Chapter 20 - Immunizations

What age groups are indicated for HPV vaccination?

- 11-12 yo - adults ≤ 26 yo who did not complete HPV series - indicated up to 45 yo

How is Varivax used?

- 2 dose series given at age 12-15 months & 4-6 years - give 2 doses to any adolescent or adult without evidence of immunity to varicella

How is HPV9 (Gardasil 9) vaccination handled if started before age 15?

- 2 doses - at month 0 & 6-12 months later

When do most vaccine series begin and what vaccines are given?

- 2 months - PCV13, DTaP, Hib, polio, rotavirus

How is IM vaccination conducted?

- 22-25 gauge - 1" needle - 90° angle - adults: deltoid - infants: anterolateral mid-thigh muscle - if < 130 lbs → use 5/8"-1" needle - if male > 260 lbs or female > 200 lbs → 1.5" needle

How is SQ vaccination conducted?

- 23-25 gauge - 5/8" needle - 45° angle - adults: inject into fatty tissue over triceps - infants (< 1 yo): anterolateral mid-thigh muscle

How is hepatitis B immunity achieved in children?

- 3 dose series started within 24 hours of birth - given at 0, 1-2, & 6-18 months old

How is HPV9 (Gardasil 9) vaccination handled if started at age 15+ or if immunocompromised?

- 3 doses - at months 0, 1-2, & 6

How is pneumococcal vaccination handled in children < 5 years old?

- 4 dose series of PCV13 given at age 2, 4, 6, & 12-15 months old - children < 2 years old should not receive polysaccharide PPSV23 as they do not produce an adequate antibody response to polysaccharide vaccines

How is DTaP vaccination handled?

- 5 dose series at 2 mo, 4 mo, 6 mo, 12-18 mo, & 4-6 yo - for children < 7 yo

What age is Menactra indicated for? What age is MenQuadfi indicated for? What age is Menveo indicated for?

- 9 months - 55 years - ≥ 2 years old - 2 months - 55 years - Menactra & Menveo can be used in ≥ 55 yo if necessary

What vaccines are given SQ only?

- MMR - MMRV - varicella - yellow fever - dengue - smallpox - monkeypox

How should pneumococcal vaccination be handled in adults aged 19-64 years with specific medical conditions or age ≥ 65 years if never received before?

- PCV20 x 1 or - PCV15 x 1 → PPSV23 x 1 ≥ 12 months later (≥ 8 weeks if immunocompromised)

What vaccines can be given IM or SQ?

- PPSV23 - IPV

What is RV5? How is it used?

- RotaTeq: rotavirus vaccine - given to all infants < 15 weeks - 3 dose series given at age 2, 4, & 6 months

What is RV1? How is it used?

- Rotarix: rotavirus vaccine - given to all infants < 15 weeks - 2 dose series given at age 2 & 4 months

What vaccine is recommended for pregnancy and when is it given?

- Tdap with each pregnancy - at 27-36 weeks optimally

What should be avoided when receiving any varicella vaccines?

- acyclovir, famciclovir, or valacyclovir 24 hrs before vaccination - avoid antivirals for 14 days after vaccination

What are recommendations regarding pneumococcal vaccination?

- age 19-64 with specific medical condition (alcohol use, smoking, diabetes, HIV, liver disease, immunosuppressed) OR - age ≥ 65 yo if never received before give - PCV20 x 1 or - PCV15 x 1 → PPSV23 ≥ 12 months later (≥ 8 weeks later if immunocompromised)

How is Heplisav-B given?

- age ≥ 18 yo - 2 dose series at 0 and 1 month - do not use in pregnant women

What are characteristics of live attenuated vaccines?

- aka weakened - produced by modifying a virus/bacterium - ability to replicate and grow - produce strong immune response

What patients are indicated for HBV vaccination?

