Chapter 20: Immunizations

Twinrix dosing schedule

1 mL IM for 3 or 4 doses. 1.) For the 3 dose standard regiment, given the second dose at 1 month after the initial, and the third dose 6 months at the initial (0, 1 and 6 months) 2.) For the 4 dose accelerated regimen, give the second dose 7 days after the initial dose and third dose 21 to 30 days after the initial dose, followed by a booster dose at month 12.

Eight common live vaccines

1. Cholera 2. Oral Typhoid 3. Zoster (Zostavax) 4. Yellow Fever 5. Intranasal Influenza (FluMist) 6. Varicella 7. Rotavirus 8. MMR Remember: COZY IV RM Others: 1. Tuberculosis (BCG) 2. Dengue 3. Smallpox 4. Ebola

Adult HAV vaccination recommendations

1.) Adults traveling to developing countries outside of the U.S. 2.) Household members and other close contacts of adopted children newly arriving from countries with moderate-high endemicity 3.) Those with liver disease 4.) Those with hemophilia 5.) Men who have sex with men 6.) Intravenous drug users 7.) Homeless individuals 8.) Those with HIV+/AIDS NOTE: Give single agent product (e.g., Havrix, VAQTA) or with hepatitis B vaccine (Twinrix)

Vaccination recommendations for infants and children

1.) An annual influenza vaccine is recommended for all special groups aged ≥ 6 months 2.) 3-dose hepatitis B vaccination started at birth 3.) Prevnar 13, DTaP, Hib, polio, and rotavirus should be started at 2 months of age 4.) Live vaccine series typically start at ≥ 12 months of age and includes MMR and varicella 5.) No polysaccharide vaccines should be administered prior to 2 years of age

Vaccination recommendations for those with sickle cell disease or any pathology of the spleen

1.) An annual influenza vaccine is recommended for all special groups aged ≥ 6 months 2.) H. influenzae type b (Hib) vaccine 3.) Pneumococcal vaccines (Prevnar 13 and Pneumovax 23) - Before aged 65 years: 1 dose of Prevnar 13 and 2 doses of Pneumovax 23 - Give Prevnar 13 first, then the 1st Pneumovax 23 ≥ 8 weeks later; give the 2nd Pneumovax 23 ≥ 5 years after the first 4.) Meningococcal vaccines - Meningococcal conjugate vaccine (Menactra or Menveo) - Serogroup B meningococcal vaccine (Bexsero or Trumenba)

Vaccination recommendations for healthcare professionals

1.) An annual influenza vaccine is recommended for all special groups aged ≥ 6 months 2.) Hepatitis B - only if there is no evidence of vaccine series completion or a titer test returns negative or inconclusive 3.) Tdap - 1 dose, if not up-to-date, then Td or Tdap every 10 years 4.) Varicella - if there is no history of vaccination or chickenpox infection 5.) MMR - if there is no history of vaccination or a titer test returns negative or inconclusive

Vaccination recommendations for older adults

1.) An annual influenza vaccine is recommended for all special groups aged ≥ 6 months 2.) Herpes zoster vaccine: - Shingrix: ≥ 50 years of age, 2 doses, at 2 to 6 months apart 3.) Pneumococcal vaccine (age ≥ 65 years) - Pneumovac 23 once (wait at least 1 year after Prevnar 13, if given, and at least 5 years after any prior dose of Pneumovax 23) - Prevnar 13 once if immunocompromised and not received previously, optional for all other adults)

Vaccination recommendations for those with immunodeficiencies

1.) An annual influenza vaccine is recommended for all special groups aged ≥ 6 months 2.) Live vaccines are contraindicated 3.) Pneumococcal vaccines (Prevnar 13 and Pneumovax 23) - Before aged 65 years: 1 dose of Prevnar 13 and 2 doses of Pneumovax 23 - Give Prevnar 13 first, then the 1st Pneumovax 23 ≥ 8 weeks later; give the 2nd Pneumovax 23 ≥ 5 years after the first 4.) HIV (CD4 count < 200 cells/mm3) - Meningococcal conjugate vaccine (Menactra or Menveo) - Hepatitis A vaccine - Hepatitis B vaccine

Vaccination recommendations for adolescents and young adults

1.) An annual influenza vaccine is recommended for all special groups aged ≥ 6 months 2.) Meningococcal vaccine (MCV4; Menactra or Menveo) - 2 doses: 1 dose at age 11 to 12 years and 1 dose at age 16 - First year college students in residential housing: 1 dose if not previously vaccinated 3.) Human papillomavirus vaccine - Recommended at age 11 to 12 years - 2 to 3 doses depending on what age series started 4.) Tdap: - First dose at age > 11 years

Vaccination recommendations for those with diabetes

1.) An annual influenza vaccine is recommended for all special groups aged ≥ 6 months 2.) Pneumococcal vaccine - 1 dose of Pneumovax prior to age 65 years 3.) Hepatitis B - Age 19 to 59 years (or at age ≥ 60 years at HCP discretion)

Adult influenza vaccination recommendations

1.) Annually for all adults

Compare and contrast the active and passive immunity phases associated with vaccination

1.) Antibodies are produced naturally to provide immunity against antigens. - When an antigen is detected, the body will then produce antibodies (immunoglobulins) against that specific antigen 2.) Immunity is acquired actively or passively. - Active immunity develops when the person's own immune system produces antibodies to fight an infection or in response to vaccine administration. - Passive immunity occurs when the antibodies are provided via a donor (e.g., vertical transmission from mother to fetus or IVIG)

Interactions between parenterally administered immunoglobulins and live vaccines

1.) Antibodies may be found in some blood products and are available as IVIG to enhance the immune response to certain disease states 2.) Antibodies can interfere with live vaccine replication and a separation may be required. 3.) Live organism vaccination (e.g., MMR but NOT zoster) should be withheld for as long as 6 to 11 months following immune globulin administration. Recommendations vary by product and immune globulin dose. - Minimum of 3 months - Reference the Pink Book for details - Recommendations: Vaccine → 2 weeks → antibody-containing product Antibody-containing products → 3 months or longer → vaccine 4.) Maternal antibodies delivered through vertical transmission can reduce the neonatal response to live vaccines. - Most live vaccines are held until the infant is 12 months of age, unless otherwise indicated (e.g., rotavirus) 5.) Inactivated vaccines can be given at any time, and are usually started at two months of chronological age, except for the hepatitis B vaccine series, which is started at birth. 6.) In select disease states, simultaneous administration of vaccine and antibody is recommended for post-exposure prophylaxis (e.g., hepatitis A and B, rabies, and tetanus)

Ten basic questions to ask during the vaccination screening process to rule out potential contraindications or to aid in vaccine selection.

