343 Drug Ch. 43 Immunizing Agents

Hepatitis B Vaccine (Engerix-B, Recombivax HB) Administration Alerts

- In adults: use deltoid muscle for injection site - Recombivax HB does not contain preservative, once drawn up use right away - Pregnancy Category C - Epinephrine (1:1,000) should be immediately available to treat anaphylactic reaction

Hepatitis B Vaccine (Engerix-B, Recombivax HB) Pharmacokinetics

- Onset: 2 wk - Peak: 6 mo - Half-life: Unknown - Duration: 5-7 yrs

Hepatitis B Vaccine (Engerix-B, Recombivax HB) Adverse Effects

- Pain at the injection site - fever and chills - approx 15% or pts: systemic effects - fatigue, dizziness fever & HA - Possible: hypersensitivity reactions such as urticaria or anaphylaxis

Rabies Immunization: preexposure/ postexposure

- Preexposure: rabies vaccine. includes 3 inoculations -Postexposure: 1 dose of rabies immune globulin first for immediate protection, 5 doses of rabies vaccine over 28 day period. AE: pain, redness at the injection site, flulike symptoms

Hepatitis B Vaccine (Engerix-B, Recombivax HB) Contraindications

- in pts with hypersensitivity to yeast or HBV vaccine - Pts who demonstrate hypersensitivity to the 1st dose should not receive subsequent doses. - administer with caution in pts with fever or active infections or compromised cardiopulmonary status

Hepatitis B Vaccine (Engerix-B, Recombivax HB) Indicated for

- infants born to HBV+ mothers - those at high risk for exposure to HBV-infected blood: nurses, physicians, dentists, dental hygienists, morticians, paramedics - those that engage in high risk sexual practices: multi-partners, prostitutes, homosexual, bisexual

Rabies

-A bite from an infected animal is the most common method of contracting rabies. -Transmission begins when saliva is passed through a bite from infected dogs, coyotes, wolves, foxes, racoons and mortality rate is 100% - Incubation period is 20-60 days. Sx: pain, paresthesia surrounding the bite, fever, HA, malaise, irritability, anxiety, insomnia, hyperactivity, -If untreated, rabies will progress to cardiac or respiratory arrest or paralysis, and death (within 10 days)

Measles (rubeloa)

-Airborne droplets/ direct contact w/ respiratory secretions. -Measles virus, Morbillivirus invades the body via blood vessels and reaches first in the respiratory tract. -Incubation period is 10-14 days. Sx: cough, malaise, fever (40C), rash on the face to extremities,

Mumps

-viral infection in the parotid salivary glands that is transmitted by direct contact w/ saliva. Sx: begins after 16-18 days: fever, HA, anoreia, malaise, parotid/ saliva gland swelling -Complications: orchitis (swelling testes), postpubescent males, deafness child

Rho[D] Immune Globulin pt teaching

1)don't drive: may cause drowsiness/ dizziness 2)after using RhoGAM, avoid vaccinations w/ liver virus vaccines (Measles, mumps, oral polio) for 3 months, vaccinations may less effective. 3) check lab results; CBC, antibody titers

Diphtheria toxoid

• Detoxified bacterial, protein toxin • Injectable, IM • Toxigenic Corynebacterium diphtheriae formalin inactivated. • Single antigen diphtheria toxoid is not available. It available with tetanus toxoid (DT) or adult (Td) and as DTAP, and Tdap.

Pertussis (Whooping cough)

• Highly contagious respiratory infection caused by G- bacterium Bordetella pertussis • transmitted via aerosolized droplets S/Sx: fever, whooping cough Antibody: active pertussis is tx w/ erythromycin

Hepatitis A Vaccine

Recommendations: children over 2yrs, those who travel oversease, ilicit drug users. Give by IM: children receive 2 doses, travelers receive 3doses. AE: soreness at the injection site, HA, anorexia, fatigue

Attenuated (live) vaccines

capable of replicating and causing disease Ex) polio, MMR (measles, mumps, rubella), varicella Adv.: similar to natural infection, w/ low dose, cellular and humoral response, herd immunity Disadv.: dangerous to immunosuppressed pt, can be infection form

