Immunization Final
If a patient is a candidate for revaccination with PPSV23, what is the ACIP-recommended interval between doses of this vaccine?
5 years
Which type of influenza strain is responsible for pandemics?
A
Multiple Vaccines in One Day?
Data show does not cause any AEs; consider how many pathogens on surfaces you tough every day - immune sys. designed to handle it; delaying vaccines inc. risks or inf.. and outbreaks, number of appointments/health care sys. burden; likelihood vaccine schedule will not be completed
What Happens if Interval B/t Vaccine Doses in Series Decreased?
Dec. interval may interfere w/ Ab response and proteciton
Kate is a 24-year-old woman with asthma. She requests a refill of her albuterol inhaler on November 1st. Kate's immunization record indicates that she completed the primary series of MMR, varicella, DTaP, HepA, and HepB vaccines, and she received a dose of Tdap 2 years ago. For complete coverage, which of the following vaccines should she receive?
PPSV23, IIV, and HPV.
Hep B
Signs/SX: jaundice, yellow skin/eyes, dark urine; Complications: acute - fulminant hep (1-2%), chronic - cirrhosis, liver cancer, death
Rubella Complications
Arthralgia or arthritis in adult women (50-70%) - duration up to 1 mos; congenital rubella syndrome (CRS) - cataracts, heart defects, deafness, mental retardation, miscarriage; 1963-1964: worldwide pandemic; more than 20,000 babies born w/ CRS in US
Children are more likely to get what type of influenza strain?
B
Which of the following statements is true regarding administration of LAIV?
Administer with the patient's head tilted slightly backward.
Which of the following statements about pharmacy-based vaccination programs is true?
Administratively, billing for vaccines covered by Medicare Part D may be easier for pharmacists than physicians.
How often should an adult patient with a history of heart failure receive IIV to prevent influenza?
Annually.
Time-Motion Analysis
"After a little practice, immunizing one pt takes about the same amt of time as filling one prescription"; Hint: let professionals do professional tasks, technicians do technical tasks
Screening Questions: Precautions w/ Live Vaccines
"Do you have cancer, leukemia, AIDS, or any other immune sys. problem?", "In the past 3 mos, have you taken meds that weaken your immune sys, such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?", "During past year, have you received transfusion of blood or blood products, or been given immune (gamma) globulin or antiviral drug?", "Have you received any vaccination in past 4 wks?"; For women: "Are you pregnant or is there a chance you could become pregnant during next month?"
Pharmacists Are Part of the Immunization Neighborhood
"Immunization neighborhood," coined by APhA, gaining acceptance by immunization stakeholders; "collaboration, coordination, communication among immunization stakeholders dedicated to meeting immunization needs of pt and protecting community from vaccine-preventable diseases"
Pharmacists' Authority to Administer
"Practice of pharmacy" shall mean a health care service that includes, but not limited to, compounding, dispensing, and labeling of drugs or devices; interpreting/evaluating prescriptions; administering and distributing drugs and devices
Health Care Personnel Vaccination Policy of APhA
"Walking the walk"; 2011 adopted statement: APhA supports annual influenza vaccination as condition of employment, training, or volunteering, w/in organization that provides pharmacy services or operates pharmacy or pharmacy dep. (unless valid medical or religious reason precludes vaccination)
Robert is a 48-year-old pharmacist who is preparing to provide immunizations in his pharmacy for the first time next fall. He has no documentation of receiving the hepatitis B vaccine and would like to be vaccinated before administering vaccines in his practice. What is the recommended routine schedule for vaccination against hepatitis B?
0, 1, and 6 months.
What is the standard dose of epinephrine for managing anaphylaxis?
0.01 mg per kg body weight, up to a maximum of 0.5 mg.
Tom is a 9-month-old boy who received his last set of vaccinations 3 months ago. Tom's mother shows you his up-to-date immunization record and reports that he has never had any adverse reactions to vaccinations. You notice that he has not received an influenza vaccine in the past. What dose of IIV should be administered to Tom?
0.25 mL.
What is the minimum needle length is recommended for administering HepB vaccine to an adult patient weighing 130 lb?
1 inch.
HPV vaccine is recommended for which of the following individuals?
12-year-old boy.
Hib Vaccines
3 conjugated vaccines - ActHIB (Sanofi Pasteur), PedvaxHIB (Merck), Hiberix (GSK) - only approved for booster dose; 1 combo vaccine w/ meningococcal vaccine) - MenHibrix (GSK); Dose and route: 0.5 ml IM; Primary series: 1 dose at 2 mos of age, follow w/ 1 or 2 additional doses depending on vaccine brand; Booster dose: 1 dose at 12-15 mos
According to ACIP recommendations, what is the maximum number of doses of PPSV23 a patient should receive in his or her lifetime?
3 doses
RotaTeq should be administered as a:
3-dose series to infants at 2, 4, and 6 months of age.
After reconstitution, within what time frame must HZV be administered?
30 minutes.
Which of the following patients would be a candidate for PPSV23?
33-year-old woman who is pregnant.
If a patient is a candidate for revaccination with PPSV23, what is the ACIP-recommended interval between doses of this vaccine?
5 years.
How long does immunity from the influenza vaccine typically last?
6-8 months
According to ACIP recommendations, HZV is indicated for the prevention of herpes zoster in adults aged:
60 years and older.
Infulenza Virus - A/California/7/2009 (H1N1)
A = Virus type California = Geographic origin 7 = Strain number 2009 = Yr of isolation (H1N1) = Virus subtype Look at hemagglutinin and Neuraminidase
Which of the following patients should receive the MMR vaccine?
A pharmacist born in 1975 with documentation of 1 dose of MMR vaccine.
Alex is a 32-year-old man who is scheduled to travel to a country where hepatitis A is endemic. He received his first dose of hepatitis A vaccine today. Alex should be counseled to return for his second dose of hepatitis A vaccine:
A second dose of vaccine is not recommended for this patient.
Administration of immunoglobulin following exposure to a pathogen is an example of which type of immunity?
Active immunity.
For a patient who is going to receive IIV and HZV, which of the following best describes appropriate administration of these vaccines?
Administer these 2 vaccines at the same visit, using injection sites on opposite arms or at least 1 inch apart if using the same arm.
Hep B Vaccine Duration
After seroconversion, protection appears to persist indefinitely - memory cells present, despite undetectable circ. Ab, no booster needed; What if health care provider's titer is zero? Give 1 dose, wait 1 mos and repeat titer, if high, no more doses needed, if low or none, complete series
Routine Vaccination w/ Meningococcal Vaccine
All adolescents - give 1 dose of MCV4 at age 11-12 yrs; give 1 booster dose of MCV4 at age 16 yrs; Give only 1 dose if 1st dose after age 16 yrs - not routinely recommended after age 19 yrs; adults w/ certain medical conditions (persistent complement component def., anatomical or funcitonal asplenia, HIV) - give 2 doses of MCV4 at least 8 wks apart
What are target groups for MMR vaccination?
