THE APhA COMPLETE REVIEW FOR PHARMACY, 7th Ed

32. Immunization - Stephan L. Foster, PharmD

32-1. Introduction

Definitions

• Immunity: A naturally or artificially acquired state resulting in an individual being resistant or relatively resistant to the occurrence or effects of a foreign substance. Immunity is the mechanism the body develops for protection from infectious disease. It is usually very specific to a single organism or to a group of closely related organisms.

• Antigen: A live or inactivated substance capable of evoking antibody production; antigens can be a live organism, such as bacteria or virus, or an inactivated or killed organism or portion of an organism. A live organism generally evokes the most effective immune response.

• Antibody: A protein evoked by an antigen that acts to eliminate that antigen.

Mechanisms for Acquiring Immunity

Active immunity

Active immunity is produced by an individual's own immune system. Immunity acquired in this manner has a delayed onset and is usually permanent. Active immunity may be acquired by having an active disease or by vaccination. B-lymphocytes (B cells) circulate in the blood and bone marrow for many years. Reexposure to the antigen causes the cells to replicate and to produce antibody. These cells are also called memory B cells.

Passive immunity

Passive immunity is produced by an animal or human and transferred to another. Immunity acquired in this manner has a rapid onset and usually has a brief duration. An infant receives this type of immunity from his or her mother. All types of blood products contain varying amounts of antibody. Immune globulins and hyperimmune globulins are also used to induce passive immunity. One source of passive immunity is antitoxins, which contain antibodies against a known toxin.

32-2. Vaccines

Introduction

Vaccination is the process of producing active immunity through the use of vaccines. The immunological response is similar to natural infection, with a lower risk than that of the disease itself.

Classification of Vaccines

Live, attenuated vaccines

Live vaccines are produced by modifying a virus or bacteria to produce immunity. These vaccines usually do not produce disease, but they may. When disease occurs, it is usually much milder than the natural disease. These vaccines must replicate to be effective. They require special handling, such as protection from heat and light, to keep them alive. Circulating antibody from another source may destroy the vaccine virus and cause vaccine failure.

The following live vaccines are available in the United States in 2009:

• Herpes zoster

• Influenza (live attenuated)

• Measles

• Mumps

• Rotavirus

• Rubella

• Typhoid oral

• Varicella

• Vaccinia (smallpox)

• Yellow fever

Inactivated vaccines

Inactivated vaccines are composed of all or a fraction of a virus or bacterium. These fractions include subunits (subvirions), bacterial cell wall polysaccharides, conjugated (attached to a protein carrier) bacteria cell wall polysaccharides, or inactivated toxins (toxoids). The bacteria or virus is inactivated using heat, chemicals, or both. Inactivated vaccines are not alive and cannot replicate; therefore, they are unable to induce disease. Inactivated antigens are not affected by circulating antibody.

The following inactivated vaccines are available in the United States in 2009:

• Anthrax

• Diphtheria

• Haemophilus influenzae type B

• Hepatitis A

• Hepatitis B

• Human papillomavirus

• Influenza

• Japanese encephalitis

• Meningococcal A, C, Y, W-135 polysaccharide

• Meningococcal A, C, Y, W-135 conjugate

• Pertussis, acellular

• Pneumococcal polysaccharide

• Pneumococcal conjugate

• Polio

• Rabies

• Tetanus toxoid

• Typhoid injectable

Vaccination Schedules

Vaccination schedules are available for children, adolescents, and adults from the U.S. Centers for Disease Control and Prevention (CDC). These schedules are updated yearly and can be found at www.cdc.gov/vaccines/recs/schedules. The schedules indicate the best times to administer vaccines. Additional catch-up schedules are available for children and adolescents who are behind in their vaccinations.

The CDC schedules describe intervals between doses of the same vaccine in a series. The minimum interval in a series for most vaccines is 4 weeks. Decreasing the interval may interfere with antibody response and protection. Usually, the last dose in a series is separated from the previous dose by 4-6 months.

Increasing the interval does not affect vaccine effectiveness. It is never necessary to restart a series except for oral typhoid vaccine.

Administration of Multiple Vaccines

There are no contraindications to the simultaneous administration of any vaccines. Inactivated and live vaccines may be given in any combination at the same time.

Live vaccines must be separated from the administration of antibodies, such as blood products and immune globulins. Inactivated vaccines are not affected by circulating antibody.

If two live vaccines are not given at the same time, a 4-week minimal interval must be observed. The same is not true for two inactivated vaccines or an inactivated plus a live vaccine.

Vaccine Adverse Reactions

Adverse reactions are any untoward side effects caused by a vaccine.

Local reactions are the most common type of adverse reaction. They include pain, swelling, and redness at the site of injection. They usually occur within minutes to hours of the injection and are usually mild and self-limiting. Occasionally, severe local reactions occur that are known as hypersensitivity reactions.

Systemic adverse reactions include fever, malaise, myalgias, and headache. Systemic adverse reactions are more common following live vaccines and are similar to a mild case of the disease.

Allergic reactions are reactions to the vaccine antigens or to some component of the vaccine. Although rare, these reactions may be life threatening.

Another type of problem increasingly seen with vaccination is syncope; therefore, it is important to monitor patients for at least 15 minutes following vaccination.

The Vaccine Adverse Events Reporting System is a surveillance system monitored by the CDC, which should be notified within 30 days of an adverse event that requires medical attention.

Contraindications and Precautions

contraindication is a condition that increases the risk of an adverse reaction or decreases the effect of a vaccine.

precaution is a condition that might increase the risk of an adverse event or decrease the effect of a vaccine.

Contraindications include the following:

• An anaphylactic reaction to any previous dose of vaccine or to any of its components

• Pregnancy for live vaccines and selected inactivated vaccines

• Immunosuppression for live vaccines and selected inactivated vaccines

• Active, untreated tuberculosis for live vaccines

• In the case of the diphtheria, tetanus, and pertussis (DTaP or Tdap), encephalopathy that occurred within 7 days of a previous DTaP or DTP vaccine

Precautions include the following:

• Acute moderate to severe illness

• Recent administration of antibody-containing blood products and live vaccines

• For the Tdap or DTaP vaccine, unstable or evolving neurological disorder

• For the measles, mumps, and rubella (MMR) vaccine, history of thrombocytopenia or thrombocytopenic purpura

• High fever, shock, persistent crying, seizure caused by a previous dose of DTP, DTaP, or Tdap

• Guillain-Barre syndrome caused by a previous dose of DTP, TDaP, Tdap, or meningococcal conjugate vaccine

Vaccine Management

• Maintain cold chain during shipping.