1.) Are you sick today? 2.) Do you have allergies to medications, food, a vaccine component, or latex? 3.) Have you ever had a serious reaction after receiving a vaccine? 4.) Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder? 5.) Do you have cancer, leukemia, AIDS or any other immune system problem? 6.) Do you take cortisone, prednisone, other steroids, anticancer drugs, or have you have radiation treatment? 7.) Have you ever had a seizure or nervous system problem? 8.) During the past year, have you received a transfusion of blood or blood products, or been given immune globulin or an antiviral drug? 9.) For women: are you pregnant or do you plan to become pregnant during the next month 10.) Have you received any vaccinations in the past 4 weeks?

Management of sever allergic reactions due to vaccination

1.) Call emergency medical services 2.) For adults, administer epinephrine 1 mg/mL (1:1000 dilution) IM, 0.01 mg/kg, up to a 0.5 mg dose. May use prefilled autoinjector - At least three adult (0.3 mg) autoinjectors should be available at any time in close proximity to the location in which the vaccines are administered. Most adults will require 1 to 3 doses every 5 to 15 minutes 3.) Diphenhydramine can be given to reduce swelling and pruritus. Drugs cannot be administered orally in severe reactions due to airway swelling. 4.) Place patient in supine position, unless there is difficulty breathing. Elevating the head will help breathing, but blood pressure must be kept adequate. If BP is low, elevate legs. Monitor BP/pulse every 5 minutes 5.) Provide CPIR if necessary 6.) Record all vital signs and administered medications

Potential causes of immunodeficiency

1.) Chemotherapy/bone marrow transplant drugs that may induce myelosuppression (↓ WBC, RBC, platelets) 2.) Strong immunosuppressant drugs used for autoimmune disorders (e.g., etanercept, infliximab) or transplant (e.g., everolimus, tacrolimus, sirolimus, mycophenolate mofetil, cyclosporine, etc.) 3.) HIV with a CD4 count< 200 cells/mm3 4.) Systemic steroids for ≥ 14 days at ≥ 20 mg or 2 mg/kg prednisone or equivalent daily. 5.) Chronic renal failure

Specific recommendations for Prevnar 13 vaccination

1.) Children < 5 years - 4 dose series given at age 2, 4, 6, and 12 to 15 months. 2.) Immunocompromised patients aged 2 to 64 years should receive one dose if never received before 3.) Adults ≥ 65 years - optional to give 1 dose if never received before

General recommendations for pneumococcal vaccination

1.) Children age < 5 years receive PCV13 as part of routine childhood vaccinations. - This is because children < 2 years of age do not produce an adequate antibody response to polysaccharide vaccines 2.) The following patients are candidates for one dose of PCV13, if not received previously as part of routine childhood vaccinations: - Immunocompromised patients ≥ 6 years of age - Adults ≥ 65 years (not routinely recommended unless immunocompromised) 3.) PPSV23 is recommended in all adults ≥ 65 years and in select patients between 2 to 64 years 4.) The pneumococcal vaccine recommendations and spacing varies based on patient risks. The usual interval between PCV13 and PPSV23 vaccines when both are indicated is 12 months. A shorter interval (8 weeks) is used for immunocompromised patients, to provide protection more quickly - Multiple doses of PPSV23 are separated by at least 5 years.

Compare and Contrast the various diphtheria toxoid, tetanus toxoid, and cellular pertussis containing vaccines

1.) DTaP is a pediatric formulation (for children under 7 years old) which contains 3 to 5 times as much diphtheria toxoid as compared to the Tdap vaccine - Daptacel - Infanrix With Inactivated Polio Vaccine (IPV) - Kinrix - Quadracel With HBV vaccine and IPV - Pediarix With IPV and Haemophilus influenzae type B(Hib) - Pentacel With IPV, Hib, and HBV - Vaxelis Dosing (No Contraindication to Acellular Pertussis) - 5 doses given at 2 months, 4 months, 6 months, 12 to 18 months, and 4 to 6 years of age 2.) Tdap is intended for adults - Adacel - Boostrix Dosing (No Contraindication to Acellular Pertussis) - Booster given at ≥ 11 years if not previously received - Routine booster every 10 years in those ≥ 7 years of age 3.) DT and Td are used in those who have a contraindication to administration of vaccines containing acellular pertussis. (Diphtheria toxoid, tetanus toxoid adsorbed (DT, Td) - Tenivac - TDVAX Dosing (Contraindication to Acellular Pertussis) - Give Tenivac or TDVAX only - Same schedule as other DTaP vaccines if aged 6 weeks to 6 years - DT vaccine is for use in infants and children 6 weeks up to 7 years of age for primary immunization - Td vaccine is for use in children 7 years of age or older for booster and catch-up immunization; Td may be used to complete the primary immunization series for tetanus and diphtheria after 1 or more doses of DTaP or DT

Select vaccines contain gelatin as an excipient. What issues may this pose in certain populations?

1.) Gelatin is an animal-derived product derived from pigs. 2.) Select religious groups (e.g., Jews, Muslims, Seventh-Day Adventists) and vegetarians/vegans may find issue with this 3.) Most religious leaders permit the use of gelatin-containing vaccines because the gelatin is administered parenterally rather than ingested and the end-product has been rendered pure.

Japanese encephalitis vaccine (Ixiaro)

1.) Give if spending ≥ 1 month in endemic areas during transmission season, especially if travelling in rural areas 2.) Give 2 doses 28 days apart. Complete at least 1 week prior to potential exposure

Rabies vaccines (RabAvert and Imovax)

1.) Give preventatively for high risk exposure 2.) Prevention requires 3 doses 3.) May be given for post-exposure prophylaxis - 2 doses if previously vaccinated - 4 doses without previous vaccination + rabies immunoglobulin with first dose

Influenza vaccination timing

1.) Give the vaccine as soon as available, even if it arrives in late summer 2.) It is preferable to administer vaccine prior to October, but individuals should be vaccinated later in the season. 3.) Outbreaks tend to peak in February

Smallpox and Monkeypox Vaccine (Jynneos)

1.) Give to adults ≥ 18 years who are at high risk for infection 2.) Give 2 doses four weeks apart 4.) Given SQ

Ebola vaccine (Ervebo)

1.) Live vaccine 2.) Give to adults ≥ 18 years for the prevention of disease caused by the Zaire ebolavirus 3.) Not protective against other species Ebolavirus or Marburgvirus 4.) Give 1 dose

Cholera Vaccine (Vaxchora)

1.) Live vaccine 2.) Give to people age 18 to 64 years who are travelling to an area of active toxigenic Vibrio cholerae transmission 3.) Give 1 oral dose ≥ 10 days prior to exposure 4.) Store the packet for reconstitution in the freezer. Remove no more than 15 minutes prior to reconstitution

Dengue Fever Vaccine (Dengvazia)

1.) Live vaccine 2.) Give to people age 9 to 16 years who have previously tested positive for dengue infection and live in endemic areas 3.) Not indicated for primary prevention 4.) Give 3 doses at months 0, 6, and 12 5.) Given SQ 6.) Do NOT shake

Yellow Fever Vaccine (YF-VAX)

1.) Live vaccine 2.) Give to those who travel to, or live in areas of risk, and to travelers to countries that require vaccination 3.) Contraindicated with a severe (life-threatening) allergy to eggs or gelatin, immunosuppression, age < 6 months, or breastfeeding 4.) Avoid donating blood for 2 weeks after receiving the vaccine 5.) The International Certificate of Vaccination (Yellow Card) is provided and is valid for 10 years, starting 10 days after vaccination. - May be required to enter into endemic areas 6.) Given SQ

Tuberculosis Bacille Calmette-Guerin (BCG) Vaccine

1.) Live vaccine 2.) Not used often in the U.S. 3.) Given to infants and small children in countries with higher TB incidence. Provides weak protection. 4.) May cause false positive TB test

Vaccination recommendations for those who are pregnant

1.) Live vaccines are contraindicated 2.) Inactivated influenza vaccines may be administered at any point during pregnancy; avoid live attenuated influenza vaccine 3.) A single dose Tdap vaccine should be given with each pregnancy between 27 to 36 weeks - Vaccinate family members and those who intend to be in close contact with the infant

Interactions between live vaccines and the PPD test

1.) Live vaccines may cause a false negative result (i.e., the recipient does indeed have TB, but the test results negative) 2.) Options to reduce the risk of a false-negative PPD test result include: - Give the live vaccine on the same day as the skin test - Wait 4 weeks after a live vaccine to perform the skin test - Administer the PPD test first, wait 48 to 72 hours to get the result, the give the live vaccine

Invalid contraindications to vaccination

1.) Mild acute illness (slight fever, mild diarrhea) 2.) Current antimicrobial therapy (some exceptions) 3.) Previous local skin reaction (mild/moderate) from a vaccine 4.) Allergies: bird feathers, penicillin, allergies to products not in the vaccine 5.) Pregnancy (except live vaccines), breastfeeding, preterm birth 6.) Recent tuberculin skin test 7.) Immunosuppressed person in the household, recent exposure to the disease or convalescence 8.) Family history of adverse events to the vaccine

Specific recommendations for Pneumovax 23 vaccination

1.) Patients age 2 to 64 years with select risk factors should receive 1 or 2 doses 2.) Adults ≥ 65 years - 1 dose 3.) May give IM or SQ

Haemophilus influenze type b (Hib)-containing vaccines

1.) PedvaxHIB Sol'n for Injection - Hib capsular polysaccharide meningococcal outer membrane protein conjugate antigen 2.) ActHIB Powder for Injection - Hib strain 1482 capsular polysaccharide tetanus toxoid conjugate antigen lyophilisate 3.) HIBERIX Powder for Injection - Hib strain 20752 capsular polysaccharide tetanus toxoid conjugate antigen lyophilisate 4.) Pentacel - DTaP-IPV/Hib 5.) Vaxelis - DTaP-IPV/ Hib/ HBV

Two important contraindications for the administration of live vaccines aside from a known allergy to the vaccine or components to the vaccine.

1.) Pregnancy 2.) Immunosuppression

Aside from those scheduled to receive Tdap/Td vaccines, in which other populations may administration be recommended in?

1.) Pregnant or postpartum women, with each pregnancy 2.) Those in close contact of infants younger than 12 months of age, if not up-to-date 3.) Healthcare personnel with direct patient contact, if not up-to-date 4.) Children aged 7 to 10 years who did not get fully vaccinated with the DTaP series; administer a single dose of Tdap instead of DTaP

Dosing of diphtheria toxoid, tetanus toxoid, and cellular pertussis containing vaccines for prophylaxis against diphtheria and tetanus for patients with large, contaminated wounds (post-exposure prophylaxis)

1.) Revaccinate with Td or Tdap if it has been ≥ 5 years since the last dose. 2.) Tetanus immunoglobulin, human (TIG) (HyperTET) may be required if no previous tetanus vaccines have been provided or patient is uncertain. - 250 units IM once.

Adult meningococcal vaccination recommendations

1.) Serogroup B vaccine (Bexsero, Trumenba) - Give if: a.) Complement component deficiency b.) Taking eculizumab (Soliris) c.) Asplenia d.) Microbiologist with exposure to Neisseria meningitidis e.) Serogroup B meningococcal disease outbreak exposure 2.) Conjugate vaccines (Menactra, Menveo) - Provide to patients with all of the above plus: a.) HIV+/AIDS b.) Travelers to or residents of countries in which the disease is endemic c.) Military recruits d.) First year college students living in dormitories, if not up to date

Contraindications that apply to yellow fever vaccines.

1.) Severe allergic reaction to eggs

Adult HBV vaccination recommendations

1.) Sexually active adults who are not in long-term monogamous relationships 2.) Patients with diabetes aged 19 to 59 years (or ≥ 60 years per HCP discretion) 3.) Household contact with an infected person 4.) IV drug users 5.) Patients with HIV or chronic liver disease NOTE: Give single agent product (e.g., Engerix-B, Recombivax HB, Heplisav-B) or with hepatitis A vaccine (Twinrix)

Adult shingles vaccination recommendations

1.) Shingrix is preferred and is the only product available on the market since the removal of Zostavax 2.) Recommended for all adults ≥ 50 years, even if they have had chickenpox or shingle or previously received Zostavax 3.) Shingrix - 2 dose series, with second dose given 2 to 6 months after the first dose; wait ≥ 8 weeks after Zostavax

Storage and administration recommendations for Tdap/DTaP/Td/DT vaccines

1.) Store in the refrigerator, do not freeze 2.) Shake the prefilled syringe or vial beforehand 3.) Administer IM

Adult Tdap, td vaccination recommendations

1.) Tdap once if not received previously 2.) Td or Tdap every 10 years

Typhoid vaccines [Vivotif (Live/Oral) and Typhim IV (Inactived/IM)

1.) To prevent typhoid fever caused by Salmonella typhi 2.) Oral - take 1 capsule PO on alternate days (day 0, 2, 4, and 6); complete at least 1 week prior to possible exposure. - Give every 5 years if continued risk or exposure - Take on an empty stomach (1 hour prior to meal) with cold or lukewarm water 3.) Injection -give 1 dose at least 2 weeks prior to possible exposure. - Give every 2 years if continued risk or exposuer

Contrast trivalent and quadrivalent influenza vaccines

1.) Trivalent vaccines protect against three influenza viruses: - 2 influenza A viruses (H1N1 and H3N2) - 1 influenza B virus 2.) Quadrivalent vaccines protect against four influenza viruses: - 2 influenza A viruses - 2 influenza B viruses

General vaccine storage recommendations

1.) Vaccines should be kept in their original packaging (box) until used 2.) Never place vaccines in the doors of the freezer or refrigerator 3.) Rotate stock so vaccines and diluents with the earliest expiration date are used first. 4.) Utilize a calibrated thermometer or a digital data logger connected to a buffered temperature probe present in the freezer and refrigerator to log temperatures at least twice daily 5.) Keep temperature logs for 3 years or longer based upon state law 6.) Most vaccines are stored in the refrigerator between 36°F and 46°F (2 to 8°C) 7.) Vaccines that should be stored in the freezer between -58°F and +5°F (-50 to -15°C) include: - Varicella vaccine (Varivax) - Zoster vaccine (Zostavax only) - MMRV vaccine (ProQuad) - Cholera vaccine (Vaxchora) - Ebola vaccine (Ervebo) - Smallpox/Monkeypox Vaccine (Jynneos) 8.) MMR can be stored in EITHER the refrigerator OR freezer 9.) Generally speaking, diluents should either be kept in the refrigerator or at room temperature

Hepatitis-containing vaccines

1.) Vaqta Suspension for Injection - HAV Strain CR 326F antigen (Formaldehyde inactivated) suspension for injection 2.) Havrix Suspension for Injection - HAV Strain HM175 antigen (Formaldehyde inactivated) suspension for injection 3.) HEPLISAV-B Solution for Injection - HBV Subtype ADW HBSAG Surface Protein Antigen 4.) Recombivax HB Suspension for Injection - HBV Subtype ADW HBSAG Surface Protein Antigen 5.) Engerix-B Suspension for Injection - HBV Subtype ADW2 HBSAG Surface Protein Antigen 6.) TWINRIX Suspension for Injection - HAV Strain HM175 antigen (Formaldehyde inactivated), HBV subtype ADW2 HBSAG Surface Protein Antigen

Contraindications associated with hepatitis B vaccines and human papillomavirus vaccines

A hypersensitivity to yeast

Adult HPV vaccination recommendations

Adults ≤ 26 years of age who did not complete HPV series - Indicated up to 45 years of age Gardasil 9 (9vHPV) - FDA approved for boys, girls, men, and women aged 9 to 45 years Adults 18 to 45 Years of Age - 0.5 mL IM x 3 doses. Administer the second dose 1 to 2 months after the first and the third dose 6 months after the first. - Repeat doses if administered too soon. - ACIP recommends administering the first dose at age 11 or 12 years, or any time between 13 and 26 years if not previously vaccinated.

Contraindications and precautions that apply to diphtheria, tetanus, and pertussis vaccines

Contraindications: 1.) For pertussis-containing vaccines: encephalopathy that is not attribute to another cause within 7 days after receiving the vaccine Precautions: 1.) Guillain-Barre Syndrome (GBS) within 6 weeks of a previous diphtheria, tetanus, and/or pertussis vaccine 2.) For DTaP and Tdap only: infantile spasms, uncontrolled seizures

Contraindications and precautions that apply to rotavirus vaccines.