All children, all susceptible people at high risk - health care personnnel, college students, international travelers, nonpregnant women of childbearing age w/o evidence of immunity to rubella, pts w/ HIV if CD4 cound adequate or if given before antiretroviral therapy; adults born in 1957 or later who have not been vaccinated w/ MMR
Hep A Target Groups for Vaccination
All infants at least 1 yo; people w/ chronic liver disease; men who have sex w/ men; illicit drug users; people receiving clotting factor concentrates; travelers (except to Canada, W. Europe, Scandinavia, Japan, New Zealand, Australia); close to personal contacts of internationally adopted children arriving from hep A - endemic areas of world; people w/ occupational exposure to hep A virus (working w/ HAV-inf primates or in HAV research lab); any person for whom hep A immunity desired
Target Groups for Hep B Vaccination
All infants; all adolescents who haven't been previously vaccinated; all high-risk adults: multiple sex partners, pts seeking tx for STDS, pts w/ HIV inf, inj. drug users, pts on dialysis, pts w/ chronic liver disease, health care providers, pts w/ diabetes 19-59 yo (permissive if 60 + yo)
Influenza Pearls
All influenza vaccines must be shaken - Flucelvax: Contains less than 50 femtograms (5 x 10^8 ug) of total egg protein of which albumin is fraction per dose; for 2014-15, children only need 1 dose of vaccine this yr if they received vaccine last yr for 1st time and only received 1 dose - this will not be true next yr
Acute Rxns
Allow for fainting w/o injury, plus access to hard surface if CPR needed; be prepared for anaphylaxis - extremely rare, potentially fatal, usually reversible w/ immediate recognition/tx; remind pts/caregivers to report any adverse events that happen at home - submit these events to VAERS
Vaccine Injury Table (VIT) - Condensed (VAERS Reports Required)
Anaphylaxis; encephalopathy or encephalitis; brachial neuritis after tetanus toxoid (any form); chronic arthritis after rubella vaccine (any form); thrombocytopenic purpura after measles vaccine; vaccine-strain measles infection in immunodeficient person after any form of measles vaccine; paralytic polio or poliovirus infection after OPV; intussusception after rotavirus vaccine; any acute sequelae of these events (including death)
Pertussis
Another epidemic in California - last epidemic in 2010 - 9000 cases, 808 hospitalizations, 10 deaths; California: June 2014 - 9,935 cases, incidence by age; 211 infants < 4 mos of age; 17% mothers vaccinated
What's in the Pipeline
As of 2013, nearly 300 vaccines in development - 137 for infectious diseases - both for diseases for which vaccines already available (new influenza), and new disease states (malaria), 16 in phase III trials and 2 submitted for approval; 99 for cancer; 15 for allergies; 10 for neurological disorders; 13 "other" (nicotine addiction); need to stay up to date
Pharmacists' Admin of Influenza Vaccine: 2010-11
CDC est. that pharmacists admin almost 20% of influenza vaccinations provided to adults in US in 2010-11 season; est. number of vaccines admin by pharmacists was 17 mill to 25 mill doses
Poliomyelitis
Can lead to flaccid paralysis of muscles, leaves sensory function intact
Pertussis (Whooping Cough)
Caused by Bordetella pertussis - very contagious; SX: paroxysmal cough, whooping caused by inspiration against closed glottis; clinical course: incubation 9-10 days (range 6-20); Catarrhal stage 1-2 wks - runny nose, sneezing, low-grade fever, mild non-productive cough; Paroxysmal stage 1-6 wks - intense paroxysmal cough, gagging, gasping, whoop, vomiting, exhaustion; Convalescent stage 2-3 wks (range wks to mos) - gradual recovery, cough dec. in intensity and freq.
Diphtheria
Caused by Corynebacterium diphtheriae; rare in US due to vaccination rates; widespread in other countries; transmission resp or contact w/ lesion; SX: may involve any mucus membrane or skin - exudate forms of adherent membrane w/in 2-3 days causing obstruction; complications due to absorbed toxin - myocarditis, neuritis, death; case fatality rate 5-10%; manage w/ antitoxin and antibiotics
Intranasal Vaccine
Check exp. date, product must be used before date on sprayer label; remove rubber tip protector; do not remove dose divider clip at other end of sprayer; w/ pt in upright position, place tip just inside nostril to ensure vaccine is delivered into nose; w/ single motion, depress plunger as rapidly as possible until dose divider clip prevents you from going further; pinch and remove clip from plunger; place tip just inside other nostril and repeat
Revaccination w/ Meningococcal Vaccine
Children at continued risk for meningococcal disease who were previously vaccinated w/ MCV4 or MPSV4 - additional dose of MCV4 after 3 yrs if 1st dose was admin at age 2-6 yrs; persons who have completed 2-dose primary series and remain at cont. risk for meningococcal disease - revacc. q5yrs after last dose of primary series; persons w/ persistent complement component def. or anatomic or functional asplenia - 1 dose of MCV4 q5yrs after completing 2 dose primary series w/ MCV4
Pneumococcal Vaccine for Adults 19-64 yo Select Conditions and Risks
Chronic heart disease (excluding HTN), chronic lung disease (including COPD, emphysema, asthma), diabetes, alcoholism, cigarette smoking, residents of long-term or nursing home facilities
Opportunities for Collaboration
Collaborate w/ state/local efforts - state/local health dep. organize, admin, and maintain vaccine campaigns and registries and educational activities; emergency preparedness - natural disasters, pandemics, bioterrorism; Join immunization coalitions - organizations that foster collaboration among stakeholders to inc. immunization rates
According to ACIP, which of the following is a contraindication to receiving HZV?
Current treatment for lymphoma.
Kyle is a 5-year-old boy who is up to date with his vaccinations. He has never experienced any adverse effects from vaccinations. At his next well-child check-up, Kyle will be receiving the following vaccines: IPV, MMR, varicella vaccine, and a tetanus-containing vaccine. Which of the following tetanus-containing vaccines would be appropriate for him?
DTaP
General Guidelines for Immunosuppression
Decisions should be made w/ medical provider; vaccines should be given before immunosupp. if feasible - most live vaccines admin 4 wks or more prior to immunosupp. and avoid w/in 2 wks prior to initiation; immunocompetent individuals who reside in household w/ pts can receive vaccines and most live vaccines - avoid oral polio virus, caution handling diapers following oral rotavirus vaccine, avoid contact w/ skin lesions if occur following varicella or zoster vaccine
According to the Advisory Committee on Immunization Practices (ACIP), which of the following would be considered adequate evidence of immunity to varicella, indicating that administration of varicella vaccine is unnecessary?
Diagnosis of chickenpox by a health care provider.
Measles Complications
Diarrhea (8%), otitis media (7%), pneumonia (6%), encephalitis (0.1%), death (0.2%), hospitalization (18%)
Immunosuppressive Meds: IDSA (2013)
Diff. rules for levels of immunosupp.; low-level immunosupp, - Prednisone dose 2 mg/kg/day or less or 20 mg/day; Methotrexate dose 0.4 mg/kg/wk or less; Azothiaprine dose 3 mg/kg/day or less; 6-MP dose 1.5 mg/kg/day or less; High-level immunosupp: higher dose; tumor necrosis factor; ACIP discussing IDSA recommendations
New Meningococcal B Vaccines
Difficult to develop - outer coating of bacteria not recognized by immune sys; Pfizer/Novartis given expedited FDA approval process
Common Myths
Diseases began to disappear long before vaccines were available due to improved hygiene/sanitation; Most people who get vaccine-preventable diseases have been vaccinated; Some vaccine-preventable diseases aren't that bad; Vaccines cause autism; Thimerosal in vaccines cause autism; Vaccines are not safe and cause diseases/illnesses that no one knows about; Giving several vaccines on same day overloads immune sys; There are "hot lots" of vaccines that may cause greater number of adverse events
How Can a Pt Demonstrate Immunity?
Documentation of age-approp. vaccination; lab confirmation after natural inf; birth in US before 1980; dx or verification of hx of varicella or herpes zoster by health care provider
Differences B/t DTap and Tdap
Dose: Tdap - lower diphtheria/acellular pertussis dose to avoid local rxns in adults; FDA app. age indications: DTap younger than 7 yrs, Tdap - Boostrix (GSK) 10 yrs or more, Adacel (Sanofi Pasteur) 11-64 yrs; ACIP recommendations for 65+ yo - when feasible, use Boostrix, use Adacel to not miss opportunity if Boostrix not available
Epinephrine
Doses (based on 1:1000 w/v, 1 mg/ml); dosing by body wt preferred; 0.01 mg/kg/dose (max of 0.5 mg/dose); have repeat doses available; IM more prompt than SQ; Dosage forms - 1 mg/ml ampule; Epi autoinjectors - EpiPen and EpiPen Jr.; Auvi-Q; 0.15 mg and 0.3 mg doses available
To Whom Will You Market Your Service?
Existing/potential pts; prescribers - ensure other health care providers in area are familiar w/ services you provide, develop partnership to complete immunization services; other health care providers/employees of your organization; market to other stakeholders - organizations (businesses, community groups) willing to host clinics
Practice Setting Requirements
Facility layout - pt privacy, approp. refrigerator and/or freezer, place for dose prep, supplies, seating/waiting area; Services: biohazardous waste disposal; Program req. (exposure control plan, staff training, supplies, marketing materials)
Screening Questions
For all vaccines: "Are you sick today?", "Do you have allergies to meds, food, vaccine component or latex?", "Have you ever had a serious rxn after receiving vaccination?", "Do you have long-term health problem w. heart disease, lung disease, asthma, kidney disease, metabolic disease (diabetes), anemia, other blood disorder?"; Precaution w. pertussis-containing vaccines: "Have you had seizure, brain or other nervous sys. problem?"
How long must pharmacists maintain records of immunizations?
For the patient's lifetime.
Which of the following statements is true regarding the difference in coverage between Gardasil and Cervarix?
Gardasil will provide protection against diseases caused by HPV types 6, 11, 16, and 18, whereas Cervarix will provide protection against diseases caused by HPV types 16 and 18.