DTaP vaccine

diphtheria toxoid, Tetanus toxoids, accellular pertussis for infants >6month

What is vaccination?

immunization: Active/ Passive immunity • some once/ some require follow- up doses (boosters) ex) measles, influenza, diphtheria, polio, pertussis (whooping cough), tetanus, hepatitis B HIV vaccines are given AFTER infection has occurred (increase the immune response) • The administration of an antigen (vaccine) to an animal or individual with the intention of stimulating a protective immune response • result: memory B and T cells are formed

Rotavirus

infected by age 5 experience gastroenteritis, resulting in severe diarrhea, dehydration. -oral- fecal viral transmission bc replication occurs only in intestinal vili Rotavirus Immunization (RotaTeq) 3 doses: oral series; infants 6-32 weeks age AE: N/V

Varicella zoster Immunization

live/ attenuated virus -for children: routin 2 dose VZV vaccine. 1st dose (12-15 months), 2nd dose (4-6 yrs) -All healthy ppl over age 13: routine vaccination -All Americans at age 60: shingles vaccine (Zostavax) AE: fever, tenderness/ rash at the injection site, * caution w/ allergy to egg/ gelatin, pregnant/ lactation (birth defects), immunosuppressed

MMR Immunization

live/ attenuated viruses 2 dose SQ w/ the first given at 12-15 months and the second at 4-6 yrs. -First dose: born after 1957 -Second dose: epidemic outbreak, exposure to measles, HCP, travelers, -should NOT given to: pregnant pt (attenuated rubella virus), immunosuppresed, allergy to neomycin/ gelatin AE: fever, lymphadenopathy

Human Papillomavirus (HPV) Immunization (Gardasil, Vervarix)

recombinant DNA technology: noninfectious, virus-like particle (VLP) containing only proteins from the coat of the virus (bc of the cancer risk) -to prevent cervical, vulvar, vaginal cancer, genital warts caused by HPV for age 9-26 yo -admin. via 3 IM injections: 2&3 doses 2-6 months after 1st dose. AE: pain, swelling, redness at the injection site

Hepatitis B immune globulin (HBIG)

to prevent the transmission of HBV to those who have been exposed to the virus -admin: 1)nonimmunized individuals who have had acute and significant exposure to hepatitis B infected blood. (needlestick, oral ingestion)- 1st dose & 2nd dose after a month 2)infants born to mom infected w/ HBV need HBV vaccine series within 12hrs of birth. 3) sexual partners of HBV infected pt. - 1dose within 2 weeks AE: loccal site reactions, hypersensitivity reactions

Diphtheria characteristics

upper respiratory tract infecction by G+ bacterium Corynebacterium diphtheriae. Transmission is caused by toxins created by the bacteria which is deposited in the nasopharynx

Varicella Zoster

varicella zoster virus (VZV) leads 2 diseases a. Chickenpox b. Herpes zoster/ shingles Initial infection;Chickenpox: VZV infection is transmitted through inhaled droplet/ by direct ontact w/ infectious skin lesions. Sx: (5-7 days) fever, malaise, anorexia, (10-14 days) blistered rash, draining, crusting * Adults w/ chickenpox have 7x greater risk of encephalitis Herpes zoster/ shingles: the virus migrates to the spinal nerves, dormant for the life and appears after age 50. Sx: burning/ tingling pain, numbness, itch, blisters, painful. >30% of shingles get postherpetic neuralgia, >15% become blind.

Rubella/ German measles

-transmitteed by infected aerosol droplets: coughing, sneezing, talking -Sx: enlarged cervical lymph nodes, fever, malaise, rash (14-17 days)

Polio

-The virus replicates in the GI tract and spred by oral-fecal route via contaminated food and water Sx: 90% are asymptomatic. others may have flaccid muscle paralysis (virus reaches the motor tracts of spinal cord), respiratory muscles

Meningococcus immunization

-at age 11 w/ a booster at 16 yrs -specific: who travel regions where meningococcal infection is endemic, living in crowded conditions (college residence halls) 2 Type of vaccines a. Menningococcal polysaccharide vaccine (MPSV-4) - adm. SQ for age >2 -age: 2-10, >55 b. Menningococcal conjugate vaccine (MCV) - adm. IM -longer lasting than MPSV-4, -age: 11-55