• Follow manufacturers' recommendation for shipping.

• Keep nonfrozen vaccines from freezing during transport.

• Refrigerate or freeze depending on vaccine immediately on arrival.

• Use proper refrigerators.

• Monitor temperatures daily.

• Do not store vaccines in refrigerator door.

• Store in the middle of the refrigerator.

• Keep a temperature log.

• Perform proper inventory management.

• Maintain inventory log.

• Rotate stock.

• Follow manufacturers' guidelines for shelf life.

• Check expiration dates.

• Designate a person to be responsible for vaccines.

• Train all staff members to recognize vaccine shipment arrivals.

• Follow manufacturers' directions for reconstitution.

32-3. Diseases and Vaccines

Pneumococcal Disease

There are 90 known serotypes of Gram-positive Streptococcal pneumonia bacteria with a polysaccharide capsule. Serious primary diseases associated with Streptococcal pneumonia include pneumonia, sepsis, and meningitis.

Rates of disease

Highest rates are seen in children less than 2 years of age. Other children at high risk include those with asplenia, patients with HIV, American Indian and Alaskan Natives, African Americans, and day care attendees. Patients over the age of 50 have fatality rates of 30-60%.

Pneumococcal disease is one of the leading causes of vaccine-preventable diseases, with 20,000-40,000 cases of invasive disease every year. Pneumococcal bacteria are common respiratory tract inhabitants, with estimated asymptomatic carriage rates varying from 5% to 70%. Transmission is through direct person-to-person droplet contamination or autoinoculation by carriers.

Clinical features include abrupt onset, fever, otitis media, shaking chills, productive cough, pleuritic chest pain, dyspnea, hypoxia, tachypnea, headaches, lethargy, vomiting, irritability, nuchal rigidity, seizures, coma, and death.

Resistance to antibiotics is up to 40% in some areas of the United States.

23-valent polysaccharide vaccine (Pneumovax-23 by Merck)

The vaccine is effective against 88% of serotypes causing bacteremic disease; however, it is ineffective in children less than 2 years old.

Indications

• Adults over the age of 65

• Everyone over 2 years of age with chronic disease

• Smokers 19-64 years of age

Dose

The dosage is 0.5 mL intramuscular (IM) or subcutaneous (SC).

Revaccination (two-dose maximum) is recommended in the following cases:

• Patients at high risk of disease if more than 5 years have passed since the previous dose

• Everyone 65 years and older who received an initial dose under the age of 65 and if more than 5 years have passed since the previous dose

Adverse reactions

Adverse reactions include pain, swelling, and redness at the injection site and slight to moderate systemic reactions such as fever and myalgias.

7-valent conjugated polysaccharide vaccine (Prevnar by Wyeth)

The vaccine is effective against 86% of serotypes causing bacteremic disease, 83% of serotypes against meningitis, and 65% of serotypes causing otitis media.

Indications

• All children less than 2 years of age

• Children 24-59 months of age with high-risk medical conditions

Dose

The usual dose is 0.5 mL IM at 2, 4, 6, and 12-15 months of age (see schedules for catch-up recommendations).

Revaccination is not recommended, but high-risk children should receive 23-valent polysaccharide vaccine after 2 years of age.

Adverse reactions

Adverse reactions include pain, swelling, and redness at the injection site, difficulty moving the limb (rare), and slight to moderate systemic reactions such as fever and myalgias.

Influenza

Influenza is an RNA (ribonucleic acid) virus of the orthomyxovirus family.

Antigenic drift, which is frequent minor changes in the antigenic structure of the virus, can reach epidemic proportions, but not every year. For this reason, yearly adjustments in vaccine formulations are required. All three types (A, B, and C) can undergo drifts.

Antigenic shift, which is major changes in one or both of the major antigens in influenza A, resulting in a different subtype, can cause major pandemics in all ages.

Influenza A

Subtypes are based on two surface antigens: hemagglutinin and neuraminidase. Six types of hemagglutinin (H1, H2, H3, H5, H7, and H9) cause disease in humans and cause virus attachment to cells. Two types of neuraminidase cause disease in humans (N1 and N2) and have a role in viral release from cells.

Influenza A causes moderate to severe disease in all ages and can be transmitted in other animals.

Influenza B

Influenza B has no subgroups but has two distinct genetic lineages. It causes milder disease and affects primarily children. It only affects humans.

Influenza C

Influenza C is rarely reported and many cases are subclinical.

Influenza disease

Major serious complications in all types include pneumonia, Reye's syndrome (progressive neurological symptoms associated with aspirin use in children), myocarditis, worsening of chronic bronchitis, and death.

Influenza is one of the leading causes of vaccine-preventable disease, with 20,000-40,000 deaths during epidemics. Pandemics could result in the deaths of millions of people. Rates of disease are highest in the elderly (> 65), children less than 2 years of age, and persons of any age with medical conditions.

Influenza virus penetrates the respiratory epithelial cells and destroys the host. Virus is shed in respiratory secretions for 5-10 days, and transmission is through direct person-to-person droplet contamination or contact. The incubation period is approximately 2 days (range, 1-5 days).

Clinical features include abrupt onset, fever, myalgias, sore throat, nonproductive cough, and headache.

Disease peaks between December and March in the Northern Hemisphere but may occur earlier or later. Year-round cases may be seen in tropical climates.

Resistance to antivirals is increasing.

Inactive influenza vaccine (Fluvirin by Novartis, Fluzone by Sanofi Pasteur, Fluarix and FluLavel by GlaxoSmithKline, Afluria by CSL)

All are inactivated, split-virus vaccines. They contain three vaccine components (two type A viruses and one type B virus).

Vaccines are named according to the virus type/geographic origin/strain sequence number/year of isolation (hemagglutinin neuraminidase for type A only): for example, A/Bisbane/10/2007(H3N2) or B/Florida/4/2006.

Vaccines are effective in up to 90% of healthy adults, 50-60% of the elderly, and 30-40% of the frail elderly.