Contraindications: 1.) History of intussusception 2.) Severe combined immunodeficiency Precautions: 1.) Chronic gastrointestinal disease 2.) Immunocompromise

Contraindications and precautions that apply to varicella vaccines.

Contraindications: 1.) History of severe allergic reaction to gelatin or neomycin Precautions: - Use of acyclovir, famciclovir, or valacyclovir in the 24 hour prior to vaccination - These products should be avoided for at least 14 days after vaccination

Contraindications and precautions that apply to influenza vaccines

Contraindications: 1.) Live, attenuated influenza vaccine (LAIV) - severe egg allergy (e.g., anaphylaxis) - use of aspirin-containing products (children and adolescents) - use of influenza antiviral medications within the past 48 hours - children aged 2 to 4 years with asthma or a wheezing episode in the last 12 months - close contact with an immunosuppressed person Precautions: 1.) All influenza vaccines - History of GBS within 6 weeks of a previous influenza vaccination 2.) LAIV - Asthma in any patient age ≥ 5 years - Underlying chronic conditions that predispose to influenza complications (e.g., chronic lung, heart, renal, hepatic, neurologic, hematologic, and metabolic disorders) 3.) Inactivated Influenza Vaccine (IIV): - Egg allergy other than hives - Give IIV only under the supervision of a healthcare provider who can manage severe allergic reactions

Contraindications and precautions that apply to live vaccines.

Contraindications: 1.) Pregnancy - avoid pregnancy for at least 4 weeks after receiving a live vaccine per CDC recommendations 2.) Immunosuppression Precautions: 1.) Recent administration of an antibody-containing blood product

Contraindications and precautions that apply to live and recombinant zoster vaccines.

Contraindications: 1.) Recombinant vaccine only (Shingrix): - Lactation 2.) Live vaccine only (Zostavax): - History of severe allergic reaction to gelatin or neomycin - NOTE: No longer available, replaced by Shingrix 3.) Both vaccines: - Pregnancy (perhaps not so much for Shingrix, data lacking at this time) Precautions: 1.) Live vaccine only: - Use of acyclovir, famciclovir, or valacyclovir in the 24 hour prior to vaccination - These products should be avoided for at least 14 days after vaccination

Contraindications and precautions that apply to all vaccines.

Contraindications: 1.) Severe allergic reactions (e.g., anaphylaxis) to a vaccine or vaccine component after a previous dose. Precautions: Illness: - If a child or adult has only a mild illness (e.g., common cold), vaccines should be given. Treatment with antibiotics is not a valid contraindication or a reason to delay vaccination - If the person has a moderate or severe acute illness, it is reasonable to delay vaccination until the condition has improved

Hepatitis A vaccine administration recommendations

For Primary Immunization 1.) Children and Adolescents - 0.5 mL IM given at 12 to 23 months of age followed by a 0.5 mL booster dose at least 6 months after the first dose - Complete Havrix series 6 to 12 months apart or Vaqta series 6 to 18 months apart. - Catch-up vaccination may occur in patients 2 years and older, with doses separated by 6 to 18 months 2.) Adults 18 years - 0.5 mL IM followed by a 0.5 mL booster dose at least 6 months after the first dose. - Complete Havrix series 6 to 12 months apart or Vaqta series 6 to 18 months apart. - Catch-up vaccination may occur in patients 2 years and older, with doses separated by 6 to 18 months 3.) Adults ≥ 19 years - 1 mL IM followed by a 1 mL booster at least 6 months after the first dose. - Complete Havrix series 6 to 12 months apart or Vaqta series 6 to 18 months apart. Additional Recommendations - Primary immunization with hepatitis A vaccine is universally recommended for all pediatric patients; routine vaccination can be administered to children as young as 12 months of age. Children who are not vaccinated by age 2 years can be vaccinated at subsequent visits. Patients 18 years and older may receive the combined hepatitis A and hepatitis B vaccine, Twinrix, as a 3-dose standard series (0, 1, and 6 months) or on an accelerated schedule of 4 doses at 0, 7, and 21 to 30 days, followed by a booster dose at 12 months. - Vaccinate patients traveling to, living in, or relocating to an area of high endemic risk. - Hepatitis A vaccination is recommended for all previously unvaccinated persons who anticipate close personal contact (e.g., household contact or regular babysitting) with an international adoptee from a country of high or intermediate endemicity during the first 60 days after arrival of the adoptee in the United States. - Different brands of hepatitis A vaccines are interchangeable. - Vaccine administration is recommended for several at risk patient groups: a.) Patients with chronic liver disease b.) Homosexually active males c.) Users of injectable and non-injectable illicit drugs d.) Patients ≥ 1 years of age with HIV e.) Pregnant women at risk for HAV during pregnancy f.) Handlers of HAV-infected primates g.) Lab workers handling HAV.

Vaccine routes of administration for adults, children, and infants

Intramuscular Only: 1.) Most vaccines are given IM Subcutaneous Only: 1.) MMR 2.) MMRV 3.) Varicella 4.) Zostavax 5.) Yellow fever 6.) Dengue fever 7.) Smallpox/Monkeypox IM or SC: 1.) PPSV23 2.) IPV (IPOL) Intranasal: 1.) Flumist Oral: 1.) Typhoid (Vivotif) 2.) Vaxchora 3.) Rotateq/ Rotarix Administration Technique 1.) Subcutaneous - Use a 23 to 25 gauge needle, 5/8" at a 45° angle - Adults/Children: Inject into the fatty tissue over the triceps - Infants: Inject into the anterolateral mid-thigh muscle 2.) Intramuscular - Use a 22 to 25 gauge needle, 1" at a 90° angle EXCEPT if weight < 130 lbs, then use a 5/8" to 1" needle, and if male >260 lbs or female >200 lbs, then use a 1.5" needle - Adults/Children: Inject into the deltoid muscle above the level of the armpit and below the shoulder joint - Infants: Inject into the anterolateral mid-thigh muscle 3.) Never mix vaccines in the same syringe 4.) Use of APAP before vaccine administration, to prevent adverse effects, is not recommended. May be used if symptoms occur afterwards.