Haemophilus Influenzae Type B (Hib)
Gram (-) coccobacillus (polysaccharide capsule); resp spread - enters nasopharynx (some become symptomatic carriers), invades bloodstream and causes disease, not common after age 5; clinical features - causes meningitis, pneumonia, arthritis, cellulitis, hearing impairment or neurological sequelae in 15-30%, case fatality rate 2-5%; incidence - dec. 99% since vaccine (1985)
Approved Dec. 10, 2014
HPV 9 Vaccine - Merck 9 valent; serotypes 6, 11, 16, 18, 31, 33, 45, 52, 58; virus like particle (VLP); alum adjuvanted; 3 dose series; same target age group; coparable safety; inc. coverage rates for cervical cancer serotypes to 90% - precancers to 85%; no ACIP recommendations yet
Model for Collaboration Example: HPV Vaccine
HPV is 3 dose series - completion of vaccine series: below 40% for girls and 10% for boys; inital evaluation/education could be done by medical provider or pharmacist; 1st dose admin could be provided by medical provider or pharmacist; remaining 2 doses provided by pharmacist - documentation sent to medical provider
Which of the following vaccines may be administered to boys and young men aged 9 to 26 years to reduce the likelihood of acquiring genital warts?
HPV4.
Barbara is a 60-year-old woman who presents to the pharmacy for two vaccines: HZV and IIV. Which of the following are the appropriate doses and routes for administering these vaccines to this patient?
HZV 0.65 mL subcutaneously; IIV 0.5 mL intramuscularly.
Emergency Preparedness
Have plan and practice it; screen pts before vaccination; observe for 15 min post-vaccination; if rxn occurs - evaluate severity/call 911 if necessary, take blood pressure, pulse and resp q5min, admin epi if necessary, monitor closely, be prepared for CPR, document events
Hep B Virus
Hepadnaviridae - humans only known host, stable on environmental surfaces for 7 days; Disease: blood-borne pathogen - incubation 45-160 days; SX: more common in adults - 50% still asymptomatic; Preicteric 3-10 days - N/V, anorexia, abd pain; Icteric 1-3 wks; Convalescence - wks to mos
Which of the following vaccines is recommended for infants to receive at birth?
Hepatitis B
Which of the following vaccines is recommended for infants to receive at birth?
Hepatitis B.
Which of the following vaccines is a live vaccine?
Herpes zoster (HZV).
Which viruses are associated with the development of cancer?
Human papillomavirus and hepatitis B virus.
What type of immunity targets pathogens that are circulating freely in body fluids, such as blood, plasma, and lymph.
Humoral immunity
Trivalent Influenza Vaccine (TIV)
IIV3
A history of anaphylaxis caused by neomycin would be a contraindication to receiving which of the following vaccines?
IPV.
Pneumococcal Vaccination for Adults Over 65 Years
If vaccine naive: give PCV13 followed by PPSV23 6-12 mos. later; if PPSV23 vaccinated at age 65+ yo: give PCV13 at least 1 yr after PPSV23; PCV13 recommendation to be re-evaluated by ACIP in 2018 - herd immunity may make vaccine unnecessary
True vs. False Allergy
Immediate-type hypersensitivity (typically w/in min to hr or so); True (immediate) allergy - itching, erythema, hives, urticaria; SX progressing toward anaphylaxis; False allergy - fever, GI upset, red eyes w/ thimerosal (contact lens solns), neurologic events
Which of the following is the best example of a group that individual pharmacists can collaborate with to help increase immunization rates?
Immunization coalitions.
Pneumococcal Vaccine for Adults w/ Select Conditions
Immunocompromised, functional or anatomical asplenia, CSF leaks, cochlear implants; it is possible that these pts could receive 3 doses of PPSV23 in lifetime
Alex is a 32-year-old man who is scheduled to travel to a country where hepatitis A is endemic. He received his first dose of hepatitis A vaccine today. Alex should be counseled to return for his second dose of hepatitis A vaccine:
In 6 months.
General Rule: Adverse Reactions
Inact. vaccines expected to commonly produce rxns at inj. site; may be w/ or w/o fever; live attenuated vaccines expected to produce mild form of natural illness, in process of replicating, after incubation period
Pertussis: Complications
Infants/Children: pneumonia, seizures, encephalopathy, hypoxia, hospitalization, death; Teens/Adults: persistent cough, wt loss, passing out, rib fractures; Disease more severe among younger children - among those <1 yr, 50% hospitalized and 1.6% die
Which of the following best describes how to administer Tdap vaccine to an adult patient weighing 130 lb?
Inject intramuscularly at a 90° angle in the deltoid muscle.
Which of the following best describes how to administer MMR vaccine to an adult patient weighing 155 lb?
Inject subcutaneously at a 45° angle in the outer aspect of the upper arm.
Live vaccines are contraindicated in a patient who:
Is immunosuppressed.
Live Attenuated Influenza Vaccine (Flumist)
LAIV/LAIV4
Federal law makes offering an influenza vaccination a requirement for continued federal funding in which setting?
Long-term care facilities.
Antigenic shifts produce ________ changes in type _____ antigens
MAJOR; A
Inactivated Vaccines
Made from viruses or bacteria - various fractions: subvirions, subunits, polysaccharides, toxoids, recombinant Ags; do not replicate b/c they are killed - Ag load stimulates immune response
Grace Period
Min. interval on catch-up schedule - most 28 days; admin slightly earlier unlikely to interfere w/ Ab production - ACIP grace period of 4 days, applies to same-Ag live vaccines, doesn't apply to diff. live vaccines, oral, live vaccines don't have restriction and don't have interval rules (typhoid, rotavirus); diff. live vaccines may have interference if interval less than 28 days - Grace period cannot be applied to sequential dosing if MMRV or MMR and varicella
False CIs
Minor illness (mild fever, upper resp. inf., otitis media, mild diarrhea) - vaccine should not be given if pt ill enough to refer to physician or hospital; allergies to products not in vaccine (penicillin, bird feathers); allergies not immediate and life-threatening (other than anaphylaxis or laryngeal edema); pregnancy in household (even varicella); breastfeeding (even rubella); premature birth (do not adjust for gestation)
HPV
Most common STD; high risk types found in 99% of cervical cancers - type 16/18 account for 70%; involved in most low-grade PAP abnormalities, precursors to cancers, anogenital cancers, and oropharyngeal cancers; low risk types - genital warts, low-grade PAP abnormalities; inf w/ 1 type doesn't prevent inf w/ another type
If a baby is born prematurely, do you need to adjust their vaccination schedule to begin at their due date?
No, no adjustment--use actual birthday
Should a Pt who Provides Verbal History of Chickenpox be Considered Immune?
No, pt's verbal hx no longer considered sufficient evidence of immunity
Immunosuppressive Meds: ACIP (2011)
Not CI to live vaccines; Prednisone 2 mg/kg/day or less or 20 mg/day - higher doses for fewer than 14 days; long-term, alt. day tx w/ short-acting corticosteroids; maintenance physiologic doses; topical, inhaled, injected; other immunosupp. drugs - avoid live vaccines unless other info available
Marketing Materials and Strategies
Numerous free resources available online; advertisements, letters to editor, etc; word of mouth; media: print, radio, television, newspapers, website; storefront displays; flyers, posters, bag stuffers; circulars or weekly advertisements; overhead announcements; direct mail: personalized (HIPAA compliant); buttons, stickers
Kate is a 24-year-old woman with asthma. She requests a refill of her albuterol inhaler on November 1st. Kate's immunization record indicates that she completed the primary series of MMR, varicella, DTaP, HepA, and HepB vaccines, and she received a dose of Tdap 2 years ago. For complete coverage, which of the following vaccines should she receive?
PCV13 and IIV.
Which of the following immunization strategies is preferred for adults under the age of 65 years with immunocompromising conditions who require both PCV13 and PPSV23?
PCV13 first, followed by PPSV23 at least 8 weeks later
Which of the following immunization strategies is preferred for adults under the age of 65 years with immunocompromising conditions who require both PCV13 and PPSV23?
PCV13 first, followed by PPSV23 at least 8 weeks later.
John is a 46-year-old man with diabetes. He requests a refill of his diabetes testing supplies on October 21st. His immunization record indicates that he has completed the primary series of MMR, DTaP, HepA, and HepB vaccines. John has a documented history of chickenpox, and his last Td booster dose was 19 years ago. Which of the following vaccines should he receive?
PPSV23, Tdap, and IIV.