Hepatitis B Immunization

1. Current HBV vaccines contain highly antigenic proteins from the viral coat. Recombinant hepatitis vaccines contain no blood products and therefore do not represent a risk for HIV infection. 2. All workers whose jobs involve participation in tasks or activities with exposure to blood or other body fluids, to which universal precautions apply, should be vaccinated

Hepatitis B

1. Disease is spread by the HBV virus. Transmitted by contaminated serum in blood Viral infection and inflammation of the liver, causing jaundice and easily transmissible. 2. A form of hepatitis that is transmitted through contact with infected blood, body fluids (sexually transmitted), contaminated needles.

Pertussis immunization

1. killed whole cell, 2. Acellular (aP) -killed whole cell: old, still used in developing countries, cheap -Acellular (aP): recombinant, highly effective -SE: local injection site, drowsiness, crying, fever -Admin.: children always w/ diphtheria and tetanus toxoids (DTaP), (Adults Tdap) -IM for children 6 weeks through 6yrs

Inactivated (killed vaccines)

1. whole agent 2. subunit whole agent vaccines consist of microbes killed, subunit vaccines consist of segments of a cell memb, protein, chromosome Ex) salk polio, influenza, rabies, hepatities A Adv.: safer, subsequent booster doeses are required Disadv.: Does not confer lifelong immunity

Pneumococcus Immunization

2 diff formulas: PPV/ PCV a. Pneumococcal polysaccharide vaccine (PPV) -for age >65, pts from 2-64 who have a chronic illness, immunocompromised who have HIV, leukemia, dialysis, corticosteroid, transplant -A booster 5 b. Penumococcal conjugate vaccine (PCV) - routine vaccine in children under 2 -Admin. 4 IM age 2 through 15 months both Sx: fever, redness, swelling, pain

Polio Immunization

2 forms of polio vaccines a. inactivated polio vaccine (IPV) b. oral polio vaccine (OPV) - IPV is for infants. children get 4 doses (2,4,6,18 months), and a booster at (4-6 yrs), available as a single or combination (DTaP, hepatitis B, influenza) AE: IM- redness, swelling, tenderness at the site -OPV is widely used, prevents the intestinal spread which provide 100% lifelong immunity

Influenza

3 types of viruses: type A (most prevalent form in humans, causes epidemic influenza) type B (less common, causes flu outbreaks every 2-4yrs) type C (least common, causes sporadic & milder infections)

Hepatitis A

A virus that is spread by the fecal-oral route through contaminated food and water or by close and intimate contact and results in liver inflammation, flu-like symptoms, nausea, poor appetite, abdominal pain, fatigue, yellow eyes and skin, and dark urine that can last weeks to months.

Rho[D] Immune Globulin (RhoGAM) AE, Contraindications

AE: common: local swelling, redness, pain at the injection site, fever. rare: Hypersensitivity reactions include hives, generalized urticaria anemia, anorexia, , dyspnea, edema, hemolysis, HTN, Contraindications: individuals w/ a Hx of hypersensitivity reaction to human immunoglobulin injection. pt having IgA deficiencies, pt w/ anemia, pregnancy category C

Passive immunity?

Administration of immunoglobulins (antibodies) gives passive immunity which has a fast onset, but lasts only 3-6 month (not activated and no memory cells) ex) maternal antibodies, admin. of immune globulin to treat botulism, tetanus, rabies. Adv.: 1) when immediate tx is indicated (no time for activation) 2) to complete immunity: antibodies are given concurrently w/ the vaccine series 3) for situations where the activation of the immune system and the development of memory are not desirable (RhoGAM) Uses: recent/ potential infection, disease in progress, pt has already been exposed to a virulent pathogen, very high risk for exposure, immunosuppressed pt

Active immunity?