Indications

• All children 6 months to 18 years of age

• Close contacts of children 0-59 months of age

• Adults 50 years of age or older

• Adults 19 years and older with certain chronic diseases

• Residents of nursing homes or long-term care facilities

• People who may infect others, including contacts of patients with diseases and health care workers

• Pregnant women in all trimesters or women who will become pregnant during the influenza season

• Patients 6 months to 18 years of age on chronic aspirin therapy

• Patients with neurological or neuromuscular disorders

• Anyone who wishes to decrease the likelihood of influenza disease

Contraindications

Contraindications include severe allergic reactions to previous dose and egg allergy.

Adverse reactions

Adverse reactions include pain, swelling, and redness at the injection site and slight to moderate systemic reactions such as fever, myalgias, chills, and malaise. Severe neurologic reactions are rare.

Dose

Normal doses are 6-35 months: 0.25 mL IM (repeat in 1 month if first time); 3-8 years: 0.5 mL (repeat in 1 month if first time); > 8 years: 0.5 mL.

Fluvirin by Novartis is indicated for those ≥ 4 years of age.

Fluarix by GlaxoSmithKline is indicated for those ≥ 3 years of age. FluLaval by GlaxoSmithKline and Afluria by CSL are indicated for those ≥ 18 years of age.

Revaccination yearly is needed.

Intranasal live attenuated influenza vaccine (FluMist by MedImmune)

Intranasal live attenuated influenza vaccine (LAIV) is an attenuated, cold-adapted live influenza vaccine. It has the same vaccine antigens as in inactivated influenza vaccine. Its efficacy is 86-93%. LAIV must be kept refrigerated.

Indications

Indications are similar to those of inactivated vaccine unless contraindications exist:

• Healthy persons 2-49 years of age

• Contacts with high-risk patients, except the severely immunocompromised

Contraindications

With the following contraindications, use inactivated influenza vaccine:

• Children 2-4 years of age with a history of wheezing or asthma

• Persons with chronic medical diseases

• Close contacts of severely immunocompromised persons

• Pregnant women

• Children receiving aspirin therapy

• Persons with a history of Guillain-Barre syndrome

Dose

The dose is 0.1 mL sprayed in each nostril (0.2 mL total). Children age 2-8 who receive influenza vaccine for the first time need two doses 6-8 weeks apart.

Adverse reactions

Adverse reactions are similar to those of the inactivated vaccine and include nasal congestion, headache, and vomiting.

Tetanus

Exotoxin is produced by Clostridium tetani, a Gram-positive anaerobic rod that may develop a highly resistant spore. These spores are widely spread in soil, animal intestines and feces, skin surfaces, and infected plants.

The disease is characterized by generalized rigidity and convulsive spasms of skeletal muscles. It usually involves muscles of the face (lockjaw) and neck. Spasms may last 3-4 weeks, and complete recovery may take months.

The bacteria enter the body through contamination of a wound. Spores germinate in an anaerobic environment. Toxins are released and transported through the body.

The incubation period is usually 8 days (range, 3-21 days).

Transmission risk factors include puncture wounds, surgery, burns, minor wounds, dental infections, animal bites, injection drug use, and diabetes. Approximately 10% of cases are of unknown cause. Tetanus is not contagious person to person.

Tetanus occurs in the United States at a rate of 0.02-0.05 per 100,000 persons per year. The case fatality rate is approximately 10-20%.

Complications include laryngospasm, fractures, hypertension, nosocomial infections, pulmonary embolism, aspiration, and death. Wound management recommendations may include tetanus immune globulin (

Table 32-1).

Tetanus toxoid vaccine

Tetanus toxoid is usually combined with diphtheria toxoid and pertussis vaccine. Toxoid is formaldehyde-inactivated toxin adsorbed to aluminum. The pediatric version of the vaccine is DT or DTaP. The adult version is Td or Tdap.

Dose

• Pediatric dose: A 0.5 mL IM dose of DT or DTaP vaccine is given at 2, 4, 6, and 15-18 months of age. A booster dose should be given at 4-6 years.

• Adolescent dose: A 0.5 mL dose of Tdap vaccine is given at 11-12 years.

• Adult dose: A 0.5 mL dose of Tdap vaccine is required if tetanus-containing vaccine is indicated.

• Revaccination: Every 10 years, revaccination with Td vaccine is required.

[Table 32-1. Guidelines for Tetanus Wound Management]

Adverse reactions

Adverse reactions include pain, swelling (nodule may form), and redness at the injection site; systemic reactions are uncommon. An exaggerated (Arthus-type) reaction with extensive, painful swelling from shoulder to elbow can occur at the injection site and is thought to be caused by too-frequent injections.

Diphtheria

Toxin is produced by Corynebacterium diphtheriae, an aerobic Gram-positive bacterium. This bacterium must be infected by a virus that carries a genetic code for toxin production.

The most common presentation of diphtheria is characterized by early, nonspecific upper respiratory infection symptoms that develop into pharyngitis. Two to three days later, a bluish-white membrane starts to form that can cover the entire soft palate. The membrane can turn dark if bleeding occurs, and manipulation of the membrane can result in bleeding. Airway obstruction may occur.

Other sites of infection may include the larynx or the skin.

Other complications may include myocarditis, neuritis with paralysis, respiratory failure, and death. The overall case fatality rate is 5-10%.

Asymptomatic human carriers are the source of most infections. The incubation period is usually 2-5 days (range, 1-10 days).

Treatment of acute disease is with antitoxin and antibiotics.

Diphtheria toxoid vaccine

Diphtheria toxoid vaccine is combined with tetanus toxoid and pertussis vaccine. A single-toxoid antigen is not available. Toxoid is formaldehyde-inactivated toxin adsorbed to aluminum.

The pediatric version of the combination (DT or DTaP) contains three or four times as much antigen as the adult version (Td or Tdap).

Dose

• Pediatric dose: A 0.5 mL IM dose of DT or DTaP vaccine is given at 2, 4, 6, and 15-18 months of age. A booster dose should be given at 4-6 years.

• Adolescent dose: A 0.5 mL dose of Tdap is given at 11-12 years.

• Adult dose: A 0.5 mL dose of Tdap vaccine is required if tetanus-containing vaccine is indicated.

• Revaccination: Every 10 years, revaccination with Td vaccine is required.