Vasovagal Syncope SX
Paleness, sweating, coldness of hands/feet, nausea, lightheadedness, dizziness, weakness, visual disturbances, loss of consciousness
Mumps
Paramyxovirus; clinical features - resp. transmission - contagious 3 days before to 4 days after onset; incubation 14-18 days; Prodrome - myalgias, anorexia, HA, low-grade fever; Parotitis in 1st 2 days - 30-40% of cases, unilateral or bilateral, duration 7-10 days; asymptomatic in 20% - nonspecific sx in 40-50%
Administration of immunoglobulin following exposure to a pathogen is an example of which type of immunity?
Passive immunity.
Which of the following best describes an opportunity for pharmacists to use diagnosis-based screening to identify people at risk for vaccine-preventable diseases?
Performing a medication review for a patient who has diabetes.
Which of the following vaccine-preventable diseases had the highest incidence in the United States in 2012?
Pertussis.
Info to Include in Standing Order/Protocol
Physician authorization; qualifications of person(s) admin vaccines; vaccine(s) covered in standing order/protocol; policies - screening pts for indications/CIs, info to provide to pts (VIS), how to admin vaccine (dose, route, anatomic location), documentation requirements, communication to physician and reporting requirements, emergency precautions including specific protocol
Pneumococcal Conjugate Vaccine 13-valent (PCV13)
Prevnar 13 (Pfizer) - replaced PCV7, 1 serotype not in PPSV23 (6A); indicated for immunization of children ages 6 wks - 5 yrs; routine schedule: 2, 4, 6, 12 to 15 mos.; for prevention of invasive disease caused by 13 serotypes; for prevention of otitis media caused by 7 serotypes; FDA approved for adults aged 50 yrs and older - ACIP recommended for routine use over 65 yrs; Dose and route: 0.5 ml IM
A health care provider who previously has not been vaccinated against hepatitis B is stuck by a contaminated needle after administering an immunization to a hepatitis B positive patient during a seasonal influenza clinic. In addition to hepatitis B vaccine, the health care provider also should receive hepatitis B Immunoglobulin (HBIG) as postexposure prophylaxis because the HBIG provides:
Prompt immunity while the vaccine provides long-term protection.
Vaccines Available
Protect against tetanus, diphtheria, and pertussis - diphtheria and tetanus toxoid, and acellular pertussis adsorbed (DTap); tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis adsorbed (Tdap); Protect against tetanus and diphtheria - diphtheria/tetanus toxoids adsorbed (DT), tetanus/diphtheria toxoids adsorbed, adult (Td); Dose and route: 0.5 ml IM
How Should Varicella/Zoster Vaccines be Stored?
Protect from light/store in freezer at ~15 C (5 F) before use; important not upon removal from freezer - may be stored and/or transported at refrigerator temperature (2 C to 8 C, 35 F to 46 F) for up to 72 continuous hrs prior to reconstitution, vaccine stored at 2-8 C (35-46 F) that isn't used w/in 72h of removal from ~15 C (5 F) storage should be discarded, expires after 30 min when reconstituted - do not get distracted
Clinical Pearls for Intranasal Admin of LAIV
Provide pt w/ tissue prior to admin; instruct pt not to sniff or inhale spray; insert tip of sprayer just inside nose and depress plunger to spray half dose into 1st nostril; remove dose-divider clip; admin 2nd dose in other nostril; no need to repeat if sneezing or coughing occur
What is an example of mass screening?
Providing vaccine information at a booth of a health fair.
Factors Associated w/ Low Vaccination Among Adults
Pt factors - no regular health care provider, inconvenient access, many underinsured; Provider factors - poor preventative services, lack of provider recommendation, lack of effective reminders; System factors - fewer req. for vaccination (by employers), state regulation vary; complex adult vaccine schedule
IM Injection Prep
Pt should be seated; uncover area; wipe w/ alcohol/let dry; tell pt to relax; insert needle at 90 degree angle to skin in smooth controlled motion while bracing against arm; depress plunger; w/draw needle swiftly; activate safety device immediately; dispose of syringe in sharps container; press cotton or gauze and tape to pt; wash hands
SQ Injection Prep
Pt should be seated; uncover area; wipe w/ alcohol/let dry; tell pt to relax; pinch fold of skin; insert needle at 45 degree angle to skin while bracing against arm; depress plunger; w/draw needle swiftly; act. safety device immediately; dispose of syringe in sharps container; press cotton or gauze and tape to pt; wash hands
Clinical Pearls for Injection Admin
Pt should be sitting - may want to use chair w/ arms, have adequate space to lay person down if necessary; Expect bleeding - pt can hold cotton swab until bandage placed; hitting bone doesn't hurt pt; avoid (when possible) - scars, tattoos, moles; do not aspirate syringe in pt
Tetanus Transmission
Puncture wounds (insect bites); lacerations; abrasions; chronic wounds; injection drug use; amateur piercings and tattoos; incubation 3-21 days; can occur indoors or outdoors
Which type of vaccine involves stimulation of B cells without the assistance of T helper cells?
Pure polysaccharide vaccines.
Which influenza vaccine is approved by the FDA for use in patients with severe egg allergy?
RIV.
Immunization Resources: Staying Up to Date
Read literature, keep current references, APhA Immunization Center, APhA-APPM Immunization SIG and e-community (Engage), Electronic mailing lists - IAC Express, APhA Immunizing Pharmacists News, MMWR, attend refresher/advanced practice courses - APhA Annual Meeting, collaborate (associations, coalitions), Pharmacist.com CPE Center
To reduce liability, pharmacists administering immunizations should take the following three steps:
Receive specialized training and stay current with vaccine information updates; educate patients about the benefits and risks of vaccinations; and emulate local standards of care.
Becoming a Vaccine Provider
Receive specialized training; identify what is allowed/req. by state laws/regulations - standing orders, OSHA, etc; plan your service - program offerings, workflow considerations, prepare to manage vaccines appropriately - storage requirements, have emergency response plan; address reimbursement/compensation; have plan to stay up to date
International Travel Medicine
Recommendations for travel are complex: more than just vaccines, pts may need follow-up upon return, variety of diseases to consider - Typhoid, Yellow fever, Japanese encephalitis, Malaria, Parasites, etc.; Need advanced training in travel medicine - consider attending APhA's Pharmacy-Based Travel Health Services advanced competency training
Hep B Vaccine
Recommended schedule: Infants - birth, 1-2 mos, 6 mos (no earlier than 24 wks); Adolescents and Adults - 0, 1, 6 mos; adult formulation of Recombivax is licensed for 2-dose schedule for adolescents 11-15 yo; What is approp. route of admin for hep B vaccine? Should be admin IM
Additional Doses of PPSV23
Recommended total of 2 doses 5 yrs apart for younger than 65 yrs w/: immunosupp, asplenia (includes sickle cell disease), cochlear implants, CSF leaks; recommend 1 dose for pts older than 65 yo who received 1 or 2 doses at least 5 yrs ago and when younger than 65 yo; PVC1 also recommended in these pts
What is an example of a procedure-based screening?
Recommending vaccinations for a patient undergoing a splenectomy.
OSHA Bloodborne Pathogens Standard
Req. training w/ annual updates (specific training); req. use of universal precautions; req. exposure control plan (ECP); req. employer to provide Hep B vaccine to employees w/ potential risk; mandates use of safer devices (safety needles); req. documentation of safety device evaluation; req. documentation of injuries
Rotavirus Vaccine Recommended Schedule
RotaTeq: 3-dose series (2, 4, 6 mos), 1 ml oral; Rotarix: 2-dose series (2, 4 mos), 2 ml oral; age for admin - min age for 1st dose: 6 wks, max age for 1st dose: 14 wks 6 days, max age for final dose: 8 mos 0 days
Hib Vaccine Recommendations
Routine - infants/young children; High risk persons - people w/o spleens (anatomic or functional) - undergoing elective splenectomy (14 or more days before splenectomy), sickle cell disease; recipients of hematopoietic stem cell transplant (6-12 mos after transplant): 3 doses
Influenza Vaccine
Routine annual influenza vaccination is recommended for all persons aged 6 mos. or older who do not have CIs; Children 6 mos. to 8 yrs receiving influenza vaccination for 1st time need 2 doses, admin at least 4 wks apart in same season
Hep A Vaccination
Routine vaccination - for all children 1-2 yo; catch up by preschool if possible; catch up by age 18, esp if risk factors; adults if risk factors are present or for any person for whom immunity against hep A desired
Which disease was the leading cause of acquired mental retardation before introduction of a vaccine?
Rubella.