Administration of vaccine/ exposure to an antigen stimulates the body to produce antibodies and memory cells • effectiveness can be measured by 'antibodies titer' (amount)

4 Types of Vaccines

Attenuated (live) vaccines, Inactivated (killed) vaccines, Toxoid vaccines, Recombinant technology vaccines

Hepatitis B Vaccine (Engerix-B, Recombivax HB) actions

Class: Vaccine - Used to provide active immunity in individuals who are at risk for exposure to hepB (HBV) - Does NOT provide protection against other hepatitis viruses - produced through recombinant DNA technology using yeast cells - not prepared from human blood

Tetanus

Clostridium tetani (lives in soil) can infect when the G+ anaerobe enters. Toxin binds in CNS -Incubation period; 3-21days Sx: painful muscular contractions (lockjaw/trismus), muscle spasm, neck stiffness, seizures. -Fetality rate: -90% w/o Tx, -30% w/ Tx

Influenza Immunization

Each year one influenza vaccine is prepared that contains portions of the most likely strains of type A and type B. 2 types of influenza vaccines a. trivalent inactivated influenza vaccine (TiIV) b. attenuated intranasal vaccine (LAIV) TiIV is a SQ formulation that is for >6 month, pregnancy, chronic conditions. LAIV is a nasal spray to age 2-49 yrs who are NOT pregnant. Annual influenza vaccination indications: everyone over >50, RN, chronic conditions, immunocompromised, pregnant, HCP AE: SQ-soreness, redness at the site. Nasal spray-nasal congestion, HA

inoculation

First natural live viral vaccine placement of an individual to prevent disease - Smallpox vaccine

Intravenous immune globulin (IVIG, Gammagard, Carimune, Octagam)

Ig contains antibodies obtained from human plasma that is used to provided passive immunity. Use: -Passive immunity induced by IVIG prevents a wide range of infectious diseases and AE from toxins, mycoplasma, parasites, bacteria, viruses. -Balancing immune systems (strengthen/ suppress) Duration: last for 3 weeks Considerations: active vaccinations should NOT be given until 3-5 months after IVIG has been admin.

Rho[D] Immune Globulin (RhoGAM) Use

Indications: administration to Rh-negative pregnant mother, so this will prevent forming Rh antibodies (if not, baby will have Erythroblastosis fetalis (EF) disorder) -Admin.: IM/ IV at 28 weeks' gestation, within 72 hrs pp, transplancental hemorrhage MOA: Rh[D] antibodies suppress the immune response of Rh-mothers to Rh+fetus.

MMR

Measles, Mumps, Rubella

Recombinant technology vaccines

Modern biologic tech. gene encoding the antigen of interest Ex) hepatitis B Adv.: can produce many through using cloning Disadv.: risk of transmitting HIV (bc originally obtained from serum of infected individuals), area of current research interest (not safe yet)

Cytomegalovirus immune globulin (CM-IGIV) (CytoGam)

Passive immunity; against cytomegalovirus (CMV) -Indications: kidney, liver, pancreas, heart transplants. -admin: IV- seven doses -AE: flushing chills, muscle cramps, back pain, fever, N/V

Passive Immunity Agents-(Immune globulin; Antibodies)

RhoGAM, Cytomegalovirus immune globulin, Hepatitis B immune globulin, IV immune globulin

Human Papillomavirus (HPV)

STDs w/ a risk of cervical cancer. HPV cause genital warts. can transmitted from mom to child Sx: may asymptomatic, dysplasia, precancerous change in cervical cells

Pneumococcus

Streptococcus pneumoniae begins in the nasopharynx and spread to the ears, sinuses, lower respiratory tract. Risk: whohave difficulty clearning seccretions from the upper airway , neuromuscular dissase, smoking

Tetanus immunization

Tetanus toxoid (TT) available alone, combined (DT, DTaP). 5 doeses during -6yrs. Admin: IM, SQ

Rho[D] Immune Globulin (RhoGAM) class

Therapeutic: Immunizing agent (passive) Pharmacologic: Antibody, Immunoglobulin

Meningococcus

by Neisseria meningitidis, a G-, toxin secreting organism. Sx: fever, rash, neurologic, HA, phtophobia, seizure, petechiae, purpura, Tx: IV penicillin based antibiotic

Toxoid vaccines

bacterial toxins (Sx of infection), incapable of causing disease, neutralizing the real toxins, not attack pathogen itself but boxterial toxin Ex) ditetanus toxoid, diphtheria toxoid Disadv.: Large quantities of antigen needed