Immunizations

Interval for Administration of Live Vaccines and TB Skin Test

1. Administer the live vaccine on the same day as the skin test 2. If a life vaccine has already been administered, but wait 4 weeks before placement of PPD 3. OR place the PPD then wait 48 - 72 hours and read the test -- then give live vaccine

Pneumococcal General Tips

1. Children aged < 2 years receive PCV13 (Prevnar), a conjugate vaccine, becasue they do not produce an adequate antibody response to the polysaccharide vaccines such as Pneumovax 23 (PPSV23) 2. Adults aged 65 years and older, who have no previous pneumococcal vaccine, should receive PCV13 then PPSV23 12 months later. 3. Some patients age 2 - 64 should receive PCV13 +/- PPSV23. The recommended vaccines and spacing varies based on patient characteristics and may involved a shorter interval in immunocompromised patients

Flu: Precautions

1. Defer if patient has a moderate to severe acute illness 2. Refer to physician if patient had Guillain-Barre within 6 weeks of a prior dose of flu vaccine 3. Those who can eat lightly cooked eggs without reactions or if they experience only hives after eating eggs can receive any inactivated vaccine

Influenza Vaccine - General Information

1. Everyone >6 months old should be vaccinated annually - persons at highest risk will be vaccinated first in the presence of a shortage 2. Pregnant women are at risk for severe disease and should be vaccinated 3. Individual can and should be vaccinated for influenza even if it is late in the season 4. The influenza vaccine cannot cause the flu -- may cause sore arm or mild systemic reaction that will resolve in 1 - 2 days 5. Chronic diseases are a precaution to receiving the intranasal vaccine 6. Influenza A and B are the 2 types of influenza that cause epidemic human disease -- Influezna A can be further categorized into 2 types based on surface antigens of glutinin and neuraminidase 7. The virus spreads from person to person primarily though respiratory droplet transmission 8. Store in the refrigerator, do not freeze

Vaccines in Asplenia

1. H. flu type B (HIB) 2. Penumococcal - Prevnar and Pneumovax 23 3. Meningococcal vaccines: - Menactra, Menveo, or Menomune - Bexsero or Trumenba

Vaccines in Healthcare Professionals

1. Hepatitis B 2. Annual influenza 3. MMR if born after 1957 4. Varicella 5. Tdap + Td booster q10years

Pneumococcal Vaccine Spacing

1. If both vaccines are indicated then give PCV13 --> PPSV23 2. In immunocompromised patients: PCV13 --> 8 weeks --> PPSV23 3. If PPSV23 is given 1st then must wait 1 year for PCV13: PPSV23 --> 1 year --> PCV13 4. In immunocompetent patients: PCV13 --> 1 year --> PPSV23 5. Doses of PPSV23 should be separated by at least 5 years (PPSV23 --> 5 years --> PPSV23)

Vaccines In Pregnancy

1. Inactivated flu vaccine 2. Tdapx1 with each pregnancy and all who will have contact with the infant 3. Live vaccines are contraindicated during pregnancy

Invalid Contraindications to Vaccination

1. Mild acute illness 2. Antimicrobial treatment - with some exceptions including varicella/zoster and oral typhoid vaccines 3. Previous local skin reaction (mild/moderate) 4. Allergies: bird feathers, penicillin, allergies to products not in the vaccine 5. Pregnancy, breastfeeding, pre=term birth 6. PPD 7. Immunosuppressed person in household, recent exposure to the disease, or convalescence 8. Family history of adverse reactions to the disease

Pneumococcal Conjugate Vaccine (PCV13) Study Tip

1. PCV13 is currently a routine childhood vaccine. once it has been given, then the patient is considered protected; no further doses are recommended, even if a patient later develops a condition for which it would be indicated (e.g., malignancy) 2. If receiving at age >/=6 years then only 1 dose of PCV13 is needed for protection 3. If PCV13 and PCV23 are both required, then PCV13 is given first 4. PCV13 was approved in 2010. If a case does not state that the patient received PCV13 previously, then it cannot be assumed

True Contraindications to Vaccines

1. Pregnancy with live vaccines 2. Immunosuppression with live vaccines 3. A severe anaphylactic reaction following a dose of vaccine is a contraindication to a subsequent dose of that specific vaccine

Study Tip: Vaccine Administration and Spacing

1. Vaccines can generally be given at the same time - same visit/same day, except Prevnar and Menactra should be separated by 4 weeks in patients with asplenia 2. Multiple live vaccines must be given on the same day or they must be spaced 4 weeks apart with the exception of the oral rotavirus which requires no separation 3. If a vaccine series requires > 1 dose, the intervals between doses can be extended without restarting the series, but cannot be shortened 4. Some products are suppled as power vaccine + diluent; others consist of 2 vaccine components, one powder + one liquid (Menveo, Pentacef) 5. Vaccines should not be mixed in the same syringe 6. It is not recommended to routinely administer acetaminophen before vaccination to prevent adverse effects -- it can be given if symptoms occur

Prevnar 13 is given how much longer after Pneumovax 23

12 months

IM

22-25 gauge

SQ

23-25 gauge 5/8 inches 45 degree angle

Flu: Which vaccine should be used?

ACIP does not have a preference for any particular flu vaccine as long as it is used within FDA indications (exception = Flumist for 2016 - 2017)

Hib

ActHIB Hiberix PedvaxHIB

Tdap

Adacel, Boostrix Give 1x booster for ages 11 years and up with no previous record of Tdap Recommendations: 1. Pregnant or postpartum 2. Close contacts to infants 3. Healthcare professional with direct patient contact 4. Since DTaP is only for children <7, then if a child doesn't get fully vaccinated with the DTaP series, a single Tdap dose is given

Altered Immunocompetence

Altered immunocompetence may make administration of live vaccines contraindicated Immunosuppressed = due to drug - systemic steroid for 14 days or longer at a daily of dose >/=20 mg prednisone/equivalent Chemotherapy must be discontinued x3 months Immunocompromised = due to disease such as HIV/AIDS MMR & Varicella re contraindicated in HIV patients with CD4+ count < 200 cells/mm3

HPV2

Cervarix Bivalent Vaccine Provides immunity against the 2 primary HPV strains that cause cancer For FEMALES ONLY

Flu: Who needs 2 doses?

Children aged 6+ months through 8 years who have never received the vaccine or who have not previously received a total of >/=2 doses in flu vaccine prior to July 1, 2016 require 2 doses for 2016-2017 given 4 weeks apart

Hepatitis A Containing Vaccines - General Information

Children: routine vaccination at age 1 year (2 doses) Adults: men who have sex with men, illicit drug users, chronic liver disease, clotting factor disorders, travelers to countries with high HepA incidence, or anyone who asks for it

Hepatitis B Containing Vaccines - General Information

Children: routine vaccination shortly after birth (3 doses) Adults: Healthcare workers, ESRD, chronic liver disease, HIV, diabetes (Age 19 - 59), IV drug users, men who have sex with men, anyone with multiple sex partners, some travelers

MCV4

Conjugate vaccines Give IM Menactra: use in age 9 months - 55 years Menveo: use in age 2 months - 55 years --> both vials (powder and liquid) contain vaccine

DTaP

Diptheria + tetanus + pertussis Daptacel Infanrix

DTaP-HepB-IPV

Diptheria + tetanus + pertussis + HepB + polio Pediarix

DTaP-IPV

Diptheria + tetanus + pertussis + polio Kinrix Quadracel

DTaP-IPV/Hib

Diptheria + tetanus + pertussis + polio + Hib Pentacel

DT

Diptheria and Tetanus Used as primary vaccination series in infants and children <7 years old who have a contraindication to the acellular pertussis antigen

Recombinant Inactivated Vaccine (RIV)

Egg Free Given IM Tri/Quadrivalent (approved in >/=18 years): Flublok (Quadrivalent)

Hepatitis B Vaccines

Energix-B Recombivax HB NOTE: higher dose of 40 mcg/mL is indicated for dialysis patients

HPV4

Gardasil Quadrivalent vaccine Provides immunity agains the HPV strains responsible for causing certain cancers and genital warts For males or females

HPV9

Gardasil 9 9-valent vaccine For males or females

Penumovax 23 (PPSV23)

Give IM or SQ, store in fridge, do not freeze, shake before administering Minimum age = 2 years old Who: 1. 1 dose before age 65: immunocompetent patient with diabetes, heart, lung, or liver disease, alcohol abuse, or those who smoke 2. 2 doses before age 65: immunocompromised patients including sickle cell disease, asplenia, HIV, chronic renal failure, malignancy, transplant, or immunocompromising drugs including steroids 3. 1 dose after age 65 = EVERYONE NOTE: some patients will receive 3 doses in their lifetime

Prevnar 13 (PCV13)

Give IM, store in fridge, do not freeze, shake before administering Who: 1. All children <5 years, some age = part of childhood vaccine series (4 doses if started as an infant) 2. If never received as a child, then patients aged 6 - 18 years with diabetes, heart disease, or lung disease should receive 1 dose 3. Immunocompromised patients aged 6 - 64 years should receive 1 dose (sickle cell disease, asplenia, HIV, chronic renal failure, malignancy, transplant, or immunocompromising drugs including steroids) 4. 1 dose after age 65 = EVERYONE (unless previously vaccinated as a child) Minimum age = 6 weeks If patient received childhood series, no further doses of PCV13 are needed for any indication

Flu: Vaccine timing

Give vaccines asap, even if it arrives late summer and preferably before October. Offer throughout the influenza season, outbreaks usually peak by February, but can be later

Inactivated Influenza Vaccine (IIV)

Given IM Quadrivalent (IIV4) grown in eggs: Fluarix Fluzone Afluria - risk of febrile seizure in patients < 9 Flulaval Trivalent (IIV3) grown in eggs: Afluria Fluarix Flulaval Fluvirin Fluzone Trivalent High Dose grown in eggs: Fluzone High-Dose Quadrivalent grown in cell culture (ccIIV4): Flucelvax (approved in >/=4 years)

Adjuvantated Inactivated Influenza Vaccine (aIIV3)

Given IM Trivalent, grown in eggs, approved in >/=65 years: Fluad

Measles, Mumps, Rubella Containing Vaccines - General Information

Given to children and non-immune adults If born before 1957 then considered immune to measles and mumps - healthcare providers must prove immunity or receive 2 doses at least 4 weeks apart Live vaccine Give SQ

Hepatitis A Vaccines

Havrix Vaqta

Haemophilus Influenzae type b (Hib) Containing Vaccines - General Information

Hib: is given to children. Given to adults following splenectomy Store in the refrigerator, do not freeze Shake the prefilled syringe before use Give IM

Intervals between doses for vaccines given in series

INCREASING the interval between doses of a multidose vaccine does not diminish the effectiveness of the vaccine after completion of all doses -- however, it DOES DELAY complete protection. DECREASING the interval between doses of a multidose vaccine MAY interfere with antibody response and protection

Polio - IVP

IPOL All children Inactivated polio virus Give IM or SQ, store in fridge, do not freeze, shake before administering Still endemic in Afghanistan, Burma, Guinea, Laos, Nigeria, Madagascar, Pakistan, Ukraine Need single booster dose 4 weeks prior to travel if spending >4 weeks in regions with wild poliovirus - will not be allowed to leave country without proof of documentation

Rabies Vaccine

Imovax, RabAvert Fridge, reconstitute with provided diluent. Give IM May be given preventively if high risk to exposure or given with rabies exposure Prevention = 3 doses Exposure without previous vaccination = 1 with RIG + 3 doses Exposure with previous vaccination = 2 doses

Japanese Encephalitis

Ixiaro, Store in fridge, do not freeze IM x 2 doses, 28 days apart and complete at least 1 week prior to potential exposure May be given if spending 1+ month in endemic areas during transmission season, especially if travel will include rural areas

Tuberculosis bacille Calmette-Guerin (BCG)

Live vaccine Not used often in the US Given to infants and small children in countries with higher TB incidence - provides weak production for pulmonary TB Can cause a positive reaction to PPD

Varicella Containing Vaccines - General Information

Live vaccines - do not use in pregnancy or if immunocompromised Do not give if hypersensitivity to gelatin or neomycin Store in freezer with diluent at room temp or fridge Give SQ Some antivirals can interfere with this live vaccine -- stop 24 hours before vaccine and do not administer for 14 days after vaccination