Varicella Complications
Secondary bacterial inf; encephalitis; pneumonia; hospitalization; death
Vaccine Schedules
Separate childhood/adolescent and adult: 2 adult schedules, many footnotes; Catch-up schedule available: lists minimal intervals; approved by ACIP in fall; released in Jan or Feb each yr; new editions on CDC website earlier if changed
Aiden is a 6-month-old healthy boy with no known allergies. He has received vaccinations in the past with no reported adverse reactions. Aiden's father asks about having his son vaccinated against influenza. The most appropriate response would be to inform the father that Aiden:
Should receive 1 dose of Fluzone today followed by a second dose of Fluzone administered 4 weeks later.
Which of the following diseases has been successfully eradicated worldwide through vaccination efforts?
Smallpox.
Perpetual Immunization Logs
Software options - pharmacy profiling software (never purge), electronic medical records (EMR), immunization info sys. (ISS), formerly known as immunization registries; report to primary care provider - immunization records should be permanent and easily retrievable
Vaccine Combinations
Some combos indicated only for certain ages or certain doses in series: consult package inserts; DTaP - Infanrix (GSK), Daptacel (Sanofi Pasteur); Tdap - Adacel (Sanofi Pasteur), Boostrix (GSK); Td (various); Kinrix (GSK) - Tdap + IPV; Pentacel (Sanofi Pasteur) - DTaP + Hib + IPV; Pediarix (GSK) - DTaP + Hep B + IPV; Twinrix (GSK) - Hep A + Hep B; ProQuad (Merck) - MMR + Varicella; MenHibrix (GSK) - MenCY + Hib
Prescribing Authority
State law governs health care practice; state-specific prescribing regulation - written or verbal prescriptions, standing orders, protocols, collaborative agreements; applies to both vaccines and epinephrine
Considerations for Determining Which Vaccines to Offer
State laws and regulations, community needs, practical/logistical considerations, compensation opportunities
Which entity determines the specific vaccines that a pharmacist may administer?
States through laws and regulations.
Standards for Adult Immunizations
Stay up-to-date, assess every pt for needed vaccines, strongly recommend needed vaccines, admin or refer, document - report to state registries (immunization info systems), provide pts w/ immunization, notify other providers (primary-care provider); follow up for future vaccine
ID Admin of Fluzone Intradermal
Step 1: Remove needle cap; Step 2: Hold syringe b/t thumb and middle finger, leaving index finger free; Step 3: Insert needle rapidly and perpendicular to skin, bracing hand against pt's arm; Step 4: Inject contents of syringe w/ index finger; Step 5: Remove needle from skin and activate needle shield by pushing firmly on plunger until you hear a click
Conjugate Polysaccharide Vaccines
Stimulate T cell dep. immunity - Th cells involved; produce immunologic memory; result in booster effect upon subsequent exposure; inc. immunogenicity in children younger than 2 yrs
Polysaccharide Vaccines
Stimulate T cell indep. immunity - stimulate B cells w/o assistance of Th cells; short-lived immunity; no booster effect; not consistently immunogenic in children younger than 2 yrs
Which of the following statements about establishing clinics for administering vaccines is true?
Technicians can administer screening questionnaires and distribute VISs.
Compensation Pearls
Tell pts what they must pay for vaccine and service before you prepare dose; give all cash-paying pts receipt so they can seek reimbursement from insurance; you cannot charge Medicare or other 3rd party payers more than your usual and customary fee
Which of the following statements is true regarding how vaccines evoke an immune response?
The antigen in the vaccine activates B cells, which produce antigen-specific antibodies and memory cells.
Which of the following statements is true regarding varicella-containing vaccines?
The potency of HZV is greater than that of varicella vaccine
Which of the following statements is true regarding varicella-containing vaccines?
The potency of HZV is greater than that of varicella vaccine.
Which of the following statements about live attenuated vaccines is true?
They should generally be avoided in immunocompromised individuals.
Rubella
Togavirus - german measles, 3 day measles; 2004 considered no longer endemic in US - cases imported, most hispanic born in areas where vacc. not routine; clinical features - resp transmission - contagious 7 days before rash and 5-7 days after onset; incubation 14 days (12-23 range); Prodrome - rare in children; low-grade fever, malaise, URI sx in older children and adults; Rash - maculopapular, starts on face then spreads from head to foot; duration 3 days
Infulenza Virus
Types A and B cause human disease; yearly changes - responds to avoid human Abs, Shifts - major change in Type A Ag, Drifts - minor change in A or B Ags; many type A lineages (human and animal) - 2 human type As in circ. - A (H1N1) and A (H3N1), responsible for pandemics; 2 type B lineages - Yamagata and Victoria, both circ. in past few yrs
Herd immunity refers to which of the following situations?
Vaccination of enough individuals in a community to prevent disease from circulating
Herd immunity refers to which of the following situations?
Vaccination of enough individuals in a community to prevent disease from circulating.
Vaccination Effect of PCV7
Vaccination of infants and children produced herd effect that also dec. disease in adults; expect herd effect of PCV13 to produce similar results
Tdap and Pregnancy
Vaccination of mother transfers Abs to fetus - provides protection until 1st few doses of DTap; 1 dose every pregnancy - preferably 27-36 wks gestation, if not given in pregnancy, admin as soon as possible post-partum; review vaccination of all family members and caregivers of infant - admin Tdap if indicated (cocooning)
The "Cold Chain"
Vaccine stability is only as good as the weakest link in the cold chain - have delivery only when trained personnel can accept; train everybody; unpack vaccines immediately; check temperature indicators and ice packs in shipping case
Hep A Vaccines
Vaccines - 95-100% effective, Havrix (GSK) and Vaqta (Merck) - brands interchangeable, give 2-dose series at least 6 mos apart; dosing: 18 yo and younger: 0.5 ml IM; 19 yo and older: 1 ml IM; Twinrix (GSK): hep A (ped dosing) + hep B (Adult dose) - 3 dose series
Varicella Zoster Virus
Varicella Zoster Virus: primary inf: varicella (chickenpox); transmission: via resp. droplets or contact w/ lesions - 1-2 days before rash and 4-5 days after onset of rash - very contagious; incubation 14-16 days; clinical features: mild prodrome - fever, HA, tiredness; rash - head first, concentrates on trunk, duration 5-10 days
A history of anaphylaxis caused by gelatin would be a contraindication to receiving which of the following vaccines?
Varicella.
Varicella Vaccination
Varivax (Merck); live attenuated virus vaccine; 2 doses about 98% effective; dose 0.5 ml SQ; children 12-15 mos and 4-6 yo; all susceptible individuals (older than 12 mos) w/ no evidence of immunity - 2 doses 4-8 wks apart
Hep A
Virus - Picornavirus - humans only natural host, stable in environment for months; Disease - Fecal-oral transmission - incubation 28 days (range 15-50), viral shedding from 10 days following exposure to 3 wks after onset of sx; SX: abrupt onset fever, malaise, nausea, anorexia, abdominal discomfort, dark urine, jaundice, duration up to 2 mos w/ relapses up to 6 mos
Timing for Influenza Vaccine Admin
When should you offer influenza vaccines? Soon after vaccine becomes available - no later than October; Offer any time you encounter a pt eligible to receive vaccine; How long should you provide influenza vaccine? Continue vaccinating until your supply is gone, even after influenza activity begins
According to ACIP recommendations, which of the following needle lengths would be appropriate for administering HZV to an adult patient?
⅝ inch.
Pneumococcal Disease: Disseminated Disease
Bacteremia; meningitis; arthritis; peritonitis
Vasovagal Syncope
Brief loss of consciousness or fainting - must occur in 5-15 min, most occuring in teens/women, 14% of episodes result in hospitalization
What form is required to receive compensation for giving a vaccination?
CMS-1500.
Mumps Complications
CNS involvement - aseptic meningitis (15%); orchitis (up to 50% in postpubescent males) - 50% develop testicular atrophy; oophoritis (5% of postpubescent females); deafness (1/20,000); myocarditis, death
Which type of immune response targets pathogens that have entered the cells of the host?
Cell-mediated immunity.
Epidemiology and Prevention of Vaccine-Preventable Diseases
Centers for Disease Control and Prevention; Epidemiology and Prevention of Vaccine-Preventable Diseases
General Rule on CIs
Condition that greatly inc. risk of AE; do not vaccinate if vaccine likely to injure pt; universal CI for all vaccines - severe allergy (immediate/life threatening anaphylaxis) to vaccine component following previous dose
Types of Immunosuppression
Congenital immunodef.; cancer; hematopoietic cell transplant pts; solid organ transplant recipients; asplenic or sickle cell diseases; CSF leaks or cochlear implants; HIV inf - vaccination depends upon degree of immunosuppression; radiation therapy or chemotherapy; immunosupp. meds - oral corticosteroid therapy, MAB, TNF/IL inhibitors, interferon
Ava has arrived at the clinic for her well-child visit. She is 4 months old. Ava's immunization record reveals that she has received the following vaccines: 2 doses of HepB 1 dose of Hib 1 dose of rotavirus 1 dose of PCV13 1 dose of DTaP 1 dose of IPV Which vaccines should Ava receive at today's visit?
DTaP, Hib, PCV13, IPV, and rotavirus.
David is a healthy 5-year-old boy who is scheduled to see his pediatrician for a checkup in July prior to starting kindergarten. David's immunization record reveals that he has received the following vaccines: 3 doses of HepB 4 doses of PCV 2 doses of HepA 3 doses of IPV 3 doses of rotavirus 1 dose of MMR 4 doses of DTaP 1 dose of varicella 4 doses of Hib Which vaccines should David receive at this visit?
DTaP, IPV, MMR, and varicella.
Kyle is a 5-year-old boy who is up to date with his vaccinations. He has never experienced any adverse effects from vaccinations. At his next well-child check-up, Kyle will be receiving the following vaccines: IPV, MMR, varicella vaccine, and a tetanus-containing vaccine. Which of the following tetanus-containing vaccines would be appropriate for him?
DTaP.
Risks From Vaccine-Preventable Diseases Remain
Despite progress, approx. 42,000 adults/300 children in US die annually from vaccine-preventable diseases; communities w/ unvaccinated and undervaccinated populations are at inc. risk; international travelers may spread diseases that remain endemic overseas - worldwide ~20 mill cases of measles and 164,000 deaths each yr
What is the only flu vaccine approved for patients under 3 years old?
Fluzone IIV
HZV should not be administered to a patient with a history of anaphylaxis to:
Gelatin.
Which of the following is a requirement of Occupational Safety and Health Administration's (OSHA's) Bloodborne Pathogens Standard?
Health care providers must use safety devices when administering injectable vaccines.
Which viruses are associated with the development of cancer?
Human papillomavirus and hepatitis B virus
Inactivated Influenza Vaccine
IIV
Which of the following vaccines should be administered to all pregnant women?
IIV.
Which of the following vaccines should be administered to all pregnant women?
IIV. (and Tdap @ 27-36 weeks)
Quadrivalent (QIV)
IIV4
What is meant by the term "immunization neighborhood"?
Immunization stakeholders collaborate to meet community immunization needs.
Where should vaccines that require refrigeration be stored?
In the middle of the refrigerator.
Cervarix (GSK)
Inact, bivalent vaccine (HPV2; types 16/18), approved for females only , 9-16 yo; 3 0.5 ml IM doses total (0, 1-2, 6 mos)
Gardasil (Merck)
Inact, quad vaccine (HPV4; types 6, 11, 16, 18), approved for males/females 9-26 yo
Pregnant women should not get what kind of vaccines?
Live
Which vaccine does ACIP recommend for all college freshmen, living in dormitories, who have not been previously vaccinated?
MCV
Which publication does the CDC generally use to quickly notify providers of updates to vaccine recommendations?
MMWR.
Live Attenuated Vaccines
Made from viruses or bacteria; must replicate to work - mimics natural inf. which stimulates immune response
If a vial of influenza vaccine is left out of the refrigerator on the pharmacy counter overnight, what should be done with the vaccine?
Mark "do not use," place in the refrigerator, and call the manufacturer for further guidance.
Meningococcal Disease SX
Meningitis - pain, HA, neck stiffness; Bacteremia - sepsis and rash; Bacteremic pneumonia; case fatality rate: 10-15%; 11-19% survivors have long-term sequelae
Can Pts who Receive Herpes Zoster Vaccine Transmit Varicella Zoster Virus (Chickenpox) to Susceptible Persons?
Transmission of varicella zoster (Oka strain) virus from vaccinated pt to susceptible person has not yet been documented; if pt develops rash after vaccination: may be active case of zoster b/c vaccine not 100% effective; rash should be covered and susceptible persons should avoid contact w/ lesions
2014-15 Influenza Vaccine
Trivalent influenza vaccine
Jackie is a 34-year-old woman who received an influenza vaccine from you today. She wants to know how long it will take for the vaccine to begin working to protect her from getting the flu. What would be the most appropriate response to this patient?
Two weeks.
Human Papillomavirus Infection (HPV)
Types (More than 100) - high risk types: 16*, 18*; cancers; low risk types: 6*, 11*; low grade Pap smear abnormalities, warts; in US, more than 20 mill people inf w/ HPV - lifetime risk for sexually active adults > 50%
Catch-Up Schedule
Use min. acceptable interval b/t doses when trying to "catch-up"; do not count doses inside min.
Professional Liablity
Must have liability insurance; common themes in malpractice litigation - failure to screen pts for CIs, negligence/failure to warn of risks/benefits, failure to stay up-to-date, practicing outside standing orders; verify that liability insurance covers all professional services; some vaccines covered for both children and adults under federal no-fault VICP
Can technicians administer vaccinations?
No
Will administering multiple vaccines on one day produce adverse effects?
No
Measles
Paramyxovirus - other names - Roseola, hard measles, 7 day measles; short survival air or surfaces; clinical features - resp transmission - highly contagious - 4 days before to 4 days after rash onset; incubation 10-12 days; Prodrome (2-4 days) fever to 103 or higher, followed by cough, runny nose, conjunctivitis; rash - 1st appears in mouth (Koplik spots), maculopapular 1-2 days later - duration 5-6 days
Name the vaccine-preventable disease that may be contracted by unimmunized children from adults (who can serve as a reservoir for the disease), which causes a paroxysmal cough and potentially can result in pneumonia, seizures, encephalopathy, hypoxia, and death.
Pertussis.
The incidence of which vaccine-preventable disease has increased dramatically in the last 5 years?
Pertussis.
Pneumococcal Disease: Lower Resp Tract
Pneumonia
Recombinant HA Vaccine (Flublok)
RIV/RIV3
Which disease is almost certain to cause death if infected patients do not receive postexposure prophylaxis?
Rabies.
Pt Observation
Serious allergic rxns and syncope rare; CDC recommends observing pts for 15 min after vaccination; if sx develop, observe until resolved
Refrigerators/Freezers
Stand alone units preffered; no dorm-type units; warning signs; stabilize temperature w/ water bottles
Differences to Consider for Live/Inactivated Vaccines
Storage; Timing for doses; Duration of protection; A/Es; CIs and precautions
SX of Anaphylaxis
Sudden or gradual onset of generalized itching, erythema (redness), urticaria (hives), angioedema (swelling of lips, face or throat), severe bronchospasm (wheezing), shortness of breath, abdominal cramping, shock, cardiovasc. collapse
Kimberly is a 34-year-old woman who is 30 weeks pregnant. She received a Td booster dose 1 year ago when she cut her hand while working in the kitchen. She has no documentation of receiving a Tdap vaccine. The most appropriate recommendation would be to administer:
Tdap as soon as possible.
Alan is a 47-year-old man who has no documentation of a primary series of tetanus-containing vaccine. Which of the following would be an appropriate primary series for Alan?
Tdap today; Td in 4 weeks; Td 6 months after the second dose.
Emily is a 16-year-old high-school student with no chronic medical conditions. Emily's immunization record shows that she completed the primary series for IPV, HepA, Hib, DTaP, and MMR, and she had a physician-diagnosed case of chickenpox at 2 years of age. Which of the following would be the most appropriate recommendation for her today?
Tdap, HPV, MCV, HepB, and influenza, if during influenza season.
Which of the following tetanus booster vaccines would be most appropriate for administration to a 12-year-old boy who has completed a primary series with DTaP and has no known allergies?
Tdap.
Which of the following vaccines containing tetanus, diphtheria, and/or pertussis would be most appropriate for administration to a 69-year-old man who is preparing to travel to see his newborn granddaughter next month?
Tdap.
Which of the following statements about establishing clinics for administering vaccines is true?
Technicians can administer screening questionnaires and distribute VIS
Dosing of Influenza Vaccine
The ACIP recommends 2 doses of age-appropriate influenza vaccine admin at least 4 wks apart for children aged 6 mos. to 8 yrs who are receiving influenza vaccine for 1st time
Which of the following statements would be accurate when responding to a patient's concerns about vaccines?
