Vaccinations and Immunizations

List the live attenuated vaccines

"COZY IV RM" - Cholera - Oral typhoid - Zostavaz - Yellow fever - Intranasal influenza - Varicella - Rotavirus - MMR

Who is the hep A vaccine recommended for?

- Adults with medical, occupational, or behavioral risk of infections

What are the ACIP recommendations for flu vaccines in patients with egg allergy?

- Any licensed flu vaccine can be used - If hx of severe allergy, administer in an inpatient or outpatient medical setting - Administration should be supervised to manage severe allergic conditions - *Contraindicated if the patient has had a severe reaction to a previous flu shot* - Observe all patients for 15 minutes after administration

What are the clinical manifestation of varicella infection? How can it be spread?

- Blister-like rash, itching, tiredness, and fever - Spreads easily from people infected to others who have never had the disease or have not been vaccinated; primarily by toughing or breathing in virus particles that come from blisters and possibly from infected respiratory droplets - Can also be spread from people with shingles by toughing or breathing in virus from shingles blisters

What is the causative agent of pertussis? Briefly describe its clinical manifestations

- Bordetella pertussis - Very contagious; bacteria attach to cilia and release toxins that damage the cilia and cause airways to swell - "whooping cough"

Compare and contrast Zostavax and Shingrix

- Both approved for persons 50 and older - Zostavax is recommended for all persons 60 years and older - Zostavax: live vaccine given one SC dose Shingrix: recombinant; 2 dose IM given 3-6 months apart

What is the HPV vaccine used to prevent?

- Cervical (16 and 18) and vaginal vancer in females - Penile cancer in males - Oropharyngeal and anal cancer in males and females - Prevent genital warts (6 and 11) *Gardasil 9*

Inactivated and live-attenuated vaccines can be administered simultaneously at separate sites, except for which ones?

- Cholera (killed) - Yellow fever (live) *Should be given at least 3 weeks apart*

What is the causative agent of tetanus? Describe its clinical manifestations

- Clostridium tetani - Severe uncontrollable muscle spasms; jaw is "locked"; in severe cases, muscles used to breathe can spasm, causing a lack of oxygen to the brain and other organs that may possibly lead to death

What is the causative agent of diphtheria? Describe its clinical manifestations

- Corynebacterium diphtheria - Thick, white, grayish coating over the back of the throat; within 2-3 days a bluish-white or grey membrane forms in the throat and on the tonsils - this membrane sticks to the soft palate of the throat and may bleed; if bleeding, the membrane may become greyish-green or black

Complications of varicella

- Dehydration - Pneumonia - Bleeding problems - Infection or inflammation of the brain (encephalitis, cerebellar ataxia) - Bacterial infections of the skin and soft tissues in children including Group A streptococcal infections - Sepsis

Name the diseases for which vaccination is routinely recommended (Hint: 18)

- Diphtheria - Pertussis - Tetanus - Haemophilus Influenza - Hepatitis A and B - Herpes Zoster - HPV - Measles - Influenza - Meningococcal - Pneumococcal - Polio - Rotavirus - Rubella - Mumps - Tetanus - Varicella

What is the management for severe allergic reactions?

- IM Epi 1:1000, 0.01 mg/kg up to a 0.5 mg max per dose - Pre-filled autoinjectors (0.3mg) Most will require 1-3 doses every 5-15 minutes

Live attenuated vaccines are contraindicated in what populations? (Hint: 2)

- Immunocompromised - Pregnant

Why does rotavirus have its own vaccine?

- Moves very quickly (diarrhea is almost uncontrollable) - Children get dehydrated faster than adults - Can possibly lead to kidney failure

What is the causative agent of meningococcal disease? What can it cause?

- Neisseria meningitidis - Limb loss through amputation, hearing loss, seizures, and stroke *One of the leading causes of bacterial meningitis in children aged 2-18 in the U.S.*

Give the administration and storage/stability information for the JNJ vaccine

- One IM dose - 2 years at -20 deg C and at least 3 months at 2 deg C to 8 deg C

What population is Menactra and Menveo recommended for?

- One dose at 11-12 years; booster at 16 - One dose for college students (1st year) up to age 21 living in residence halls - Adults with asplenia or HIV - revaccinate every 5 years

What is the causative agent of pneumococcal disease? Since it can affect different parts of the body, what can it lead to?

- Streptococcus pneumoniae - Pneumonia, bacteremia (blood infection), meningitis, ear infection

What are the clinical manifestations of mumps? What can it possible lead to? Who does it most often affect?