Compare and contrast live attenuated and inactivated vaccines.

Live Attenuated Vaccines: 1.) Produced through synthetic modification of naturally occurring viruses or bacteria; they have the ability to replicate and produce immunity, but are significantly less likely to cause pathology. 2.) Most similar to the actual disease and produce a strong immune response; provide a long-lasting, strong immune response 3.) Limitations - Contraindicated in those who are immunocompromised or immunosuppressed. - Circulating antibodies can interfere with vaccine replication Inactivated Vaccines 1.) Composed other either a whole virus or bacterium or components of either. Use the killed version of a wild virus or bacteria that causes the disease. - Cannot replicate (and therefore cannot cause pathology) 2.) Limitations - Waning immunity is possible with inactivated vaccines, therefore boosters may be required; may not produce as robust immunity as live attenuated vaccines 3.) Types: a.) Polysaccharide, Conjugate and Recombinant - Targets a section of the organism, such as a protein, saccharide, or capsid i.) Polysaccharide Vaccines - Taken from the outermost layer of the encapsulated bacteria - Do not produce a good immune response in children < 2 years of age - Ex: Pneumococcal Polysaccharide Vaccine (Pneumovax 23) ii.) Conjugate Vaccines - Use polysaccharide molecules from the outermost layer of the bacteria and join the molecules to carrier proteins. - Conjugation increases immunogenicity in infants, and the antibody booster to multiple doses of the vaccine - Ex: Prevnar 13, Menactra, Menveo iii.) Recombinant Vaccines - A gene segment that encodes for the production of a protein from an organism in inserted into the genetic code of another organism, such as a yeast cell, where it replicated - Ex: Gardasil 9, Influenza vaccines, FluBlok Quadrivalent b.) Toxoid Vaccines - The vaccine targets a toxin produced by the disease - Ex: Diphtheria toxoid vaccine, tetanus toxoid vaccine

Types of adverse drug reactions associated with vaccine administration

Local Reactions: 1.) Injection site reactions - Pain - Swelling/tenderness - Erythema 2.) More common in general, and more common with inactivated vaccines Systemic Reactions: 1.) Less common than local reactions 2.) Adverse effects include: - Fever - Malaise - Myalgias - Headache - Anorexia - Mild illness that resembles 3.) Note: The influenza vaccine is inactivated and cannot cause the flu 4.) With live vaccines, mild systemic reactions can occur 3 to 21 days after the vaccine is given True Allergic Reactions: 1.) Highly uncommon, but can be caused by the vaccine or a component of the vaccine. 2.) Minor allergic reactions will resolve with diphenhydramine or hydroxyzine 3.) Severe allergic reactions must be managed with epinephrine and requires immediate medical attention

Approach to managing a patient with a severe latex allergy in terms of exposure to the latex present on vial stoppers and within prefilled syringes

Most latex sensitivities are a contact-type allergy, which does NOT prohibit vaccine administration; if the reaction to latex is severe, avoid vaccines with latex

Adult pneumococcal vaccination recommendations

Pneumovax 23: - All adults ≥ 65 years - Patients 2 to 64 years old: 1 dose if heart, lung, liver disease, diabetes, alcohol abuse, tobacco usage - Patients 2 to 64 years old: 2 doses if immunocompromised Prevnar 13 (if not received previously): - Any patients ≥ 6 years old who are immunocompromised - Optional for adults ≥ 65 years old

Pneumococcal vaccine indications, sequence, and intervals

Prevnar 13 1.) Patients should receive PCV13 only once in their lifetime if never received pediatric dose series; if received pediatric dose series, not needed. 2.) Immunocompromised patients age 6 to 64 years 3.) Can be considered in patients age ≥ 65 years Pneumovax 23 1.) Give one dose before age 65 but after age 2 if patient is immunocompetent but possesses risk factors below: - Diabetes - Heart, lung, or liver disease - Tobacco use - Alcohol abuse 2.) Give two doses before age 65 but after age 2 if patient is immunocompromised 3.) Give 1 dose at age ≥ 65 years regardless of previous dosing

Hepatitis B vaccine administration recommendations

Primary Vaccination - Children: routine childhood vaccine series; 2 doses given at age 12 months and then 6 to 18 months later - Adults: a.) Healthcare workers b.) Patients with ESRD (on dialysis) c.) Those with chronic liver disease (incl. HCV) d.) Those with HIV, diabetes, e.) IV drug abusers f.) Homosexually active male g.) Anyone with multiple sex partners h.) Incarcerated individuals i.) Some travelers Dosing: - Engerix-B and Recombivax HB: 3-dose series given at month 0, 1, and 6 (can be completed in 6 months if necessary, but requires booster at 1 year if accelerated) - Heplisav-B (age ≥ 19 years): 2-dose series given at month 0 and 1. Do NOT use in pregnant women. Additional Recommendations - Immunization with hepatitis B vaccine, recombinant is recommended for all neonates, infants, children, and adolescents - Use monovalent hepatitis B vaccine rather than combination vaccines in patients younger than 6 weeks; a total of 4 doses of hepatitis B vaccines is recommended if a combination vaccine is used after a birth dose - Interruption of the recommended schedule with a delay between doses should not interfere with the final immunity achieved with the hepatitis B vaccine. There is no need to start the primary series over again, regardless of the time between doses

Human papillomavirus (HPV) 9-valent vaccine

Product Name: - Gardasil 9 Dosing: - Children/Adolescents 9 to 14 years of age: 0.5 mL IM x 2 or 3 doses; 2 doses recommended if started before age 15. For the 2 dose regimen, given second dose 6 to 12 months after the first. For the 3 dose regimen, given second dose 1 to 2 months after first and third dose at 6 months - Adolescents 15 to 17 years of age: 0.5 mL IM x 3 doses. Administer second dose 1 to 2 months after first, and the third at 6 months. Repeat doses if administered too soon - Adults 18 to 45 years: 0.5 mL IM x 3 doses. Administer second dose 1 to 2 months after first, and the third at 6 months. Repeat doses if administered too soon. If any recipient reaches age 27 years before 3-dose series is complete, second and/or third doses may be administered after 26 years to complete series. Additional Recommendations: - Ideally, vaccinate before sexual activity onset; recommended age = 11 to 12 years - Children 9 to 12 years: Routine vaccination with 2 doses of HPV vaccine if series is initiated before age 15. Administer vaccine series beginning at age 9 for children and youth with any history of sexual abuse or assault; vaccination may be administered starting at age 9, even in the absence of a high risk condition - Adults and Adolescents 13 to 18 years: Catch-up vaccination is recommended for adults and adolescents age 13 to 18 who have not initiated or completed the 2- or 3-dose series. A 3 dose series is recommended for adults and adolescents who receive the first dose on or after their 15th birthday - Adults 19 to 26 years: Routine vaccination recommended if not previously vaccinated - Adults 27 to 45 years: Catch-up HPV vaccination is not recommended for all patients over 27 years. ACIP recommends shared clinical decision-making regarding the decision to vaccinate this population. Patients at highest risk are those having a new sex partner

Influenza vaccination recommendations

Recommended Annually - Should there be a vaccine shortage, the highest at risk must be vaccinated first. The CDC website provides information to help determine who is at greatest risk. - All patients ≥ 6 months of age should receive the vaccine unless contraindicated Specific Patient Population Considerations - Age 6 months to 8 years (not previously vaccinated) should receive 2 doses 4 weeks apart - Patients with an egg allergy can receive any age-appropriate inactivated influenza vaccine, even if severe allergy symptoms. a.) Administration should be supervised by a healthcare provider who is able to recognize and treat severe allergic reactions, no additional observation is required beyond 15 minutes b.) Flublok is an egg-free vaccine that is approved for those ≥ 18 years of age c.) Do NOT administer the live influenza vaccine (Flumist) - Pregnant patients can receive any age-appropriate inactivated influenza vaccine. Do NOT administer the live influenza vaccine (Flumist) - Fluzone High-Dose, Fluzone High-Dose Quadrivalent and Fluad are recommended only for those patients ≥ 65 years of age; they contain 4x the antigen dose of the standard dose

Administration and storage recommendations for Haemophilus influenze type b (Hib)-containing vaccines

Storage: 1.) Store in the refrigerator, do NOT freeze Administration 1.) A routine childhood vaccine series given between ages 2 to 15 months 2.) ActHIB and HIBERIX are 4-dose series 3.) PedvaxHIB is a 3-dose series 4.) Given to adults recipient to hematopoietic stem cell transplants, adults with sickle cell disease, asplenia, or undergoing an elective splenectomy 5.) Shake the prefilled syringe or vial before use and give IM Other Considerations: 1.) PedvaxHIB, ActHIB, and Hiberix may be used for primary and booster immunization against Haemophilus influenzae type b 2.) All brands of Hib conjugate vaccines are interchangeable for primary and booster doses 3.) Interruption of the recommended schedule with a delay between doses should not interfere with the final immunity achieved with Haemophilus influenzae type b conjugate vaccine. There is no need to start the primary series over again, regardless of the time between doses 4.) Premature infants should be immunized according to their chronological age, regardless of birth weight

Discuss the following establishments in terms of their contributions to the development and regulation of vaccines: 1.) The Food and Drug Administration 2.) The Advisory Committee on Immunization Practices 3.) The Centers for Disease Control and Prevention

The Food and Drug Administration 1.) The FDA approves vaccinations based on their safety and efficacy in terms of their indication The Advisory Committee on Immunization Practices 1.) ACIP provides the recommendations for vaccine administration in children and adults (i.e., who gets what vaccine and when) The Centers for Disease Control and Prevention 1.) Approves the ACIP recommendations and publishes them in the CDC's Morbidity and Mortality Weekly Report (MMWR) and the Pink Book (Epidemiology and Prevention of Vaccine-Preventable Diseases) 2.) The Pink Book is a useful resource for details regarding immunology and immunizations

Simultaneous administration and spacing of vaccines

Timing: 1.) Most live or inactivated vaccines may be administered simultaneously without reduced immunogenicity or increasing the risk of adverse reactions (i.e., same day at the same time). 2.) Every effort should be made to provide all necessary vaccinations at one visit in terms of pediatric vaccinations as this enhances compliance and increase the probability that a child will be fully immunized. 3.) Combination vaccines can enhance the likelihood of full immunization in children. 4.) Multiple live vaccines can be given on the same day or (if not given on the same day) spaced 4 weeks apart - Exception: no separation is required for oral rotavirus vaccines - If a vaccine series requires > 1 dose, the intervals between doses can be extended without restarting the series, but they cannot be shorted in most cases. Spacing: 1.) Increasing the interval between doses of vaccine given in a series does not diminish the effectiveness of the vaccine after completion of the series, however it may delay more complete protection. 2.) Decreasing the interval between doses of vaccine can interfere with antibody production and protection. 3.) In select cases, the dosing interval may be shortened for at risk patients (e.g., pneumococcal vaccines in an immunocompromised patient)

Provide the various Brand Names and age group recommendations for the following influenza vaccine types: 1.) Trivalent Inactivated Influenza Vaccines (IIV3) 2.) Quadrivalent Inactivated Influenza Vaccines (IIV4) 3.) Quadrivalent Live Attenuated Influenza Vaccines (LAIV4)

Trivalent Inactivated Influenza Vaccines (IIV3) 1.) Fluzone High-Dose - ≥ 65 years of age 2.) Fluad (adjuvanted) - ≥ 65 years of age Quadrivalent Inactivated Influenza Vaccines (IIV4) - Afluria - infants, children, adolescents , and adults up to 64 years of age - Fluarix - infants, children, adolescents , and adults up to 64 years of age - FluLaval - infants, children, adolescents , and adults up to 64 years of age - Fluzone - infants, children, adolescents , and adults up to 64 years of age infants, children, adolescents , and adults up to 64 years of age - Fluzone High Dose - adults ≥ 65 years of age - Flucelvax Quadrivalent - infants, children, adolescents , and adults up to 64 years of age - Flublok - adults ≥ 18 years of age Quadrivalent Live Attenuated Influenza Vaccines (LAIV4) - Flumist - approved for healthy individuals aged 2 to 49 years

What is one patient-friendly resource related to vaccine information that is mandated by federal law to be provided to patients before the vaccine is given?

Vaccine information statements (VIS) - provided by the CDC

Administration and storage recommendations for meningococcal vaccines

Vaccines: 1.) MCV4 (Serotypes A, C, W, & Y) - Menactra, Menveo 2.) MenB (Group B 3 Strain) - Bexsero, Trumenba Age Recommendations 1.) Menactra - age 9 months to 55 years; can be used in adults ≥ 56 years if needed 2.) Menveo - age 2 months to 55 years; can be used in adults ≥ 56 years if needed 3.) Bexsero, Trumenba - age 10 to 25 years Administration Recommendations (MCV4) 1.) Adolescents - 2-dose series given at age 11 to 12 years and at age 16 years (booster) 2.) Special Populations at High Risk - Travelers to certain countries, such as the meningitis belt in Sub-Saharan Africa - Aged ≥ 2 months with HIV, asplenia/sickle cell disease, complement component deficiencies or eculizumab use - Lab workers with N. meningitidis exposure - First year college students (≤ 21 years) living in resident housing, if not up-to-date - Military recruits 3.) Number of doses and timing intervals will depend on age and specific risk. People with ongoing risk of meningococcal disease should be revaccinated every 5 years. 4.) MCV4 is required by Saudi Arabia for travel to the Hajj and Umrah pilgrimages; proof of vaccination is required 5.) Menveo: both vial (powder and liquid) contain active vaccine; only use the provided liquid with the powder Administration Recommendations (MenB) 1.) Asplenia/sickle cells disease, complement component deficiencies, or eculizumab use. 2.) Lab workers with N. meningitidis exposure 3.) During an outbreak 4.) Bexsero: 2 doses given 1 month apart 5.) Trumenba: 2 doses (given 6 months apart). If high risk of meningococcal disease or during an outbreak give 3 doses at months 0, 1 to 2, and 6 6.) Optional for patients age 16 to 23 years who are not at high risk but want the vaccine (if given, the preferred age is 6 to 18 years) 7.) Bexsero and Trumenba are used in addition to the quadrivalent meningococcal conjugate vaccines.

Administration and storage recommendations for MMR and MMRV vaccines

Vaccines: 1.) Measles, Mumps, and Rubella - M-M-R-II 2.) Measles, Mumps, Rubella, and Varicella Live - ProQuad Administration Recommendations: 1.) Children - a routine vaccination series; 2 doses given at age 12 to 15 months and age 4 to 6 years - ProQuad - indicated for patients aged 12 months to 12 years 2.) Adults - 1 to 2 doses if no evidence of immunity 3.) Give 2 doses four weeks apart to: - Healthcare workers - HIV+ patients with a CD4+ count ≥ 200 cells/mm3 for at least 6 months - Nonpregnant women of childbearing potential with no evidence of immunity to rubella - International travelers - Household contacts for immunocompromised people - Student in postsecondary educational institutions 4.) Do NOT administer to those who are pregnant or immunocompromised 5.) Adults born before 1957 are generally considered immune to measles and mumps 6.) Both vaccines are administered subcutaneously Storage Recommendations 1.) MMR - store in the fridge or freezer 2.) MMRV - store in freezer 3.) Store diluents at room temperature or in the refrigerator.

Poliovirus-containing vaccines and administration recommendations

Vaccines: 1.) Polio Vaccine, Inactivated, IPV - IPOL 2.) DTaP-IPV - Kinrix, Quadracel 3.) DTaP-HBV-IPV - Pediarix 4.) DTaP-IPV/ Hib - Pentacel 5.) DTaP-IPV/Hiv/HBV - Vaxelis Administration Recommendations: 1.) A routine childhood vaccine series - 4 doses given at age 2, 4, 6 to 18 months, and 4 to 6 years 2.) Store in fridge, do not freeze 3.) IPOL - give IM or SC

Rotavirus vaccines and administration recommendations

Vaccines: 1.) RV1 - Rotarix 2.) RV5 - Rotateq Administration Recommendations: 1.) Given to all infants. 2.) Do NOT initiate the series after age 15 weeks 3.) Rotarix - 2 doses at age 2 and 4 months given PO 4.) RotaTeq - 3 doses at age 2, 4, and 6 months given PO

Varicella/Zoster vaccines and administration recommendations

Vaccines: 1.) Varicella Virus Vaccine - Varivax 2.) MMRV - ProQuad 3.) Zoster Virus Vaccine - Shingrix Administration Recommendations (Varicella) 1.) A routine childhood vaccine series; 2 doses given at age 12 to 15 months and 4 to 6 years 2.) Anyone without evidence of immunity to varicella should receive 2 doses of Varivax 3.) Do NOT use in those who are pregnant or immunocompromised 4.) Given SC Administration Recommendations (Zoster) 1.) Shingrix is preferred, and the only agent left on the market as Zostavax has been removed 2.) 2 doses given at month 0 and month 2 to 6 in patients ≥ 50 years, including those who previously received varicella virus vaccine or Zostavax 3.) Vaccinate even if the patient has a history of zoster infection