Adverse reactions

Adverse reactions include pain, swelling (nodule may form), and redness at the injection site; systemic reactions are uncommon. An exaggerated (Arthus-type) reaction with extensive, painful swelling from shoulder to elbow can occur at the injection site and is thought to be caused by too-frequent injections of the tetanus antigen component of the combination vaccines.

Pertussis

Pertussis, or whooping cough, is caused by Bordetella pertussis, an aerobic, Gram-negative rod. The bacteria produce multiple antigenic products, which are responsible for the clinical disease. The bacteria produce toxin that paralyzes the respiratory cilia and causes inflammation of the respiratory tract.

The presentation of pertussis is in three stages. The first stage is a catarrhal stage with nonspecific upper respiratory infection symptoms. After 1-2 weeks, the paroxysmal stage with the characteristic cough and inspiratory whoop begins and lasts up to 6 weeks. Recovery, the third stage, is gradual, and the cough usually resolves in 2-3 weeks. The presentation in older children and adults may be much milder. They may present with a persistent mild cough that lasts up to 7 days. The illness may appear to be similar to other upper respiratory infections.

Complications may include pneumonia, encephalopathy, seizures, and death. The overall case fatality rate is 0.2%.

Asymptomatic human carriers are the source of most infections. The incubation period is usually 7-10 days (range, 4-21 days). Treatment of acute disease includes supportive care, antibiotics, and prophylaxis of contacts.

Transmission is human to human by the respiratory route. Pertussis is highly contagious, with attack rates of 80% in susceptible contacts.

Pertussis vaccine

Pertussis vaccine is combined with tetanus toxoid and diphtheria toxoid for children. A single-toxoid antigen is not available. A whole-cell vaccine was developed in the 1930s but is no longer available in the United States. Acellular pertussis vaccine was first licensed in 1991 and has fewer side effects than the whole-cell vaccine.

Dose

• Pediatric dose: A 0.5 mL IM dose of DTaP vaccine is given at 2, 4, 6, and 15-18 months of age. A booster dose should be given at 4-6 years.

• Adolescent dose: A 0.5 mL dose of Tdap of vaccine is given at 11-12 years.

• Adult dose: A 0.5 mL dose of Tdap is given one time only.

Adverse reactions

Adverse reactions include pain, swelling (nodule may form), and redness at the injection site; systemic reactions are uncommon. An exaggerated (Arthus-type) reaction with extensive, painful swelling from shoulder to elbow can occur at the injection site and is thought to be caused by too-frequent injections of the tetanus antigen component of the combination vaccines.

Available vaccines

• Tdap (Adacel by Sanofi Pasteur and Boostrix by GSK), indicated for ages 10-64

• DTaP (Tripedia and Daptacel by Sanofi Pasteur and Infanrix by GSK), indicated for age 2 months to 7 years

• Td (various manufacturers), recommended over the age of 7 following one dose of Tdap and for all over the age of 64

Hepatitis B

Hepatitis B is caused by a DNA (deoxyribonucleic acid) virus. It is one of the most common infections worldwide. An estimated 200 million to 300 million chronic carriers of hepatitis B exist worldwide.

The clinical course is similar to that of all other types of viral hepatitis, with symptoms of malaise, weakness, anorexia, nausea, jaundice, abdominal pain, headache, and dark urine. Malaise and fatigue may last for weeks to months after all other symptoms disappear.

Fulminant hepatitis occurs in 1-2% of all cases, with mortality rates of 60-90%.

Complications are usually related to chronic infections with hepatitis B virus and include chronic hepatitis, cirrhosis, liver failure, and hepatocellular carcinoma. Twenty-five percent of all carriers develop chronic, active hepatitis. The risk of becoming a carrier following infection ranges from 6% to 50%.

The incubation period is usually about 90 days (range, 60-150 days). Transmission is human to human by exposure of body fluids by parenteral or mucosal contact. Hepatitis B is a common sexually transmitted disease. Perinatal transmission is a significant mode of infection.

Hepatitis B vaccine

The first vaccine was a plasma-derived vaccine released in 1981 and removed from the market in 1992. The current vaccine is hepatitis B surface antigen (HBsAg), produced using recombinant-DNA technology. It was first released in 1986. Two products are currently marketed: Recombivax HB (Merck) and Engerix-B (GlaxoSmithKline). Although the antigen contents are different, the two vaccines are interchangeable.

Combination vaccines are available.

Dose

The usual pediatric dose is 0.5 mL IM given at birth, 2 months, and 6 months. The usual adult dose is 1.0 mL given at 0, 2, and 6 months. Indications include all infants, all adolescents, and high-risk adults (e.g., those with multiple sex partners or sexually transmitted diseases, those who use injection drugs, those on dialysis, and those with hemophilia).

Adolescents 11-15 years of age may be given a two-dose series separated by 4 months. This dose is approved for only Recombivax HB.

Serological testing may not be accurate after 2 years following vaccination, but immunity continues. Booster doses should not be given.

Adverse reactions

Adverse reactions include pain, swelling (nodule may form), and redness at the injection site; systemic reactions are uncommon.

Haemophilus Influenzae Type B

Haemophilus influenzae is a Gram-negative cocco-bacillus, whose outer shell consists of a polyribosylribitol phosphate (PRP) polysaccharide capsule. Six distinctly different types of H. influenzae exist, labeled a-f; however, H. influenzae type b (Hib) is responsible for 95% of human disease.

The organism enters through the nasopharynx and may cause disease or may colonize the nasopharynx, creating an asymptomatic carrier.

The most common clinical infections caused by Hib are meningitis, epiglottitis, pneumonia, arthritis, and cellulitis. Meningitis accounts for 50-65% of all clinical disease and results in a mortality rate of 2-5% and neurological sequelae in 15-30% of cases. Other diseases caused by H. influenzae include otitis, sinusitis, and bronchitis; however, these illnesses are usually caused by nontypable (unencapsulated) strains.

Hib is primarily a disease of children, with a peak at age 6-7 months. It rarely attacks after the age of 5 years.

Treatment of acute disease includes hospitalization, intravenous antibiotics, and prophylaxis of contacts. Transmission is human to human by respiratory droplet spread to susceptible individuals.