- all adults age 19-59 and patients ≥ 60 yo with risk factors - chronic liver disease, HIV, exposure via sexual activity (MSM, multiple sexual partners), IVDA, incarceration, endemic travel, blood exposure (healthcare, diabetes, dialysis) - give alone (Engerix-B, Recombivax HB, Heplisav-B) or with hepatitis A vaccine (Twinrix)

What are precautions for administering LAIV4?

- asthma in any patient ≥ 5 yo - underlying chronic complicating conditions

When can inactivated vaccines be given?

- at any time - started at 2 mo - exception: HBV - started at birth

When is a Td or Tdap vaccination recommended?

- booster at ≥ 11 yo if not previously received - routine booster q10 years in patients ≥ 7 yo - wound prophylaxis for deep/dirty wounds if > 5 years since last dose - recommended in 1. pregnant/postpartum women with each pregnancy 2. close contacts of infants < 12 months old 3. HCP 4. children aged 7-10 yo not fully vaccinated with DTaP series - single dose of Tdap instead of DTaP

How should influenza vaccination be handled in patients with an egg allergy?

- can receive any age-appropriate inactivated influenza vaccine - Flublok (egg-free) approved for ≥ 18 yo - Flucelvax (egg-free) approved for ≥ 4 yo - if any other influenza vaccine used, vaccination should be done in a medical setting - do not give FluMist (live influenza vaccine)

What 2 allergies are contraindicated with yellow fever vaccine?

- eggs - gelatin

What patients should receive hepatitis A vaccination?

- endemic travel - household members and other close contacts of adopted children newly arriving from countries with mod-high infection risk - liver disease - hemophilia - MSM, IVDA, homeless individuals, HIV - give alone (Havrix, VAQTA) or with HBV vaccine (Twinrix)

What is used to treat severe allergic reactions?

- epinephrine 1 mg/mL IM at 0.01 mg/kg - max dose = 0.5 mg - most adults will require 1-3 doses Q5-15 minutes

What are recombinant vaccines and what are some examples?

- gene segment of protein from organism is inserted into gene of another cell (yeast) where it replicates - HPV (Gardasil 9) - r influenza vaccine (FluBlok Quadrivalent)

What patients are indicated for MMR vaccination & how is it handled?

- healthcare workers - HIV patients - non pregnant patients - international travelers - household contacts of immunocompromised people - adults with no evidence of immunity - give 2 doses 4 weeks apart

What patients should receive meningococcal serogroup B vaccines Bexsero or Trumenba? What patients should receive conjugate meningococcal vaccines Menactra, Menveo, or MenQuadfi?

- if complement component deficiency - taking eculizumab or ravulizumab - asplenia - microbiologist with exposure to N. meningitidis - serogroup B meningococcal disease outbreak exposures - same as above, plus HIV, endemic travel - military recruits - freshman living in dorms if not up to date

What are characteristics of Typhim?

- inactivated polysaccharide typhoid vaccine - injectable - give 1 dose at least 2 weeks before possible exposure

What is the general consensus concerning vaccine intervals?

- increasing interval won't diminish effect, only delay complete protection - decreasing interval may interfere with antibody response - exception to decrease for immunocompromised

What are characteristics of Vivotif?

- live typhoid vaccine - oral capsules - must store in fridge - must take on empty stomach with cold or lukewarm water - take 1 capsule PO QOD at least 1 week before possible exposure

How is Vaxchora administered?

- oral - 1 dose ≥ 10 days before exposure - store packet in freezer - remove no more than 15 minutes prior to reconstitution

What are polysaccharide vaccines and what are some examples?

- polysaccharide molecules are taken from outside layer of encapsulated bacteria - do NOT produce good immune response in children < 2 yo - pneumococcal polysaccharide vaccine (Pneumovax 23)

How is RabAvert used for rabies?

- prevention when high-risk exposure: 3 doses - post-exposure (with previous vaccination): 2 doses - post-exposure (w/o previous vaccination): 4 doses + 1 dose of rabies immune globulin (RIG)

How should the MMR vaccine be stored? How should the MMRV vaccine be stored? How should diluents be stored?