MMR

M-M-R II Store in refrigerator or freezer

Inactivated Vaccines

May be whole virus/bacterium or fractions Immunity can diminish with time - therefore, may require supplemental doses (boosters)

Trumenba

MenB vaccine Use in age 10 - 25 years 2 doses, month 0/6 unless, if high risk of meningococcal disease or during outbreak then give 3 doses, month 0/1-2/6

Bexsero

MenB vaccine Use in ages 10 - 25 years 2 doses, month 0/1

MenCY-Hib

Menhibrix - is only for high risk infants ages 6 weeks to 18 months; it also includes serogroups C & Y

Simultaneous administration

Most common live or inactivated vaccines can be administered simultaneously without decreasing antibody response or increasing the risk of adverse reactions

Polysaccharide vaccines

Not given to infants and young children Do not consistently produce an effective immune response becasue their immune systems are not completely developed

Rotavirus Vaccines - General Information

Oral vaccine series given to all infants Store in fridge, do not freeze. Do not initiate the series after 15 weeks of age Live vaccine

Meningococcal MenB Vaccines Containing Vaccines - General Information

Patient age >/= 10 years with high risk or in outbreaks Optional in patients age 16 - 23 years who are not high risk, if given preferred at age 16 - 18 Used in combination with on of the other meningococcal vaccines

Human Papillomavirus Vaccines - General Information

Prevents ~90% of cervical cancers, as well as vulvar, vaginal, oropharyngeal, and anal cancers depending on formulation Store in the refrigerator, do not freeze Shake the prefilled syringe or vial before use Give IM Females age 9 - 26 years, ideally before sexual activity (start at 9 years with anyone with history of sexual abuse), but recommended age 11 - 12 years Males age 9 - 26 years: Recommended at 11 - 21 years and up to age 26 in immunocompromised (including HIV) and men who have sex with men Optional in patients aged 22 - 26 but not described above Regimens: 1. Age 9 - 14 years --> 2 doses (month 0/6-12) 2. Age 15 - 26 years --> 3 doses (month 0/1-2/6)

MMRV

Proquad = MMR + varicella Must store in freezer due to varicella component Indicated for patients 1 - 12 years

Passive Immunity

Protection by antibody containing products produced by an animal or human and transferred to a human, usually by injection - Rabies RIG, antibodies passed from mother to infant Usually last a few weeks to months

Active Immunity

Protection is produced by a persons own immune system

Meningococcal Quadrivalent Vaccines Containing Vaccines - General Information

Quadrivalent vaccine include meningococcal conjugate vaccine (MCV4), meningococcal polysaccharide vaccine (MPSV4). Age 2 months and older with high risk: HIV, asplenia/sickle cells disease, complement component deficiencies -- need conjugate Age 2 - 55 years old if at high risk or travelers to certain counties like the meningitis belt in sub-Saharan Africa, lab workers with N. Meningitidis exposure Age 11 - 12 years (1 dose), then 1 booster at age 16 - 18 People with continued risk of meningococcal disease should be revaccinated every 5 years

Live Attenuated Influenza Virus (LAIV4) intranasally

Quadrivalent, approved for health individuals 2 - 49 years: Flumist

Inactivated Influenza Vaccine (IIV4) given intradermally

Quadrivalent, grown in eggs: Fluzone Intradermal - ages 18 - 64 years - smaller needle 30 gauge 1.5 mm but causes more redness, swelling, itching

RV5

RotaTeq

RV1

Rotarix

Examples of Live Attenuated Vaccines

Rotavirus MMR MMRV Varicella/Zoster Flumist Cholera Typhoid (Vivotif only) Yellow Fever

Hepatitis Containing Vaccines - General Information

Store in the refrigerator, do not freeze Shake the prefilled syringe or vial before use Give IM

Adacel Boostrix

Tdap

Td

Tenivac Routine booster in patients age >/= 7 every 10 years Wound Prophylaxis: if a deep or dirty wound, revaccinate with Td if more than 5 years since last dose. Tetanus immunoglobulin (TIG) may also be required if no previous tetanus vaccines. Can use Tdapx1 if never received

Flu: Who should get vaccinated?

The CDC recommend that anyone 6+ months old should get a seasonal flu vaccine each year unless there is a contraindication

Vaccines and Antibodies

The necessary interval between an antibody containing blood product and MMR or varicella containing vaccine (not zoster): Vaccine --> 2 weeks --> antibody containing product Antibody containing product --> >/=3 months --> vaccine This is why live vaccines are held until 12 months of age because of the presence of the mothers antibodies Inactivated vaccines may be started at 2 months with the exception of hepatitis B which should be started at birth

Diptheria Toxoid, Tetanus Toxoid, and acellular Pertusssis-Containing Vaccines - General Information

The pediatric formulations (with the uppercase D) have 3 - 5 times as much of the diptheria component than the adult formulation - the adult formulation will have a lowercase d Store in the refrigerator Shake the prefilled syringe before use Give IM Children get 5 doses of DTaP ages 2//4/6/12-18 months and 4 - 6 years, then Tdap x1 at age 11 - 12 years DTaP is given to children younger than 7 years old

Conjugate vaccines

The polysaccharide is chemically combined with a protein molecule - the antibody response improves and the vaccine is viable for this patient Children<2/infants receive the pneumococcal conjugate vaccine (Prevnar 13) vs pneumococcal polysaccharide vaccine (Pneumovax) as older children

Flu: Trivalent vs. quadrivalent

Trivalent = 2 A's (H1N1 & H3N2) and 1 B Quad = 2 A's and 2B's

Hepatitis A & B Vaccines

Twinrix 3 dose series given at months 0/1/6 months

Typhoid - injection

Typhim Vi Polysaccharide - inactivate Used to prevent typhoid fever caused by Salmonella typhi Store in fridge, do not freeze give IM Complete at least 2 weeks prior to possible exposure q5years if at continued risk Ages >/= 2 years

Avoid _________ if gelatin allergy

Varicella

VAR

Varivax - chicken pox Children get varicella at 12 - 15 months and at 4 - 6 years All patients without evidence of immunity to varicella should receive 2 doses of varicella vaccine

Cholera

Vaxchora Live vaccine, oral Store in freezer, reconstitute buffer packet with 100 mL of cold or RT water then add active packet - stir for 30 seconds and drink within 15 minutes Ages 18 to 64 who are traveling to area of active toxigenic Vibrio cholerae transmission and have increased risk for exposure or poor clinical outcome if infected 1 oral dose, >/=10 days prior to exposure

Typhoid - oral

Vivotif Used to prevent typhoid fever caused by Salmonella typhi Store in fridge 1 capsule PO on alternate days (0/2/4/6) on an empty stomach 1 hour before a meal with cold or lukewarm water Complete at least 1 week prior to possible exposure q5years if at continued risk Ages >/= 6 years

Yellow Fever

YF-VAX Live vaccine Store in fridge, reconstitute with provided diluent, give SQa After vaccination give International Certificate of Vaccination - valid for 10 years staring 10 days after vaccination CI with severe allergy to eggs or gelatin, immunosuppression, age < 6 months, or breastfeeding Avoid donating blood x2 weeks

ZOS

Zostavax - herpes zoster/shingles Herpes zoster vaccine potency is 14 times greater than varicella in order to elicit needed immune response FDA indication for zoster vaccine is adults 50+ years. ACIP recommends use in 60+ years Indicated for the prevention of shingles, not treatment Will reduce complications following infections Vaccinate even if the patient has a history of zoster infection

Live Attenuated Vaccines

aka weakened Produced by modifying a disease producing wild virus or bacterium which will retain the ability to replicate and produce immunity, but usually do not cause illness May be contraindicated in immunocompromised patients Most similar to the actual disease and produce a strong immune response

MPSV4

aka, ACWY Give SQ Menomune: use in age >/= 2 years --> powder vaccine with sterile water diluent ACWY vaccine is required by Saudi Arabia for travel to the Hajj and Umrah pilgrimages; must have proof of vaccination

Menhibrix only used

in children 6 weeks to 18 months

2 types of inactivated vaccines

polysaccharide or conjugate pneumococcal and meningococcal come in both