- Swelling at the side of the face under the ears, fever, HA, and muscle aches - Can lead to viral meningitis - Most often affects 5-9 year olds *Highly contagious*

Which vaccines can be given IM?

- Tetanus, diphtheria (Td), or with pertussis (Tdap) - Hep. A - Hep. B - HPV - Trivalent inactivated influenza (TIV) - Meningococcal conjugate (MCV4) SC or IM: - Polio (IPV) - Pneumococcal polysaccharide (PPSV23)

Briefly describe how vaccines work

- The body is exposed to a weakened or dead pathogen - The body's immune cells make antibodies to attack the pathogen - If the body is exposed to the pathogen again, the body will be prepared with antibodies

For the Pfizer-BioNTech vaccine, give: Dosing Dilution Storage/stability

- Two 0.3 mL doses (0,21 days) IM for 16 years and greater of age - 1.8 mL of NS - Special dry ice shipper; ultracold freezer (-70 to -10 deg C) for 6 months or less (undiluted); thaw 30 minutes in room temperature If kept in fridge: 5 days only undiluted; 6 hours once diluted If kept at room temp: 2 hours undiluted; 6 hours once diluted minimizing light exposure *Observe patient for 15-30 min after vaccination for hypersensitivity reactions*

For the mRNA-1273 (Moderna) vaccine, give the following: Dose, frequency, route Shipping and long-term storage

- Two 0.5 mL doses (0, 1 month) IM for 18 years and older - (-25 to -15 deg C) for 6 months or less Refrigerator (2 ℃ to 8 ℃) 30 days after thawing, within 6 month shelf-life Room temperature: 12 hours *Does NOT require dilution* *Observe patient for 15-30 min after for hypersensitivity reactions*

Give the dose and storage information for the AZD1222 (AztraZeneca) vaccine

- Two doses IM (0, 28 days) - Kept in refrigerator for 6 months or less *Does not require freezer temperatures (one of the benefits*

What are the two inactivated vaccines for Hep A? How are they administered?

- Vaqta and Havrix - 2 doses separted by at least 6 months

Which vaccines MUST be stored frozen? (Hint: 2)

- Varicella - Zoster

What are factors affecting response to immunization? (hint: 4)

- Viability of antigen (live > killed) - Interval between doses and # of doses - Route and site of administration - Length of the needle (1 inch in most cases; IM

What would be the protocol if a patient older than 65 was administered the 23-valent first?

13-valent should be administered at least 12 months later

Explain the difference between Prevnar 13 and Pneumovax23

13-valent: contains the serotypes that cause disease in children - administer at 2 months of age 23-valent: serotypes that are responsible for causing more than 80% of invasive S. pneumoniae infections in adults

Dosing schedule for MMR vaccine in adults born in 1957 and after that lack documentation of vaccination

2 doses of vaccine, separated by at least 28 days For adults previously not vaccinated with HIV w/ CD4 of 200 or more, healthcare workers, and international travelers

For adults that have an uncertain history of primary vaccination, how many doses of Tdap should be given?

3 doses First 2 doses should be administered at least 4 weeks apart Third dose 6-12 months after the second

Live-virus vaccines can be administered to persons with leukemia who have not received chemotherapy for at least _____ months. For Zoster and Influenza, it is ____ weeks before chemotherapy or ____ months after completion

3;2;3

If live vaccines are not administered simultaneously, their administration should be separated by _____ weeks

4

Live viral vaccines may interfere with a patient's PPD response; thus, tuberculin testing should be postponed for ____-_____ weeks after administration of live-virus vaccine

4-6

Give the HPV vaccine schedule for the following age groups: Persons 9-14 years Persons 15-26 years

9-14: 2 shots 6-12 months apart 15-26: 3 shots; second shot 2 months after 1st, third shot 6 months after 1st shot

The HPV vaccine is FDA approved for which age group?

9-45 years of age

A single dose of a rubella vaccine can provide how much long-lasting immunity?

95%

Pneumococcal polysaccharide (PPSV23) vaccination is recommended for which of the following? A. All adults aged 65 or over B. All adult smokers C. All residents of long term care facilities or nursing homes D. Persons with asymptomatic or symptomatic HIV infection E. Children less than 2 years of age

A

Administration of one dose of Tdap is recommended at what point during pregnancy? A. 27-36 weeks B. 1-36 weeks C. After 36 weeks D. Before 27 weeks

A *Given for each pregnancy - not just the first*

Define vaccination

A biological preparation that provides active acquired immunity to a particular disease

What is recommended for patients who have completed a primary childhood series and have not received a dose of Tdap during adolescence, particularly those who have or anticipate having contact with an infant < 12 months old?