- refrigerator or in freezer - in freezer only due to varicella component - room temperature or refrigerator

When are hepatitis A vaccines given?

- routine childhood 2 dose series given at age 12 months & then 6-18 months after - adults: MSM, IVDA, chronic liver disease, homeless, HIV

When are Haemophilus influenzae type B (Hib) vaccines given?

- routine series between ages 2-15 months old - given to adults with asplenia - ActHIB & Hiberix = 4 dose series - PedvaxHIB = 3 dose series

When can live vaccines be administered?

- same day, same visit OR - at least 4 weeks apart if not given on same day

How is Varivax stored & administered?

- store in freezer - store diluent in refrigerator or at RT - reconstitute immediately after removal from freezer & inject (short stability ~30 mins) - do not give if hypersensitivity to neomycin or gelatin - SQ

What special populations are at high risk of contracting meningitis and should be vaccinated with MCV4 vaccines?

- travelers to meningitis belt in sub-saharan africa - age ≥ 2 months with HIV, asplenia/sickle cell disease - lab workers with N. meningitidis exposure - freshman ≤ 21 yo living in dorms - military recruits

How often should refrigerator temperatures be monitored? How long are temperature logs required to be kept?

- twice daily - 3 years or longer

What vaccines are given orally?

- typhoid (Vivotif) = capsules - cholera (Vaxchora), rotavirus (RotaTeq, Rotatrix) = oral solutions

What are conjugate vaccines and what are some examples?

- use polysaccharide molecules on outside of bacteria cell wall and join them to proteins - conjugation increases immune response in infants - pneumococcal conjugate vaccine (Prevnar 13) - meningococcal conjugate vaccine (Menactra)

What are characteristics of inactivated vaccines?

- used killed version of wild virus/bacterium - composed of a whole virus/bacterium or parts of either - cannot replicate and cause disease - immunity can wean over time → requiring boosters

What are recommendations for the HZV vaccine (Shingrix)?

- vaccinate all adults ≥ 50 yo or ≥ 19 yo if immunosuppressed - 2 dose series given 2-6 months apart (1-2 months if immunosuppressed) - vaccinate even if patient previously had chickenpox or shingles or received Zostavax

What vaccines should remain frozen?

- varicella - MMRV - oral cholera - ebola - smallpox - monkeypox

When do live vaccine series generally start and what vaccines are given?

- ≥ 12 months - MMR, varicella

How is FluMist administered?

0.2 mL divided between 2 nostrils

What are 2 brand names of the Tdap vaccine?

1. Adacel 2. Boostrix

What 8 quadrivalent inactivated influenza vaccines (IIV4) are available?

1. Afluria Quadrivalent ≥ 6 months 2. Fluarix Quadrivalent ≥ 6 months 3. FluLaval Quadrivalent ≥ 6 months 4. Fluzone Quadrivalent ≥ 6 months 5. Flucelvax Quadrivalent ≥ 6 months 6. Flublok Quadrivalent ≥ 18 years 7. Fluzone High-Dose Quadrivalent ≥ 65 years 8. Fluad Quadrivalent ≥ 65 years

What 2 meningococcal serogroup B vaccines are available and what age are they indicated for?

1. Bexsero 2. Trumenba - for age 10-25 years old

What 3 vaccines are available for hepatitis B?

1. Engerix-B 2. Heplisav-B 3. Recombivax HB

What 2 influenza vaccines are egg-free?

1. Flublok Quadrivalent 2. Flucelvax Quadrivalent

What 2 influenza vaccines are indicated only for patients aged ≥ 65 yo?

1. Fluzone High-Dose Quadrivalent 2. Fluad Quadrivalent

What 3 types of vaccines are recommended for patients with sickle cell disease & other causes of asplenia?