Haemophilus influenzae vaccine

The incidence of Hib disease has decreased by more than 99% since the introduction of vaccine. The first vaccine licensed (1985-88) was a pure polysaccharide vaccine that was ineffective in children less than 18 months of age. Current vaccines are polysaccharide vaccines conjugated to protein carriers. The specific carriers vary by manufacturer.

PRP-T (ActHIB by Sanofi Pasteur) and PRP-OMB (PedvaxHIB by Merck) are indicated for infants ≥ 6 weeks of age. Doses given before 6 weeks of age may inhibit the production of antibodies to subsequent doses; therefore, the vaccines are contraindicated in children less than 6 weeks of age. PRP-T (Hiberix by GlaxoSmithKline) is indicated only for the booster dose at 15 months to 4 years of age.

Dose

The usual dose for the vaccines approved for infants is 0.5 mL IM given at 2, 4, and 6 months. A booster dose is recommended for children 12-15 months of age. If PRP-OMB (PedvaxHIB) is used for the pediatric series, the 6-month dose should be omitted.

The catch-up series for Hib vaccine varies by age and manufacturer. Consult the package insert for complete dosing information.

Vaccination of children less than 59 months of age is not indicated unless certain medical indications exist. These include persons with asplenia, those with immunodeficiency conditions, and those undergoing immunosuppressive therapy.

Combination vaccines of Hib vaccine and hepatitis B vaccine (COMVAX by Merck) and Hib vaccine and DTaP (TriHIBit by Sanofi Pasteur) are available. TriHIBit is not approved for the initial pediatric series (2, 4, and 6 months) and can be used for a dose only at ≥ 12 months of age when a previous dose of Hib was given ≥ 2 months earlier, and TriHIBit will be the last dose in the Hib series. COMVAX must not be administered before 6 weeks of age. DTaP-Hib-IPV (Pentacel by Sanofi Pasteur) must not be used before the age of 6 weeks.

Adverse reactions

Adverse reactions include pain, swelling, and redness at the injection site; systemic reactions are uncommon.

Hepatitis A

Hepatitis A is caused by an RNA virus and is the most common hepatitis infection in the United States. The clinical course is similar to that of all other types of viral hepatitis, with symptoms of malaise, weakness, anorexia, nausea, jaundice, abdominal pain, headache, and dark urine. Malaise and fatigue usually last for 2 weeks; however, symptoms may last or recur for up to 6 months.

Fulminant hepatitis A is rare but can occur. The incidence increases with age over 40 years. Although serious complications are not as common as with hepatitis B, morbidity and its associated costs (health care costs and lost work days) are significant. There is no risk of the patient becoming a chronic carrier.

The incubation period averages 28 days (range, 15-50 days). Treatment of acute disease is supportive. Transmission is human to human by the fecal-oral route of exposure.

Exposure of an unimmunized person to hepatitis A requires the administration of immune globulin intramuscular (IGIM) as well as beginning the hepatitis A vaccine series, except for healthy persons 1-40 years of age, who may receive the vaccine only.

Hepatitis A vaccine

The available vaccines are Havrix by GlaxoSmithKline and VAQTA by Merck. These are inactivated whole-virus vaccines. Both vaccines are available in pediatric and adult formulations.

Hepatitis A vaccine is indicated for all high-risk patients and routinely for all children 1-2 years of age. Consideration of immunization should be given to all children up to 18 years of age. It is not indicated for children less than 1 year of age. The two vaccines use different potency measurements, but the volume and schedule of the dose is the same.

Dose

Children and adolescents over 1 year of age are given 0.5 mL, repeated in 6-12 months (Havrix) or 6-18 months (VAQTA), for two doses total.

Adults over 18 years old are given 1.0 mL, repeated in 6-12 months, for two doses total.

Combination vaccine

Twinrix, by GlaxoSmithKline, is a combination product with hepatitis B (adult dose) and hepatitis A (pediatric dose).

Dose

The usual dose is 1 mL, given at 0, 1, and 6-12 months. An accelerated schedule can be given at 0, 7 days, and 21-30 days, followed by a booster at 1 year, if protection is needed earlier.

The vaccine is indicated for persons 18 years of age and older.

Adverse reactions

Adverse reactions include pain, redness, and swelling at the injection site. Mild systemic reactions are rare.

Meningococcal Disease

Meningococcal disease is caused by Neisseria meningiditis, a Gram-negative bacteria with a polysaccharide capsule. The clinical diseases caused by N. meningiditis include meningitis, sepsis, pneumonia, myocarditis, and urethritis. N. meningiditis is one of the leading causes of meningitis in the United States. The types of N. meningiditis that cause over 95% of disease are serogroups A, B, C, W-135, and Y.

Approximately 2,500-3,000 cases occur per year, with an incidence rate of 2 cases per 100,000 people. The incidence in college freshmen who live in dormitories is approximately 4 cases per 100,000. A carrier state exists that increases in incidence during epidemics.

Parts of the world, including parts of Africa and Asia, have a high rate of disease.

Treatment of acute disease is with antibiotics.

Polysaccharide meningococcal vaccine (Menomune by Sanofi Pasteur)

This polysaccharide vaccine is effective against serogroups A, C, W-135, and Y. The vaccine does not protect against serogroup B, a common cause of infection.

The vaccine is indicated for persons over the age of 2 years. Those who should be vaccinated include military personnel, freshmen college students living in dormitories, those with anatomic or functional asplenia, and travelers to the "meningitis belt" of sub-Saharan Africa. Evidence of immunization is required for religious pilgrimages to Saudi Arabia for the Islamic Hajj. Vaccine may also be useful during an outbreak.

Dose

The dose is 0.5 mL given subcutaneously. A booster dose may be needed after 3-5 years.

Adverse reactions

Adverse reactions include pain, swelling (nodule may form), and redness at the injection site, as well as mild systemic reactions, such as fever, headaches, and malaise.

Conjugated polysaccharide meningococcal vaccine (Menactra by Sanofi Pasteur)

This polysaccharide vaccine that conjugated to diphtheria toxoid. It is effective against serogroups A, C, W-135, and Y. The vaccine does not protect against serogroup B, a common cause of infection.

Indications

The vaccine is approved for persons 2-55 years of age. The Advisory Committee on Immunization Practices (ACIP) recommends vaccination for persons age 11-12 (catch-up for ages 13-18) and for college freshmen living in dormitories.

