcal disease outbreaks) - Exposure to syphyllis or gonorrhea: * Prophylaxis: Ceftriaxone - Needle stick in HC worker: * 4 week prophylactic anti-HIV regimen

Vaccination preventable diseases:

Antrax, Diptheria (D), Hep A and B (HAV and HBV), Hemophilus influenza B (HiB), Human Papillomavirus (HPV), Influenza (flu), Measles (M), Meningococcal, Mumps, Pertussis (whooping cough), Pneumococcal, Polio, Rabies, Rotavirus, Rubella, Shingles, Tetanus, Tuberculosis, Varicella.

IMMUNIZATION GOALS:

Goals: - Eradication of disease. - Regional elimination of disease - Control of disease: reduce morbidity and mortality - Eradication programs - Total eradication of disease through immunization is only possible if humans are the sole vectors of the infectious organims - Require more resources, time, general political/popular support than disease control programs. VACCINE-RELATED SUPPLIES AND LAWSUITS: - Recent shortage of vaccines due to: * Tighter regulations regarding production * Risk of liability for companies: Lawsuits * Higher costs and risk of development - The National Vaccine Injury Compensation Program: * Protects vaccine manufactures from liability lawsuits, unless it can be proven that their vaccines differed from federal requirements * Simplifies legal process and reduces costs for people making a claim * Costs of program and payouts to pt's are borne by federal government and taxpayers. Vaccination opportunities: * clinicians should not miss opportunities to vaccinate * recent guidelines emphasize that children should received appropriate vaccines despite mild respiratory infections. * Provide accompanying siblings any necessary immunizations. * Hospitalized children and adults whose immunization records are not up-to-date should be given appropriate vaccines unless contraindications exist. The following are NOT contraindications for child/adult vaccinations: * Mild reaction to previous DTP/DTaP dose: redness/swelling at injection site, temp < 40.5 C, 104.9 F. * Nonspecific allergies * Mild illness/diarrhea with low grade fever, otherwise healthy * Current antimicrobial therapy * Infant breastfeeding * Pregnancy of another women in household

Active immunity

Longer lasting (lifetime), rapidly stimulated immunity in cases of re-exposure to same/closely related antigens. - Vaccines - Inactivated vaccines: stimulate production of humoral antibodies against antigen in vaccine - Live attenuated vaccines: humoral response and cell-mediated immune respones; retain antigenicity -Herd immunity

Trivalent: against 3 dif organisms. Quadrivalent: Against 4 dif.

MMR: Measles, Mumps, Rubella MMRV (proquad): MMR+ Varicella DTP: Diphtheria, tetanus, pertussis Twinrix: Hep A and Hep B Pediarix: DTaP, Hep B and IPV

Intact Immunity

Normal @ birth, not yet damaged by disease (eg. HIV, medications side effects) - Depression and loneliness may suppress immunity - Experimental animals are more resistant to infections when surrounded by other animals of same species.