1. H. influenzae type b (Hib) vaccine 2. pneumococcal (age 19-64) give 1 of the following regimens - PCV20 x 1 or - PCV15 x 1 → PPSV23 x 1 ≥ 8 weeks later 3. meningococcal vaccines - meningococcal conjugate (Menactra, Menveo, or MenQuadfi) - serogroup B meningococcal vaccine (Bexsero or Trumenba)

What 2 vaccines are recommended for older adults?

1. HZV (Shingrix) at age ≥ 50, 2 doses 2-6 months apart 2. pneumococcal vaccine at age ≥ 65 yo, give 1 of the following regimens - PCV20 x 1 or - PCV15 x 1 → PPSV23 x 1 ≥ 12 months apart (≥ 8 weeks if immunocompromised)

What 2 vaccines are available for hepatitis A?

1. Havrix 2. VAQTA

What 3 quadrivalent meningococcal vaccines (MCV4) are available that cover serogroups A, C, W, & Y?

1. Menactra 2. MenQuadfi 3. Menveo

What 3 pneumococcal conjugate vaccines are used?

1. Prevnar 13 (PCV13) 2. Vaxneuvance (PCV15) 3. Prevnar 20 (PCV20)

What 5 vaccines are required for healthcare professionals?

1. annual influenza 2. HBV - if no evidence of immunity 3. Tdap - 1 dose if no evidence, Td or Trap every 10 years 4. varicella - if no evidence of immunity 5. MMR - if no evidence of immunity

What 2 influenza vaccines can be used in patients with egg allergies other than hives (angioedema, respiratory distress, etc.)?

1. ccIIV4 (Flucelvax) 2. RIV4 (Flublok)

What are 5 examples of immunocompromising conditions?

1. chronic renal failure or nephrotic syndrome 2. malignancy 3. HIV infection 4. solid organ transplant 5. treatment with immunosuppressive drugs - chemotherapy - TNF-α inhibitors - transplant medications - systemic steroids ≥ 14 days at ≥ 20 mg (or 2 mg/kg) prednisone daily

What 2 agents are used to treat minor allergic reactions from vaccines?

1. diphenhydramine 2. hydroxyzine

What 2 allergies are a contraindication to varicella vaccines?

1. gelatin 2. neomycin

What 3 vaccines are recommended for adolescents and young adults?

1. meningococcal vaccine (MCV4; Menactra, Menveo, or MenQuadfi) - 2 doses: 1 dose at age 11-12 → 1 dose at age 16 - freshman living in dorms: 1 dose if not previously vaccinated 2. HPV - recommended at age 11-12 - 2 or 3 doses depending on age of start 3. Tdap - first dose at > 11 years old

What 2 vaccines are recommended for patients with diabetes?

1. pneumococcal vaccine at age ≥ 65 yo, give 1 of the following regimens - PCV20 x 1 or - PCV15 x 1 → PPSV23 x 1 ≥ 12 months apart (≥ 8 weeks if immunocompromised) 2. HBV at age 19-59 (or age ≥ 60 if at risk for HBV)

What are 5 examples of inactivated vaccines?

1. polysaccharide vaccines 2. conjugate vaccines 3. recombinant vaccines 4. toxoid vaccines 5. mRNA vaccines

What are 5 contraindications to receiving the live, attenuated influenza vaccine (LAIV4)?

1. severe egg allergy (anaphylaxis) 2. use of ASA-containing products in children/adolescents 3. recent use of influenza antivirals - oseltamivir/zanamivir in past 48 hours - peramivir in last 5 days - baloxavir in last 17 days 4. children aged 2-4 yo with asthma or wheezing episode in last 12 months 5. close contact with an immunosuppressed person

How is MMR vaccination handled in children?

2 dose series at age 12-15 months & age 4-6 years

At what age are adolescents given routine vaccination for meningitis?

2 dose series given at age 11-12 years & age 16 years

What is the recommended spacing of restarting antibody-containing products after live vaccine administration? vaccine → antibody

2 weeks

When do mild systemic reactions occur after a live vaccine is given?