A single dose to protect against pertussis, regardless of the interval since their last tetanus toxoid injection

}Which of the following patients should receive the Pneumovax 23? (Select ALL that apply) A. 53-year-old female with COPD B. 1-month old infant with patent ductus arteriosus C. 10—year-old male receiving chemotherapy D. 69-year-old male in good health E. 14-month old toddler with asthma on high-dose corticosteroid

A,C,D

What organization recommends what vaccines should be used at what age?

ACIP = Advisory Committee on Immunization Practices

What is the difference between active and passive immunity?

Active: - The body makes its own antibodies - Provides longer immunity - May take several weeks before immune protection is provided Passive: - When antibodies are given to a patient who has been exposed - Provides temporary treatment

Who should get the MMR vaccine?

Adults born in 1957 and after who lack documentation of vaccination should receive at least 1 dose of MMR vaccine unless they have laboratory evidence of immunity

Why should adults be immunized?

Adults who lack immunity can transmit disease to the vulnerable

Who should be vaccinated for varicella?

All adults without evidence of immunity with 2 doses of vaccine separated by at least 4 weeks

Which pneumococcal vaccine is recommended for adults 65 and greater?

BOTH *13-valent should be administered first followed by 23-valent vaccine 1-year later*

What would we give a patient that has a true allergic reaction?

Benadryl or Hydroxyzine for mild reactions

Give the brand names and recommended age groups for the Tdap vaccine

Boostrix - 10 years and older Adacel - 10-64 years

What is Hep B?

Contagious liver disease caused by the hepatitis B virus (chronic hep B can lead to liver cancer)

What are examples of toxoids?

Diphtheria and Tetanus

}Which of the following vaccines would be safe to give to an immunocompromised child? A. MMR B. Varicella C. Oral Polio D. Injectable Rotavirus E. Injectable Polio

E

How often is a tetanus booster recommended?

Every 10 years; Tdap instead of Td if they have not previously received Tdap

Which flu vaccine is recombinant and the only one that is egg-free?

Flublock Quadrivalent Indicated for 18 years and older

What do toxoids stimulate?

Formation of antitoxin antibodies that will neutralize the toxin

Give both fridge and freezer temperature for vaccine storage

Fridge: 2 to 8 deg C (36-46 deg F) Freezer: -50 to -15 deg C (-58 to 5 deg F)

We should take precautions in patients with a history of ________-__________ within 6 weeks after previous influenza or tetanus-toxoid-containing vaccination

Guillain-Barre

What is the cause of the most common viral infection of the reproductive tract and can cause cervical cancer and genital warts?

HPV

Which disease can cause bacterial meningitis and was a leading cause of childhood meningitis and pneumonia in the U.S.?

Haemophilus influenza type b (Hib)

Name the 3 Hep B vaccines

Heplisav-B: prevention of infection by all subtypes in adults 18 and older - 2 IM doses one month apart Recombivax HB - pediatric and adults - 3 IM doses administered on a 0-, 1-, and 6-month Energix-B: for pediatric and adults; 3 IM doses administered on a 0-, 1- and 6-month

Hiberix

Hib

MenHibrix

Hib + meningococcal

Comvax

Hib and Hep B

When would we defer the zoster and varicella vaccine?

If patients have taken acyclovir, famciclovir, or valacyclovir within 24 hours; avoid use of these meds for 14 days after vaccination

When would we consider revaccinating with the 23-valent?

If the first dose was administered when they were younger than 65 and at least 5 years have passed

What population is the Hib recommended for?

Immunocompromised adults who are asplenic

What are toxoids?

Inactivated bacterial toxins (typically with formaldehyde) combined with aluminum salts to enhance antigenicity by prolonging antigen absorption

How often do we give the following vaccinations to pregnant women: Influenza Tdap

Influenza: annually Tdap: late second trimester or third trimester of pregnancy

Describe the difference between live attenuated and inactivated vaccines

Live attenuated: produced by modifying a disease producing virus/bacteria in a lab; replicate to produce immunity (do NOT cause illness) Inactivated: composed of either a whole virus or bacteria, or fraction of either (booster doses may be needed)

Which flu vaccines are live attenuated? Which ones are inactivated?

Live: Flumist - only nasal; approved for healthy, non-pregnant people (2-49) *quadrivalent* Inactivated: - Trivalent (Afluria) - protect against 3 subtypes (2A and 1B) - Trivalent with adjuvant (Fluad) - for >65 years and older - Trivalent high-dose (Fluzone) - for >65 years and older - 60 mcg of each antigen - more potent - Quadrivalent (has one additional B virus)

What are examples of local and systemic reactions?

Local: pain, swelling Systemic: fever, malaise, myalgias; with live vaccines systemic reactions may occur 3-21 days after receiving vaccine

For patients that are HIV infected, under what conditions can we give the following: MMR Varicella Zoster

MMR: anyone without evidence of immunity and are not severely immunocompromised (CD4% > 15% and CD4 count > 200 for at least 6 months) Varicella: 2 doses separated by 3 months for those with no evidence of immunosuppression Zoster: those who do not have clinical manifestations of AIDS and have CD4 counts > 200

Name the 3 meningococcal vaccines

Menomune - polysaccharide (56 years and older) Menactra, Menveo (serogroups A,C) - conjugated (<55 years) Trumenba, Bexsero - serogroup B; *not routine, mostly for short term protection*

When would we defer a patient from immunization?

Moderate/severe acute illness with or w/o fever *Mild illness can be immunized*

Zostavax should not be given to patients with a history of anaphylaxis caused by _____________.

Neomycin

List the different COVID-19 vaccines by manufacturer and vaccine type

Pfizer-BioNTech - mRNA Moderna - mRNA-1273 AztraZeneca AZD1222 - viral vector Johnson & Johnson vaccine - viral vector

What is the leading cause of bacterial meningitis among children younger than 5 and is the most common cause of acute otitis media?

Pneumococcal disease

State and define the 3 types of inactivated vaccines

Polysaccharide: sugar molecules are taken from the outside layer of encapsulated bacteria (ex: Pneumovax23) Conjugate: use sugar molecules from outside layer of encapsulated bacteria and join the molecules to carrier proteins (ex: Prevnar13, Menactra) Recombinant: a gene segment of a protein from the organism is inserted into the gene of another cell, such as a yeast cell to replicate (ex: Gardasil9)

Describe the difference between the different quadrivalent inactivated flu vaccines

Recombinant (FluBlock) - 18 years of age and greater; egg-free; made by replicating the viral protein and not the whole virus Cell culture based (Flucelvax) - NOT egg-free; for 4 years of age and greater Flurix, Fluzone - 6 months of age and older Afluria - 5 years and greater; 18-64 years of age, use with needle free injector

Are inactivated vaccines kept in the freezer or refrigerator?

Refrigerator

How are live-attenuated influenza vaccines stored?

Refrigerator

Which vaccine is the only one administered orally?

Rotavirus Squeeze tube of vaccine inside infant's mouth towards inner cheek until dosing tube is empty - if the infant regurgitates or spits out the vaccine, re-administration is not recommended

"Acute, contagious viral infection that occurs most often in children and young adults and can cause fetal death or congenital defects (CRS) in pregnant women" describes which disease?

Rubella

Which vaccines can be given via SC?

SC: - MMR - Varicella - Meningococcal polysaccharide (MPSV4) - Zoster (shingles) SC or IM: - Polio (IPV) - Pneumococcal polysaccharide (PPSV23)

Differentiate between SC and IM injections

SC: administered into the thigh of infants and in the upper arm area over the triceps of older children and adults - A 5/8-inch, 25-gauge needle IM: the anterolateral aspect of the upper thigh (infants and toddlers) or the deltoid muscle of the upper arm (children and adults) should be used - A 1-1/2inch, 25-gauge needle

Shingrix and Zostavax both need to be mixed with diluent. Can both of them be stored in the fridge along with the diluent?

Shingrix - yes Zostavax - no, vaccine in freezer and diluent in fridge

Define immunization

The process of artificially inducing immunity or providing protection from disease

How is measles transmitted? What are the clinical manifestations and complications?

Transmission: respiratory droplets with an incubation period of 8-14 days Clinical manifestations: maculopapular rash associated with fever and the 3 C's: cough, coryza, and conjunctivitis Complications: otitis media, respiratory tract infections, convulsions *Highly contagious*

T or F: simultaneous administration of vaccine and antibody is recommended for post-exposure prophylaxis

True (hepatitis A, B, rabies, tetanus)

In the case of MMR and varicella containing vaccines, what is the recommended spacing?

Vaccine, then antibody containing product 2 weeks later Antibody-containing product, then vaccine 3 months later

MMR and ____________ containing vaccines require separation from antibody-containing products (such as blood transfusions and IVIG)

Varicella (NOT ZOSTER)

If a patient had Zostavax previously, should they still get two doses of shingrix?

Yes - wait 8 weeks after Zostavax