The immune system is capable of stimulating an immune response to multiple vaccines administered at the same time.
If a patient received the first dose of HepB but did not return for the remaining doses in the series, under what circumstances should the HepB series be restarted?
The series should not be restarted; resume the series where it was interrupted.
There should be a flat hard surface in the area where vaccines will be administered to ensure:
There is room for the patient to lie down if fainting occurs or CPR is required.
Communicating w/ Pts
Difficult w/ some pts due to misinformation - req. individualized approach, remember pt has final decision; Motivational techniques - open-ended questions, show empathy/acknowledge concern, reframe/reflect, ask permission to share info, provide info and ask for feedback
Which disease is characterized by the development of a membrane on the tonsils, pharynx, or larynx, leading to respiratory obstruction?
Diphtheria.
Breaks in Cold Chain
Document breaks in cold chain - notify supervisor, document - date/time, room/storage unit temperature, description of event, inventory; take action - separate/label vaccines "Do not use", store under corrected conditions, contact health dep. or manufacturer for guidance
What Happens if Interval B/t Vaccine Doses in Series Increased?
Dose not reduce vaccine effectiveness but does delay protection for pt
Vaccines and Pregnancy
Encourage vaccination prior to pregnancy; inact. seasonal influenza vaccine if pregnant during influenza season; Tdap for every pregnancy after 20 wks gestation (27-36 wks ideal); avoid other vaccines to women who are or might become pregnant (especially live vaccines); risks theoretical; pregnant providers may admin live vaccines; discuss w/ pt's physician or refer to physician for vaccine decisions; after pregnancy, admin any deferred vaccines
Polio
Enterovirus - 3 types - Type 1 still reported in Nigeria, Pakistan, Afghanistan, Type 2 last reported 1999, Type 3 last reported 2012; enters thru mouth; replicates in GIU tract - shed in stool; 90-100% transmission rate; clinical features - incubation 6-20 days, 95% infections asymptomatic; flaccid paralysis in 1% - most recover completely, paralysis may be permanent
What is the written vaccine update source also known as the "pink book?"
Epidemiology and Prevention of Vaccine-Preventable Diseases.
Herpes Zoster
Est. latency in cells of dorsal root ganglia; reactivates and travels along neuronal cell axons - often assoc. w/ advancing age or weakened immune sys. (including immunosupp); appears as localized rash in dermatomes; can cause following complications: postherpetic neuralgia (PHN), scarring, bacterial inf, ocular abnormalities
Trumenba (Pfizer)
FDA approved Oct. 29, 2014 for ages 10-25 yrs; 3 dose schedule (0, 2, 6 mos); Bivalent recombinant vaccine against 2 proteins on surface of bacteria (subfamilies) - effective against 4 strains seen in US; No ACIP recommendations yet
Vaccines and Immunosuppression (Altered Immunocompetence)
Very complicated issues: timing of vaccination, type of immunosuppression, duration/level of immunosuppression, individual vaccine issues; References: ACIP General Recommendations, IDSA Clinical Practice Guidelines, some diff. but in process of synchronization; Affects live/inactivated vaccines: live concerned w/ inc. risk for AE due to uninhibited replication, inactivated concerned w/ dec. effectiveness
Pharmacy Technicians
Warning: no states permit pharmacy technicians to admin meds (including immunizations)
General Guidelines for Vaccine Admin
Wash hands; check exp. dates; confirm right vaccine - be careful about look-alike/sound-alike names, packaging; verify prep instructions (many vaccines must be shaken); maintain sterility while preparing dose; draw up dose using appropriate technique; position sharps container w/in reach; never take eyes off needle; activate safety device immediately; dispose of needle properly; remove gloves and wash hands
Cell Cultured (Flucelvax)
ccIIV3
Antigenic drifts produce ________ changes in type ______ antigens
minor; A and B
What is the standard dose of epinephrine for managing anaphylaxis?
0.01 mg per kg body weight, up to a maximum of 0.5 mg
Adolescents should be routinely vaccinated with MCV4 on the following schedule:
1 dose at age 11 to 12 years, followed by a booster dose at age 16 years.
The incubation period for influenza can range from:
1 to 4 days.
After completion of a primary vaccine series and documentation of a one-time dose of Tdap, Td booster doses are recommended every:
10 years.
Justin is a healthy 16-year-old boy who has no documentation of varicella vaccine or history of the disease. He should receive:
2 doses of varicella vaccine separated by at least 4 weeks.
What is the FDA-licensed age range for the use of LAIV?
2 to 49 years of age.
According to ACIP recommendations, what is the maximum number of doses of PPSV23 a patient should receive in his or her lifetime?
3 doses.
Vaccine Storage and Management
Institute vaccine storage rules before you purchase your vaccine, protect your pts, protect your expensive inventory, develop your own plan, vaccine management guidelines
The childhood/adolescent and adult immunization schedules are updated and published annually during which months?
January or February.
HealthMap Vaccine Finder is a free online tool that allows pharmacists to:
List their vaccination services so patients can find them when searching the website for nearby immunizers.
Rotavirus Vaccines
Live attenuated vaccines - RotaTeq (Merck) - oral susp. in ready-to-use dosing tubes, Rotarix (GSK) - oral vaccine req. reconstitution before adminn; CI in children w/ GI problems or hx of intussusception
MMR Vaccine (Merck)
Live-attenuated - efficacy 98%; 2 dose series for children - 12-15 mos; 4-6 yo - 2nd dose not booster, to revaccinate non-responders; adults - born before 1957 considered immune; born in 1957 or later - documentation of 1 or more doses of MMR; CIs - allergy to gelatin or neomycin, pregnancy, immunosupp, receipt of blood products
A health care provider who previously has not been vaccinated against hepatitis B is stuck by a contaminated needle after administering an immunization to a hepatitis B positive patient during a seasonal influenza clinic. In addition to hepatitis B vaccine, the health care provider also should receive hepatitis B Immunoglobulin (HBIG) as postexposure prophylaxis because the HBIG provides:
Long-term protection while the vaccine provides prompt immunity.
Examples of Recent US Outbreaks of Vaccine-Preventable Diseases
Measles outbreak 2014 (thru Oct. 31) - 603 cases reported, most unvaccinated, most imported from Philippines; Mumps outbreak 2014, outbreaks in universities, most vaccinated (88% effective 2 doses, 78% one dose); Pertussis epidemic 2012 - pertussis cases and 14 deaths in infants < or = 12 mos; 2014 (Nov. 26) - 9935 cases in California, 347 hospitalized
The presence of fever, diffuse maculopapular rash, and Koplik spots are characteristic of which of the following diseases?
Measles.
Federal Requirement for Documentation
National Vaccine Injury Compensation Program (VICP) est. in 1986; req. documentation for all vaccines covered by VICP - pt name, date vaccine admin, vaccine manufacturer and lot number, name, address, title of person admin vaccine, date printed on VIS, date VIS given to vaccine recipient or recipient's legal representative; signature not req. by federal law - verify local or state req.
National Childhood Vaccine Injury Act
National Vaccine Injury Compensation Program (VICP) est. no-fault insurance for certain adverse reactions - VIT: vaccine injury table lists specific injuries; removed liablity from manufacturers and providers (except in negligence cases) - petitioners waive right to claim punitive damages; current VIS must be given regardless of pt's age before vaccination; must report adverse event to VAERS
Jet Injector Technology
Needle-free - eliminates needlesticks, for pts w/ fears of needles; approved 2014 - PharmaJet Needle-Free Sys. w/ Afluria vaccine
Influenza Disease
Onset: 2 days (1-4) after exposure; contagious 1 day before symptomatic and 5-7 days after onset; SX: high fever, cough (can be severe), fatigue, weakness, HA, myalgias; diff. presentation that common cold; Complications: pneumonia, exacerbation of pulmonary and cardiac conditions
Vaccine Compensation
Out-of-pocket (self-pay); pt reimbursement thru employer plans - applied to deductibles, health savings accounts, or flexible spending accounts; private employers (to reduce absenteeism); medicare (Part B, Part D); Medicaid; 3rd party insurance payers; affordable care act (ACA)
Zostavax (Zoster Vaccine Live)
Package Insert: In randomized clinical study, reduced immune response to Zostavax as measured by gpELISA was observed in individuals who received concurrent admin of Pneumovax 23 and Zostavax compared w/ individuals who received vaccines 4 wks apart; consider admin of 2 vaccines separated by at least 4 wks; ACIP hasn't changed recommendation regarding simultaneous admin of zoster and pneumococcal vaccines and states can be given together
Pneumococcal Disease: Upper Resp Tract
Sinusitis; Otitis media
SQ Injection
Site - Children 3+ yo/adults - outer aspect of upper arm (posterolateral); 5/8 inch; 23-25 gauge; insert at 45 degree angle
IM Injections
Site - Infants - Anterolateral thigh; Children 3+ yo/adults - deltoid muscle; do not inject too high on arm; insert at 90 degree angle; 22-25 gauge
Which of the following diseases has been successfully eradicated worldwide through vaccination efforts?