3 - 21 days

What is the recommended spacing interval for receiving a live vaccine after receiving antibody-containing products? antibody → vaccine

3 months +

How is polio vaccination with Pediarix handled in childhood?

4 dose series given at age 2, 4, 6-18 months & 4-6 years

What is the Pink Book?

CDC - epidemiology and prevention of vaccine-preventable diseases

What vaccine is used in children < 7 yo with a contraindication to the acellular pertussis antigen in DTaP?

DT

How is PPSV23 administered?

IM or SQ

What antibody mediates anaphylaxis?

IgE

What are examples of live vaccines?

MICRO-VY M - MMR I - intranasal influenza C - cholera R - rotavirus O - oral typhoid V - varicella Y - yellow fever others - tuberculosis (BCG) - dengue - smallpox - ebola

What vaccine can either be refrigerated or frozen?

MMR

What vaccine comes in a combination of DTaP + HepB + IPV?

Pediatrix

What is the only pneumococcal polysaccharide vaccine available?

Pneumovax 23 (PPSV23)

What vaccine is available as a combination of MMR + varicella?

ProQuad

What vaccine is available against rabies?

RabAvert

What is the most common cause of otitis media, pneumonia, meningitis, and bloodstream infections in children?

S. pneumoniae

How are MMR vaccines administered?

SQ

How is the yellow fever vaccine YF-VAX administered?

SQ

What causes typhoid fever?

Salmonella typhi

What vaccine is available for varicella virus (chickenpox)?

Varivax

What age group is ProQuad indicated for?

age 12 months - 12 years

What patients should be vaccinated for meningococcal serogroup B? How is vaccination handled?

age ≥ 10 years with high risk - asplenia/sickle cell disease - lab workers with N. meningitidis exposure - during an outbreak - Bexsero: 2 doses given 1 month apart - Trumenba: 2 doses given 6 months apart (if high risk or during outbreak give 3 doses at 0, 1-2, and 6 months) - optional for patients 16-23 yo who are not at high risk - preferred age is 16-18 yo

In what patients should Prevnar & Menactra be separated by 4 weeks?

asplenia

When is the 3-dose HBV vaccine series began?

at birth

What is the difference between Tdap & DTaP?

children formulation (DTaP) has 3-5x as much diphtheria component than adult

When should RZV vaccination be delayed?

during pregnancy, breastfeeding

What is a contraindication for pertussis-containing vaccines?

encephalopathy unattributable to another cause within 7 days after receiving vaccine

How should influenza vaccination be handled in children aged 6 months to 8 years if not previously vaccinated?

give 2 doses 4 weeks apart

What age group is indicated to receive the quadrivalent live attenuated influenza vaccine (LAIV4) FluMist Quadrivalent?

healthy people age 2-64 years old

What hepatitis B vaccine is recommended for dialysis patients?

high-dose Recombivax HB

What is a precaution for all influenza vaccines?

history of GBS within 6 weeks of a previous influenza vaccine

What is a contraindication to HBV & HPV vaccines?

hypersensitivity to yeast

When should a vaccine not be given regarding illness?

in mod-severe illness

What type of vaccine are rotavirus vaccines?

live, attenuated

What type of vaccine are those containing varicella?

live, attenuated

What type of vaccine is the MMR vaccine?

live, attenuated

What type of vaccine is the cholera vaccine Vaxchora?

live, attenuated

What type of vaccine is the yellow fever vaccine YF-VAX?

live, attenuated

What vaccines are contraindicated in pregnancy and immunocompromised patients?

live, attenuated vaccines

What is thimerosal?

mercury-containing preservative used in some vaccines - multi-dose flu

How are rotavirus vaccines Rotarix (RV1) & RotaTeq (RV5) administered?

orally

What type of vaccine is Shingrix?

recombinant (non-live)

What is a contraindication to HPV9 (Gardasil 9) vaccination?

severe yeast allergy

When are polysaccharide vaccines given to infants and children?

≥ 2 years

When are annual influenza vaccines recommended for all special groups?

≥ 6 mo