Indications are the same as for the polysaccharide vaccine; however, revaccination is recommended for persons who were previously vaccinated and who remain at high risk for the disease. The interval varies based on age at first dose.

Dose

The dose is 0.5 mL given intramuscularly.

Polio

The three poliovirus types are identified as P1, P2, and P3. The virus enters the mouth and replicates in the gastrointestinal tract. From the gastrointestinal tract, the virus enters the bloodstream and infects the cells of the central nervous system.

Up to 95% of all infections are asymptomatic; however, these persons may transmit the infection to others. Approximately 4-8% of infections are mild with nonspecific upper respiratory infection, gastroenteritis, and influenza-like symptoms. Some 1-2% of infections present as nonparalytic aseptic meningitis, which typically resolves in 2-10 days. Flaccid paralysis occurs in less than 1% of those infected.

The incubation period is usually 6-20 days (range, 3-35 days). Treatment of acute disease includes supportive care. Transmission is person to person by the fecal-oral route.

Polio vaccine (IPOL by Sanofi Pasteur)

The current vaccine available in the United States is an inactivated, trivalent injectable vaccine (IPV, or inactivated polio vaccine). Use of oral polio vaccine (OPV) was discontinued in the United States because of the elimination of wild-type polio disease and because yearly cases of vaccine-associated paralytic poliomyelitis (VAPP) were reported.

Dose

The pediatric dose is 0.5 mL IM given at 2, 4, 6-18 months, and 4-6 years of age. Routine vaccine or booster doses for adults are not recommended.

Adverse reactions

Adverse reactions include minor pain, swelling, and redness at the injection site; systemic reactions are uncommon.

Measles, Mumps, and Rubella

Measles

Measles is a viral infection whose main presentation is a maculopapular rash. The virus is shed through the nasopharynx. Ten to 12 days after exposure, the prodrome phase begins, with progressive fever, cough, coryza, and conjunctivitis. Two to 4 days after the prodrome begins, a maculopapular rash begins on the face and head and gradually spreads throughout the body. The rash lasts 3-5 days, then gradually fades.

The incubation period is 10-12 days. Transmission is person to person through large respiratory droplets. Measles is highly contagious.

Complications may include pneumonia, otitis, encephalitis, and death.

Mumps

Mumps is a viral infection with a presentation of parotitis in 30-40% of cases. The virus is shed through the nasopharynx. Fourteen to 18 days after exposure, the prodrome phase begins, with headache, malaise, myalgias, and low-grade fever. Two days after the prodrome begins is when the parotitis begins. Symptoms start to decrease after 1 week and disappear after 10 days.

The incubation period is 14-18 days (range, 14-25 days). Transmission is person to person through large respiratory droplets.

Complications can include orchitis, oophoritis, pancreatitis, and deafness.

Rubella

Rubella is a viral infection with up to 20-50% of cases subclinical and inapparent. The virus is shed through the nasopharynx. A 1-5 day prodrome phase begins after incubation, with headache, malaise, myalgias, lymphadenopathy, low-grade fever, and upper respiratory infection symptoms. This phase is rare in children. Fourteen to 17 days after exposure, a maculopapular rash appears, first on the face and then descending to cover the rest of the body. The rash disappears after about 3 days.

The incubation period is 14 days (range, 12-23 days). Transmission is person to person through large respiratory droplets.

Complications may include arthritis, arthralgias, encephalitis, and hemorrhaging. The major complication is congenital rubella syndrome (CRS), which occurs in the offspring of a woman who had rubella during pregnancy. Babies born with CRS have major birth defects that can affect many organs.

Measles-mumps-rubella vaccine (MMRII by Merck)

The current vaccine available in the United States is a live, attenuated vaccine against all three diseases.

Dose

The usual pediatric dose is 0.5 mL IM given at 12 months of age. A second dose is recommended at 4-6 years of age to produce immunity in those who did not respond to the first dose.

This vaccine is contraindicated in pregnancy. Pregnancy should be avoided for 4 weeks following vaccination.

Serologic testing may be necessary to document immunity.

Vaccination with the combination product should be used when one or more of the vaccines are needed.

Adverse reactions

Adverse reactions include minor pain, swelling, and redness at the injection site and systemic reactions that mimic a mild case of the diseases.

Varicella (Chicken Pox)

Varicella is a viral infection caused by the herpes zoster virus. The primary infection is called chicken pox, and the recurrent disease is herpes zoster (called shingles).

The virus enters through the respiratory tract and replicates in the nasopharynx and regional lymph glands. The incubation period is 14-16 days (range, 10-21 days).

A prodromal phase may precede the rash with a slight fever and malaise. The rash progresses from a macule to a papule to a vesicle before it crusts over. The rash appears in several waves that last 2-3 days each. The rash first appears on the face and then the trunk (where most of the rash occurs) and the extremities.

Recurrent disease (herpes zoster) appears to be related to aging and immunosuppression. Recurrent disease usually presents as an outbreak of lesions along a dermatome and is usually unilateral. Neuralgia and intense pain may be present.

Transmission of varicella is person to person by infected respiratory secretions. Transmission by patients with herpes zoster is by direct contact with a non-immune person.

Complications may include pneumonia, secondary bacterial infections, central nervous system infections and symptoms, and Reye's syndrome if a child is taking aspirin.

Varicella vaccine (Varivax by Merck)

The current vaccine available in the United States is a live, attenuated vaccine.

Dose

The pediatric dose is 0.5 mL IM, given at 12-18 months of age. A second dose is recommended at 4-6 years of age.

The adult dose (age > 13 years) is two doses of 0.5 mL, each separated by 4-8 weeks.

The vaccine must be stored frozen at +5°F (-15°C) or colder. The diluent used to reconstitute the vaccine should be stored at room temperature or refrigerated.

Contraindications

This vaccine is contraindicated in pregnancy, and pregnancy should be avoided for 4 weeks following vaccination. Other contraindications include immunosuppressive disease or patients receiving immunosuppressive therapy, as well as those receiving antibody-containing blood products.

Adverse reactions

Adverse reactions include minor pain, swelling, and redness at the injection site, and systemic reactions that mimic a mild case of the disease, including a mild generalized rash.

Herpes zoster vaccine (Zostavax by Merck)

This vaccine is same strain of virus as in Varivax but 14 times the dose. It is a live, attenuated vaccine that is 50% effective in preventing herpes zoster.

Indication

It is indicated for all adults over the age of 60 years, regardless of previous zoster outbreak.

Contraindications

Contraindications include immunosuppression, both disease and medically induced.

Dose

The usual dose is 0.65mL subcutaneous (must be reconstituted).

The vaccine must be stored frozen at +5°F (-15°C) or colder. The diluent used to reconstitute the vaccine should be stored at room temperature or refrigerated.

Adverse reactions

Adverse reactions include pain, redness, and swelling at the injection site and an increased incidence of headache.

Rotavirus

Rotavirus is the most common cause of severe gastroenteritis in infants and small children. Symptoms range from mild, watery diarrhea of limited duration to severe diarrhea with vomiting and fever that can result in dehydration.

In the United States, approximately 27 million episodes, 205,000-272,000 emergency visits, 410,000 outpatient visits, 55,000-70,000 hospitalizations, and 20-60 deaths occur each year because of rotavirus infection.

Rotavirus is transmitted by fecal-oral route by close person-to-person contacts and through fomites.

Rotavirus vaccines

Two rotavirus vaccines are available:

• Pentavalent human-bovine reassortant rotavirus vaccine (RotaTeq [RV5] by Merck)

• Monovalent human rotavirus vaccine (Rotarix [RV1] by GlaxoSmithKline)

RV5 is a live, oral vaccine that contains five reassortant rotaviruses and is available as a liquid that requires no reconstitution. RV1 is a live, oral vaccine that contains one human rotavirus strain and is a lyophilized powder that must be reconstituted prior to injection.

Dose

Both vaccines are administered orally. RV5 contains 2 mL per dose, and RV1 contains 1 mL per dose.

RV5 is a three-dose series given at 2, 4, and 6 months of age. RV1 is a two-dose series given at 2 and 4 months of age. The rotavirus series should be started no sooner than 6 weeks of age and must be completed by 8 months, 0 days of age.

Rotavirus vaccine can be administered simultaneously with all other pediatric vaccines indicated at the same age. It should not be given to infants who had a severe reaction to a previous dose.

Precautions include altered immunocompetence, acute gastroenteritis, moderate or severe acute illness, preexisting chronic gastrointestinal disease, and a previous history of intussusception.

Adverse effects

There does not appear to be an increase in the incidence of intussusception with the current vaccines. A previous rotavirus vaccine (Rotashield) was removed from the market in 1999.

Adverse effects may include diarrhea and vomiting.

Human Papillomavirus

Human papillomavirus (HPV) is the most common sexually transmitted disease in the United States. Although most HPV infections are asymptomatic and self-limiting, persistent infection can cause cervical cancer and genital warts.

Approximately 100 HPV types exist, with 40 types affecting the genital area and the remainder associated with skin warts. High-risk viruses can cause low- and high-grade cervical cell abnormalities and anogenital cancers. Approximately 70% of cervical cancers are caused by HPV types 16 and 18. HPV types 6 and 11 cause 90% of all genital warts.

HPV vaccines

Two HPV vaccines are available:

• Quadravalent human papillomavirus vaccine (Gardasil by Merck) protects against HPV types 6, 11, 16, and 18.

• Bivalent human papillomavirus vaccine (Cervarix by GlaxoSmithKline) protects against HPV types 16 and 18.

Indications

Both vaccines are indicated for the prevention of the types of HPV in the specific vaccine, but they are not used for the treatment of HPV infection.

The HPV vaccines are indicated for all women 9-26 years of age and should be given routinely to all 11- to 12-year-old girls. The vaccines are also indicated for the prevention of genital warts in males 9-26 years of age. Vaccination in males is not recommended by the Advisory Committee on Immunization Practices for routine use, but its use is optional.

Contraindications

HPV vaccine is contraindicated in persons who had a reaction to a previous dose.

Dose

The HPV vaccine is inactivated and administered as a three-dose series given at 0, 2, and 6 months. The vaccine must be shaken and 0.5mL administered intramuscularly in the deltoid area.

The HPV vaccine may be given simultaneously with other recommended vaccines.

Adverse reactions

Adverse reactions are primarily local and include pain, redness, and swelling at the injection site. A systemic reaction of fever may occur.

Combination Vaccines

As mentioned in previous sections, several vaccination combinations are on the market:

• Tetanus, diphtheria, and pertussis combinations (various manufacturers): DTaP, DT, Td, Tdap

• Twinrix by GlaxoSmithKline: a combination product with hepatitis B (adult dose) and hepatitis A (pediatric dose)

• Hib vaccine and hepatitis B vaccine: COMVAX by Merck

• Hib vaccine and DTaP: TriHIBit by Sanofi Pasteur

• Pediarix (GlaxoSmithKline)

• DTaP + hepatitis B + inactivated polio

• Indicated when all vaccine components indicated

• Not approved for < 6 weeks or > 7 years of age

• Efficacy, contraindications, and adverse reactions similar to those of the vaccine components given separately

• Dose: 0.5 mL IM given at 2, 4, and 6 months of age

• Must be shaken vigorously prior to drawing up in syringe

• Can be given even if infant receives birth dose of hepatitis B vaccine

• Pentacel (Sanofi Pasteur)

• DTaP + Hib + inactivated polio

• Indicated when all vaccine components indicated

• Not approved for < 6 weeks or > 4 years of age

• Efficacy, contraindications, and adverse reactions similar to those of the vaccine components given separately

• Dose: 0.5 mL IM given at 2, 4, and 6 months of age

• Must be shaken vigorously prior to drawing up in syringe

• Can be given even if infant receives birth dose of hepatitis B vaccine

• ProQuad by Merck: a combination vaccine of measles, mumps, rubella, and varicella vaccine

• Kindrix by GlaxoSmithKline: a combination of DTaP and IPV to be given at 4-6 years

32-4. Key Points

• The two types of vaccine antigens are (1) live viruses and (2) inactivated viruses or bacterial components.

• There are two types of immunity: active and passive.

• Adverse effects of inactivated vaccines include pain at the injection site and mild systemic symptoms (mild fever). Adverse effects of live vaccines mimic a mild case of the disease.

• Live vaccines should be avoided during pregnancy.

• Influenza viruses undergo shifts and drifts, which accounts for the need for yearly vaccine changes.

• Wound management must include evaluation for the need for tetanus toxoid and tetanus immune globulin.

• Diphtheria toxoid and tetanus toxoid should always be given together, unless a contraindication to one of the components exists. If there is a need for one, then there is a need for both.

• A combination vaccine of tetanus, diphtheria, and pertussis is available for use in adolescents and adults (Tdap). It is recommended one time for persons 11-64 years of age. Children under the age of 7 years receive DTaP or DT (if unable to tolerate pertussis vaccine). All other ages should receive Td if vaccination is indicated.

• Hepatitis B vaccine is now recommended for all infants, starting at birth, as well as all adolescents. Other indications include adults with high-risk occupations or behaviors.

• Hepatitis A vaccine is recommended for travel to most parts of the world.

• Inactivated polio vaccine is the only polio vaccine recommended for use in the United States. Oral polio vaccine is not recommended because of the high incidence of vaccine-associated paralytic poliomyelitis.

• A second dose of MMR vaccine and varicella vaccine is recommended at 4-6 years of age.

• Combination vaccines are available to decrease the number of injections.

32-5. Questions

1.

A 67-year-old patient presents to your pharmacy for a refill of his insulin. It is October, and he asks you to review his immunization status with him. About which adult vaccine do you need to ask his status?

I. Influenza vaccine

II. Pneumococcal vaccine

III. Meningococcal vaccine

IV. Hepatitis A vaccine

V. Diphtheria-tetanus (Td) vaccine

A. I only

B. I and II only

C. III and IV only

D. I, III, and V only

E. I, II, and V only

 

2.

The patient in question 1 states that he received his pneumococcal vaccine 4 years ago. When should he receive another?

A. Never

B. Every year

C. In 5 years

D. When he reaches the age of 68

E. When he reaches the age of 72

 

3.

Which of the following describes the current injectable influenza vaccine used in the United States?

A. Inactivated virus

B. Live attenuated virus

C. Conjugated vaccine

D. Toxoid

E. Toxin

 

4.

Indications for meningococcal conjugate vaccine include

I. all adolescents 11-12 years of age.

II. travelers to the "meningitis belt" of sub-Saharan Africa.

III. patients with asplenia.

IV. pilgrims to Saudi Arabia for the Islamic hajj.

V. college freshmen living in dormitories.

A. I only

B. II, III, and V only

C. I, II, and III only

D. II, III, IV, and V only

E. All of the above

 

5.

At what age does one switch from DTaP to Td?

A. 2 years

B. 5 years

C. 7 years

D. 10 years

E. DTaP can be used in all age groups.

 

6.

Which of the following vaccines has both a polysaccharide and a conjugated vaccine on the U.S. market?

I. Influenza

II. Meningococcal vaccine

III. Haemophilus influenzae type B vaccine

IV. Hepatitis vaccine

V. Pneumococcal vaccine

A. IV only

B. II and V only

C. I, II, and III only

D. II, III, and V only

E. All of the above

 

7.

Which polio vaccine schedule is recommended in the United States?

A. Four doses of IPV

B. Four doses of OPV

C. Four doses of IPV plus a booster at 18 years of age

D. Two doses of OPV and 2 doses of IPV

E. Polio vaccine is no longer recommended in the United States.

 

8.

Hepatitis B vaccine is a

A. polysaccharide vaccine.

B. recombinant hepatitis B surface antigen vaccine.

C. live vaccine.

D. conjugate vaccine.

E. a toxoid.

 

9.

An 18-year-old, healthy student is told that she needs to come to the pharmacy for her routine vaccinations prior to starting college. She will be living in the dormitory at school. She has not received any vaccines since grade school. Which of the following vaccines are indicated?

I. MMR if she has not received a second dose

II. Varicella vaccine if she has not received two doses, has no history of varicella infection, or has negative titers

III. Meningococcal vaccine

IV. Pneumococcal vaccine

V. Tdap if she has not received one for 10 years

A. All of the above

B. I and II only

C. I, II, III, and IV only

D. I, III, and V only

E. I, II, III, and V only

 

10.

The patient in question 9 is exposed to a patient with hepatitis A 1 month later. She should receive which of the following vaccines?

A. Hepatitis A vaccine series only

B. Hepatitis B vaccine series only

C. Hepatitis A vaccine series plus IGIM

D. Hepatitis A vaccine plus hepatitis B vaccine series

E. IGIM only

 

11.

Which of the following is a high-risk group that should be targeted for annual influenza vaccination?

A. Persons 18-49 years of age

B. Persons with diabetes

C. Patients 21-49 years of age with hypertension

D. Construction workers

E. Healthy patients 21-49 years of age

 

12.

Which complication of rubella infection is the most significant health problem?

A. Congenital rubella syndrome

B. Secondary infection

C. Patent ductus arteriosus

D. Diarrhea

E. Arthritis

 

13.

Which of the following is a valid contraindication to the receipt of a live-virus vaccine?

A. Taking antibiotics

B. Recent administration of antibody-containing blood products

C. Age over 12 months

D. Allergies to penicillin

E. A parent or sibling with a cold who is living in the same household

 

14.

The most common adverse reaction to an inactivated vaccine is

A. Rash

B. Severe headache

C. Injection-site reaction

D. Rhinorrhea

E. Stomach pain

 

15.

The only vaccine recommended at birth is

A. DTaP.

B. IPV.

C. Hib.

D. pneumococcal conjugate vaccine.

E. hepatitis B.

 

16.

A 32-year-old female is injured in an automobile accident and her spleen is removed. Which of the following vaccines is not routinely recommended for asplenic adult patients?

A. Pneumococcal vaccine

B. Meningococcal vaccine

C. IPV

D. Haemophilus influenzae type B vaccine

E. Yearly influenza vaccines

 

17.

If a second dose of a vaccine were given too soon (before the minimal interval time has passed), the correct course of action would be

A. restarting the entire series.

B. not counting that dose and repeating it after the minimal time has passed since the incorrect dose.

C. not worrying about it and continuing with the next dose as scheduled.

D. drawing antibody titers to confirm immunity.

E. doubling the next dose.

 

18.

Which of the following groups of children are not at increased risk for pneumococcal disease?

A. Obese children

B. Children of Native Alaskan descent

C. Children of African American descent

D. Children with sickle cell disease

E. