Chapter 20: Immunizations

select risk factors 65 or older IM or SC

23-valent polysaccharide vaccine (PPSV23) - Pneumovax 23: -Patients age 2-64 years with select ___ ___: 1 or 2 doses, all adults ____: 1 dose can be given ___ or ___

1) Meningococcal vaccine (MCV4: Menactra or Menveo) 2) Human papillomavirus (HPV) vaccine 3) Tdap

Adolescents/Young Adults should get... 1) the ___ vaccine: 2 doses (1 at age 11-12 and 1 at age 16) AND 1 dose for first yr college students in residential housing (if not previously vaccinated) 2) ___: recommended at age 11-12 years; 2 or 3 doses depending on age at start 3) ___: first dose at age >11 years old

emergency protocols ; anaphylaxis

All providers who administer vaccines must have ____ ___ and supplies to treat ___.

adverse reaction

All vaccines have the potential to cause an _____, which can range from local to severe and life-threatening

influenza

An annual ___ vaccine is recommended for all special groups (age >6 months)

live vaccine replication

Antibodies, in some blood products and IV immunoglobulins (IVIG) can interfere with _______ and a separation period may be required. This is a concern because replication is required to produce an immune response.

Afluria, Fluzone, FluMist

Any flu vaccine can be used within FDA indications (ACIP does not give preference to any one type of influenza vaccine) What are the flu vaccine brand names? (* they all have the word "flu" in them)

Cholera Oral Typhoid Zoster (Zostavax/Shingrix) Yellow Fever Intranasal Influenza Varicella Rotavirus MMR

Common live vaccines: (Remember *** COZY IV RM)

infants

Conjugate vaccines use polysaccharide (sugar) molecules from the outside layer on encapsulated bacteria and join the molecules to carrier proteins. Conjugation increases the immune response in ____ and the antibody booster response to multiple doses of vaccine.

upper case ; diphtheria lower case

Diphtheria Toxoid-, Tetanus Toxoid- and acellular Pertussis-Containing Vaccines: The pediatric formulations (with ____ D as in DTaP) have 3-5 times as much ____ component than the adult formulations. The adult formulations have a ___ D (Tdap or Td)

FluMist

Do not administer the live vaccine ____ to patients with an egg allergy

0.2 mL

FluMist Quadrivalent is given intramuscular ___mL, divided between the two nostrils

1) influenza 2) Hepatitis B 3) Tdap ; Td or Tdap 4) Varicella 5) MMR

Healthcare professionals (including pharmacists, doctors, nurses, etc.) should 1)get the annual ___ vaccine, 2)____ vaccine (if there is no evidence of vaccine series completion or blood test) 3)____: 1 dose, if not up-to-date then __or ___ every 10 years 4)____: if there is no hx of vaccination or chickenpox infection 5) ___: if there is no hx of vaccination or a blood test showing immunity

cervical cancer ; genital warts

Human Papillomavirus vaccine prevents 90% of _____, as well as vulvar, vaginal, oropharyngeal, penile, anal cancers, and ____

5 years

If PPSV23 is given to patients between ages 2-64 with risk factors or immunocompromised, then after 65, patient should receive PPSV23 ___ apart from last time

8 weeks

If patient is immunocompromised and receives PCV13, they must wait ___ weeks before getting PPSV23

actively or passively

Immunity is acquired ____ (when a person's own immune system produces antibodies to fight infection or in response to vaccine admin) or ____ (acquired when antibodies are provided from someone else)

killed ; replicate

Inactivated vaccines use the ___ version of a wild virus or bacteria that causes the disease. Inactivated vaccines cannot _____ (cause disease). Limitations: immunity not as strong as live vaccines so will require Boosters

hemagglutinin and neuraminidase

Influenza A virus has subtypes based on the two surface antigens, ____ and ____. Immunity to the surface antigens reduces the likelihood of infection, and severity of disease if infection occurs.

immunocompromised ; pregnant

Live attenuated vaccines are most similar to the actual disease and produce a strong immune response to the vaccine, they are contraindicated in ____ and ____ patients since uncontrolled replication of the pathogen can occur.

immunocompromised ; antibodies

Live vaccines are most similar to the actual disease and provide a long-lasting immune response. Limitations: 1) patients who are _____ may not be able to halt replication ; vaccination could cause the disease 2) circulating ___ can interfere with vaccine replication

injection site ; common

Local reactions occur at or near the ___ ___. These are ___, more so with inactivated vaccines, and include pain, swelling, and redness.

2 ; 3

MMR and varicella-containing vaccines (not zoster) require separation from antibody-containing products (like blood transfusions, etc.). The recommended spacing is: Vaccine --> __ weeks --> antibody containing product Antibody containing product --> ___months or longer --> vaccine

refrigerator ; freezer

MMR should be stored in the ___ or ___

freezer ; room

MMRV should be stored in the ____ only (for varicella component). Store the diluents at ___ temperature or in the refrigerator.

12 months of age

Maternal antibodies are passed from the mother to the baby before birth, and will reduce the baby's response to live vaccines. Most live vaccines are withheld until the child is....

HIV, asplenia/sickle cell disease

Meningococcal Vaccines - MCV4 (Menactra and Menveo): for adolescents, and travelers to certain countries, such as meningitis belt in sub-Saharan Africa; age 2 months and older with: ___, _____, complement component deficiencies or eclizumab use

diphenhydramine ; hydroxyzine

Minor allergic reactions to vaccines will resolve quickly and can be treated with _____ (OTC) or ___ (prescription)

simultaneously

Most live or inactivated vaccines can be administered ____ (on same day/visit) without decreasing the antibody response or increasing the risk of adverse effects.

1-3 ; 5-15

Most pharmacies use refilled epinephrine auto-injectors. At least three adult (0.3mg) auto-injectors should be available. Most adults will require ___ doses administered every ___ minutes.

same ; 4

Multiple live vaccines can be given on the ___ day or (if not given on the same day) spaced ___ weeks apart

same day 4 weeks 48-72 hours

Options to reduce the risk of a false-negative TST result include: 1) Give the live vaccine on the ___ ___ as the skin test 2) Wait _____ after a live vaccine to perform the skin test 3) Administer the skin test first, wait ____ hours to get the result, then give the live vaccines.

recommended ; 1 year

Patients age >65: PCV13 is no longer routinely ____, but can be given if the patient and healthcare provider decide it would be beneficial (if never received before). If PCV13 is given, then ___ later give PPSV23 x 1

4

Patients who are 6 months to 8 years old and have not been previously vaccinated should get 2 doses (___ weeks apart)

inactivated (killed) vaccine ; cannot

Patients who have experienced systemic symptoms after a flu shot might think (incorrectly) that the vaccine caused the flu. The flu shot is an ______ vaccine and ___ cause the flu

egg allergy

Patients with an _____ can receive any age-appropriate inactivated influenza vaccine, even if severe allergy symptoms (like wheezing requiring epinephrine, hypotension, or cardiovascular changes)

healthcare provider ; 15

Patients with an egg allergy should receive vaccine under supervision by a ____ ____who is able to recognize and treat severe allergic reactions. No additional observation period is recommended beyond the required ___ minutes.

DTaP-HepB-IPV: Pediarix (there are several others)

Poliovirus-Containing Vaccines: ___ is a routine childhood vaccine series (4 doses give at age 2,4,6-18months, and 4-6 years

children <2 years of age

Polysaccharide vaccines do not produce a good immune response in....

inactivated ; live

Pregnant patients can receive any age-appropriate ____ flu vaccine. DO NOT administer a ___ vaccine (FluMist)

Rabies immune globulin (RIG)

Rabies vaccine given post-exposure (without previous vaccination): 4 doses - 1 dose of ____ (RIG) should be given with the first vaccine dose.

1) Herpes zoster vaccine ; Shingrix ; Zostavax 2)Pneumococcal vaccine

Recommended vaccine for older adults: 1) ____: the preferred one is ___ at age >50, 2 doses 2-6 months apart; the other is ___ admin. at age >60 2) ____ vaccine (at age >65) - Penumovax 23 x 1 (wait at least 1 year after prevnar13, if given, and at least 5 years after any prior dose of pneumovax 23) -Prevnar 13 x 1 (if immunocompromised and not received previously. optional for all other adults)

epinephrine

Severe allergic reactions are very rare. A severe reaction with anaphylaxis can be life-threatening if not managed correctly. Symptoms include: urticaria (hives), swelling of the mouth and throat, difficulty breathing, wheezing, abdominal cramping, and hypotension or shock. The protocol for emergency management will include the use of ____, which must be available to quickly reverse breathing difficulty.

NOT ; intramuscularly

Shingrix: store vaccine and adjuvant liquid in the refrigerator. Do ___ freeze! Give ____

live ; 24 ; 14

Some antivirals (acyclovir, valacyclovir, famciclovir) can interfere with the __ vaccines (Viravax and Zostavax). Stop ___ hours before vaccine administration and do not take for ___ days after vaccination.

2, 4, 6, and 12-15 months optional

The 13-valent conjugate vaccine (PCV13) Prevnar 13: -given to children <5 years old: 4-dose series given at age ___, ___, ___ and ___ months -given to immunocompromised patients age 6-64 years: 1 dose if never received before -adults >65 or older: ___ to give 1 dose if never received before

Pink Book

The CDC's _____ is a useful resource for details regarding immunology and immunizations

FDA

The ___ approves vaccinations based on the safety and efficacy for the indication

Centers for Disease Control and Prevention (CDC)

The ____ approves the ACIP recommendations and publishes them in the Morbidity and Mortality Weekly Report (MMWR) and The Pink Book (Epidemiology and Prevention of Vaccine-Preventable Diseases)

tuberculin skin test ; false negative

The _____ (TST), also called a purified protein derivative (PPD) test, is used to determine if a person has tuberculosis. Live vaccines can cause a _____ ____.

Advisory Committee on Immunization Practices (ACIP)

The _____ provides the recommendations for vaccine administration in children and adults (ie who gets vaccinated and when)

S. pneumoniae

The bacteria____, called pneumococcus, is the most common cause of otitis media, pneumonia, meningitis, and bloodstream infections in children.

no evidence

The cause of autism is not understood, but there is ___ ___ that autism is caused by vaccines.

annually ; >6 months

The flu vaccine is recommended ____ for all patients who are ____ (unless contraindicated)

abrupt ; fever, myalgia, headache, malaise, nonproductive cough, sore throat, and rhinitis)

The influenza virus has an ___ onset of symptoms, including:

respiratory droplet transmission

The influenza virus spreads from person to person, primarily through ___ ___ transmission (which can happen when an infected person coughs or sneezes in close proximity to uninfected people)

3 ; 11

The interval between an antibody-containing product and a measles-mumps-rubella-containing vaccine (MMR) or a varicella-containing vaccine (MMRV) is a minimum of ___ months and canoe up to ___ months. The specific product and dose determines the separation time.

15 ; emergency management

The patient should be monitored for at least ___minutes after vaccination. Pharmacists who give vaccines need a plan/protocol that covers ____ ____ of severe reactions until emergency medical help arrives

immune system

The purpose of the _____ is to identify self substances (normal body parts/components) and non-self (foreign) substances, which are called antigens.

Varivax ; 2 doses

The varicella virus vaccine was ___ - a routine childhood vaccine series; 2 doses given at age 12-15 months and age 4-6 years. Anyone without evidence of immunity to varicella should receive ____ of Varivax. Do not use in pregnancy or immunocompromised

3-trivalent or 4-quadrivalent

There are many formulations of influenza vaccine. Key differences between them include the number of strains (___ or ___), whether the virus is inactivated (IIV) or live attenuated (LAIV), the route (IM, intranasal), the antigen dose or the presence of adjuvant.

thimerosal

There is no evidence that _____ (a mercury-containing preservative used in some vaccines) poses a risk for autism.

3-7

Uncomplicated influenza illness typically resolves after ___ days, though cough and malaise can persist for more than 2 weeks. In some people, the flu can exacerbate underlying medical conditions (like pulmonary or cardiac disease)

1)Influenza 2) Tdap ; Td or Tdap 3) Shingles ; at least 8 weeks 4)HPV (Human Papillomavirus) 5) Pneumococcal 6) Serogroup B and Conjugate vaccines 7)Hepatitis B 8)Hepatitis C

Vaccinations all adults should have.... 1) ___ (for all patients >6 months old) 2)___ x 1 (if not received previously); then ___or___ every 10 years 3)___ vaccine (Shingrix is preferred, vaccinate all adults >50y.o, even if they had chickenpox or shingles or previously Zostavax Shingrix is a 2 dose series, with second dose given 2-6 months after the first dose; wait ____weeks after zostavax 4) ___ vaccine: adults <26 y.o who did not complete HPV series. 5) ____ vaccine: Pneumovax 23 - all adults >65 -patients 2-64 y.o.: 1 dose if heart, lung, liver disease, diabetes, alcoholic abuse, smokers/2 doses if immunocompromised Prevnar 13 (if not received before) -Any patients >6y.o. who are immunocompromised -Optional for adults >65y.o. 6) Meningococcal vaccines: 2 types... 7) ___ vaccines: sexually active adults who aren't in a long term monogamous relationship, pts with diabetes age 19-59 y.o. (or >60y.o. per healthcare provider discretion), household contact with an infected person, IV drug abusers (IVDAs), pts. w HIV or chronic liver disease -you can give alone (Engerix-B,Recombivax HB, Heplisav-B) or with Hepatitis A vaccine (Twinrix) 8) ____: adults traveling to underdeveloped countries outside of US -give along (Havrix, VAQTA) or with Hep B vaccine (Twinrix)

mild antimicrobial vaccine pregnancy tuberculin skin test immunosuppressed family history

Vaccinations may be given, if indicated, in the following situations: ___ acute symptoms(mild diarrhea, slight fever) current ____ treatment (* some exceptions) previous local ___ reaction (mild/mod) from a vaccine Allergies to bird feathers, penicillin, other things not in the ___ ____ (except live vaccines), breastfeeding, preterm birth Recent ____ _____ person in household, recent exposure to disease or convalescence _____ of adverse events to vaccine

1) H.influenzae type b (Hib) vaccine 2) Pneumococcal ; Prevnar 13 and Pneumovax 23 3)Meningococcal vaccines ; Meningococcal conjugate vaccine ; Serogroup B meningococcal vaccine

Vaccines recommended for Sickle Cell Disease & Other Causes of Asplenia (Damages/Missing Spleen): 1) _____ vaccine 2)_____ vaccines (___ and ___): Before 65 y.o.: 1 dose of Prevnar (if not received previously) and 2 doses of Pneumovax. Give prevnar 1st then the 1st pneumovax >5 years after the 1st dose. 3) ____ vaccines: 2 types - 1st type: ____ vaccine (Menactra or Menveo) 2nd type: ____ vaccine (Bexsero or Trumenba)

1) Pneumococcal (Pneumovax 23) 2) Hepatitis B

Vaccines recommended for patients with diabetes: 1) ___ vaccine (Before age 65 y.o.: 1 dose of ______) 2)___ vaccine at age 19-59 years (or at age >60 years per healthcare provider discretion)

1) Live vaccines 2) Influenza 3) Tdap

Vaccines recommended for pregnant patients: 1) ____ are CONTRAINDICATED 2) ___ vaccine (inactivated not live) can be given any trimester 3) ____ x 1 with each pregnancy (optimally at weeks 27-36)

1) Meningococcal conjugate vaccine (Menactra or Menveo) 2) Hepatitis A vaccine 3) Hepatitis B vaccine

Vaccines recommended for the immunocompromised: 1) _____ vaccines are CONTRAINDICATED 2) ___ vaccines (___ and ___): before age 65, 1 dose of prevnar (if not received previously) and 2 doses of pneumovax 23. Give prevnar first, then the first pneumovax 23 >8wks later; give the 2nd pneumovax 23 >5 years after the first dose 3 vaccines specifically for HIV patients:

live ; Shingrix ; non-live

Varicella-containing vaccines and the Zostavax brand of zoster vaccine are ___ attenuated vaccines. The ___ brand of zoster vaccine is the recombinant (___) vaccine

freezer ; subcutaneously ;

Varivax and Zostavax: store in ___ and store diluent in refrigerator or room temperature. Reconstitute immediately upon removal from freezer and inject (short stability of 30 min). Injected ___ and do not give if there is a hypersensitivity to gelatin or neomycin.

pregnant or immunocompromised

We should give the vaccine as soon as it is available, even if it arrives in late summer. Live attenuated vaccines are not used in patients who are ___ or ___.

Afluria, Fluarix, FluLaval, Fluzone (approved for all ages) Flucelvax (approved for age >65 years old) Flublok (egg free vaccine approved for >18 years old) Fluzone High Dose Quadrivalent (approved for >65 years old)

What are the quadrivalent inactivated influenza vaccines (IIV4)?

FluMist (approved for healthy people age 2-49 years old)

What are the quadrivalent live attenuated influenza vaccine (LAIV4)?

Fluzone High-Dose Fluad

What are the trivalent inactivated influenza vaccines (IIV3)? (2 that are approved for age >65 years)

Immunoglobulin

When an antigen is detected, the body produces antibodies and destroys the antigen. _____ is the medical term for antibody.

3 dose hepatitis b vaccines starting at birth Other vaccine series starting a 2 months (like Prevnar 13, DTaP, Hib, polio, rotavirus) Live vaccine series generally start at >12 months old: MMR, varicella ** No polysaccharide vaccines before the age of 2!!!

Which vaccines can infants and children receive?

systemic ; 3-21

With live vaccines, mild ____ reactions can occur __-___ days after the vaccine is given.

Shingrix ; 2 ; 50

Zoster virus vaccines (___) is preferred ACIP recommends routine vaccination (__ doses given at month 0 and month 2-6) in patients age >__years, including those who previously received varicella virus vaccine or Zostavax (wait at least 8 weeks after Zostavax before starting the 2-dose series of Shingrix) Vaccinate even if the patient has a hx of zoster infection!!!

Hepatitis A: Havrix, VAQTA

___ vaccine: a routine vaccine series, 2 doses given at age 12 months and then 6-18 months later ; also for certain adults (men whsw men, illicit drug users, chronic liver disease, homeless adults, HIV, travelers to countries, etc.

Hepatitis B vaccine: Engerix B, Heplisav-B, Recombivax HB

___ vaccine: routine childhood vaccine series started within ____ after birth (3 doses given at age 0,1-2, and 6-18 months) ; adults who would need the vaccine: healthcare workers, chronic liver disease, HIV, diabetes, etc. ; *** Heplisav-B is for adults (>18y.o.): 2 dose series given at month 0 and 1. do not use in pregnant women

Tdap or Td 1) pregnant ; post-partum ; each 2) close contact 4) tdap

___: routine booster given every 10 years in patients age >7 years old. ; wound prophylaxis for deep and dirty wounds (revaccinate if it has been more than 5 years). This vaccine is recommended in: 1) ___ or ____ women with ___ pregnancy 2)_____ of infants younger than age 12 months, if not up to date 3) healthcare professionals 4) kids aged 7-10 who did not get fully vaccinated with the DTaP series; give a single dose of ___ instead of DTaP.

DT

___: used for routine vaccine series in infants and children <7 years old who have a contraindication to the acellular pertussis antigen in DTaP

Antibodies

____ are produced naturally to provide immunity against antigens

Intranasal ; cold-like

____ flu vaccine can replicate in the upper airways (nose and throat) and can cause mild ____ symptoms , such as a runny nose.

Flublok

____ is an egg-free product and is approved for patients >18 y.o. only

Influenza ; Influenza A and B

____ is the most common vaccine preventable illness in the US. The two types that can cause epidemic human disease are:

Decreasing ; antibody

____ the interval between the doses of vaccine can interfere with ___ response and protection. In a few cases, the interval can be shortened for high-risk patients. (ie 2 pneuma vaccine in an immunocompromised patient)

HPV9 (Gardasil 9) ; 11-12 years 2 3

____ vaccine: is recommended in kids aged ____ (may be started as early as 9) -regimen: -if started before age 15 = ___ doses (at month 0 and 6-12 months) -if started at age 15 or older, or if immunocompromised = ____ doses (at month 0, 1-2, & 6) * this vaccine is FDA-approved up to age 45 * start at age 9 in anyone with hx of sexual abuse

Fluzone High-Dose Fluzone High-Dose Quadrivalent Fluid (adjuvanted influenza vaccine)

____, ____, and ____ are indicated only for patients >65 y.o.

DTaP ; 6

____: a route childhood vaccine series; 5 doses given at ages 2,4,6,12-18 months and 4-6 years ; it is specifically for children __ years old or younger

Rotavirus (live attenuated) 2 ; 3 orally

____: given to all infants. do not initiate the series after age 15 weeks -Rotarix is __ doses at age 2, and 4 months -RotaTeq is __ doses given at age 2,4, and 6 months -can be given ___

Vaccine Information Statement (VIS's) ; before

_____ are prepared by the CDC for each vaccine, to explain the benefits and risks. Federal law requires that it be handed to the patient ____ the vaccination is given.

Increasing ; delay

_____ the interval between doses of vaccine given in a series of does not diminish the effectiveness of the vaccine after completion of the series. It may ____ more complete protection.

Haemophilus influenzae type b (Hib)- containing vaccines Hib: ActHIB, Hiberix, PedvaxHIB DTaP-IPV/Hib: Pentacel DTap-IPV/Hib/Hep B: Vaxelis

_____ vaccine: given to adults with asplenia

Inactivated ; hepatitis B vaccine

_____ vaccines can be given at any time. They are started when a baby is 2 months old, except for _____ (which is started at birth).

Live attenuated ; replicate

______ (weakened vaccines) are produced by modifying a disease-producing ("wild") virus or bacterium in a lab. they have the ability to ___ (grow) and produce immunity but usually do not cause illness.

Inactivated ; supplemental doses

______ vaccines can be composed of either a whole virus or bacterium, or fractions of either. Immunity resulting from it can diminish with time and ____ ____ may be required to increase, or "boost" immunity.

MMR: M-M-R II MMRV (MMR + Varicella): ProQuad

what are the measles, mumps, and rubella-containing vaccines (live attenuated)?