Smallpox
Meningococcal Vaccines
Types A C Y W-135 - polysaccharide (MPSV4) - menomune (sanofi pasteur); Dose: 0.5 ml SQ - single dose for individuals 2 yo +; Conjugate (MCV4) - menactra (sanofi pasteur) (MenACWY-D); Dose: 0.5 ml IM; Age 9 mos-55 yrs; 2 doses series age 9-23 mos; single dose age 2-55 yo; Menveo (Novartis) (MenACWY-CRM); Dose: 0.5 ml IM; Age 2 mos - 55 yo; 4 dose series age 2-23 mos; single dose 2-55 yo; Combination Conjugate (HibMenCY); Meningococcal types CY and Haemophilus influenza (Hib); Menhibrix (GSK); Dose: 0.5 ml IM; Age 6 wks - 18 mos 4 dose series; dosen't contain serotypes A or W-135 if traveling
Storage
Use temperature monitor - preferable continuous but min of twice a day, use encased probe (glycol) rather than measurement of ambient air temperatures, if alarm activates, take immediate corrective action, keep log; protect power supply; no food or drinks; some vaccines are light sensitive
The documentation system that health care providers should use to report serious adverse events after vaccination is:
VAERS.
Which of the following documents must be given to every patient or patient's caregiver before administration of a vaccine covered by the NCVIA?
VIS.
Rotavirus Gastroenteritis
Virus - 5 predominant strains in US, stable in environment for wks or mos, spread fecal-oral route; Clinical features - diarrhea (may lead to dehydration), fever, vomiting, infects more than 95% or all children by age 5, before vaccination - every child 1 or more episodes by age 5
Syncope
What do you do if pt faints after vaccination? Follow emergency response protocol, help pt to ground so they do not fall, causing injury, lay pt flat on floor w/ feet elevated, if pt doesn't regain consciousness quickly call 911
Tdap Clinical Pearl
What is recommended interval b/t dose of Tdap and last Td booster? Tdap can be admin regardless of interval since last tetanus and diphtheria toxoid-containing vaccine
Can a Pt Transmit the Live Attenuated Influenza Vaccine Virus to Another Person?
While shedding of vaccine virus occurs following admin of LAIV, transmission to another person is rare
Which of the following diseases are transmitted through mosquito bites?
Yellow fever and Japanese encephalitis.
What Would You Do?
You are asked to prepare dose of zoster vaccine for pt to transport to physician's office for admin. What would you do? You are responsible for maintaining cold chain until vaccine admin to pt; avoid premixing expensive or temperature-sensitive vaccines (zoster); do not let pt transport
Which of the following is most likely to result in an influenza pandemic?
Antigenic shift in an influenza A virus
Which of the following is most likely to result in an influenza pandemic?
Antigenic shift in an influenza A virus.
Bexsero (Novartis)
Approved in Europe, Canda, Australia - awaiting US FDA approval; used in US outbreak in 2 college campuses; 2 dose schedule for children adults - 3 doses for infants; 4 antigenic components - 3 recombinant proteins and 1 outer membrane vesicle (4CMenB)
Which of the following key questions is important to ask a patient before administering IIV?
Are you sick today?
What if Someone Loses an Immunization Record?
Ask pt to look again; ask previous provider(s), day care, schools - but do not waste too much time; do not assume events w/o documentation; vaccinate to be sure; duplicate doses might mean sore are, but that is preferrable to being susceptible to fatal diseases
Tetanus
Caused by Clostridium tetani; spores found in soil, dust feces; toxin binds to CNS, prevents muscle relaxation; sx of trismus (lockjaw), muscle rigidity, and spasms; 10% case-fatality rate
Meningococcal Disease
Caused by Neisseriea meningitidis; serogroups B, C, and Y acct for most disease in US; Serogroup B - causes 60% disease in children < 5 yrs, 40% college age group (50 cases/yr); Serogroups C, Y, W-135 - 73% cases of individuals older than 11 yo; peaks in 3 age groups; incidence declining of all serotypes - most cases sporadic, but outbreaks continue
Pneumococcal Disease
Caused by Streptococcus pneumoniae - gram + coccobacillus w/ polysaccharide cellular capsule, colonizes upper resp. tract as part of normal flora - inf. result of autoinoculation; leading cause of vaccine-preventable illness and death in US; freq. cause of secondary bacterial pneumonia following influenza; threat exists yr-round, not just in winter; antibiotic resistance common; more than 90 serotypes based upon polysaccharide capsules
Resources About Vaccine Safety
Centers for Disease Control and Prevention - vaccine safety and adverse events, provider resources for vaccine conversations w/ parents; Immunization Action Coalition; World Health Organization (WHO)
In the event that a young child is fussy following the receipt of a vaccine, pharmacists should advise parents to:
Comfort the child and engage in quiet activities.
Vaccine Licensure
1977: 14-valent Pneumococcal Polysaccharide Vaccine (PPSV14); 1983: 23-valent Pneumococcal Polysaccharide Vaccine (PPSV23); 2000: 7-valent Pneumococcal Conjugate Vaccine (PCV7); 2010: 13-valent Pneumococcal Conjugate Vaccine (PCV13)
Zoster Vaccine
Zostavax (Merck); live attenuated virus vaccine; higher strength than varicella vaccine; ACIP target group for vaccination - adults at least 60 yo; FDA app. for prevention (not tx) in adults at least 50 yo - ACIP recommendations still adults 60 yo +; dose and route: 0.65 ml (entire contents of vial) SQ
Mark, a 65-year-old man, is a candidate for the following vaccines: IIV3 or IIV4, PPSV23, zoster, and a booster dose of Td. Which of these vaccines is a live attenuated vaccine?
Zoster.
Safeguarding Against Needlesticks
"Following injection, activate safety device and deposit it in sharps container. Do not take eyes off needle!"
Which of the following patients would be a candidate for PPSV23?
25-year-old man who smokes cigarettes.
Which of the following is recognized by sociologists as a factor in a patient's decision whether to be vaccinated?
Influence of a health care provider.
All Medicare Part B enrollees are covered for which two vaccines?
Influenza and pneumococcal.
Can a pregnant pharmacist administer a live vaccine?
Yes
Pneumococcal Polysaccharide Vaccine 23-Valent (PPSV23)
Pneumovax 23 (Merck); Recommended single dose for: all people 65+ yo, people 19-64 yo who smoke cigarettes, people 19-64 yo w/ asthma, people at least 2 yo w/ chronic illness; contains 11 serotypes not found in PPCV13; more efficacious against bacteremia than pneumonia; not adequately effective in children younger than 2 yrs; dose and route: 0.5 mL IM (or SQ)
What is an example of an occurrence-based screening?
Providing hospital discharge counseling to a patient.
Which type of vaccine involves stimulation of B cells without the assistance of T helper cells?
Pure polysaccharide vaccines
Preparing Vaccine Doses from Vials
Remove protective cap; swab top of vial w/ alcohol; pull back plunger to draw air into syringe equal to designated volume for injection; insert syringe into vial and inject air to displace volume to be withdrawn; turn vial/syringe upside down and w/draw dose; ensure large air bubbles do not exist
True or false: you should never vaccinate somebody with a mild illness? (mild fever, upper respiratory tract infection, otitis media, mild diarrhea)
False--you can vaccinate people with mild illnesses
Poliomyelitis Vaccine
1st vaccines - salk injectable (inactivated) - 1955; Sabin's oral polio (live) - 1963 - OPV removed from US market in 2000 - vaccine assoc. paralytic polio (VAPP); IPOL (Sanofi Pasteur) - Dose: 0.5 ml IM or SQ; all infants (routine) - 2, 4, 6 - 18 mos, 4-6 yrs; international adult travelers to polio-endemic areas; important to keep vaccinating even tho polio limited to only a few countries
Measles Incidence
Resurgence, caused by low vaccination coverage; recent outbreaks - Autism myth and antivacc. groups, low vacc. rates in US and Europe
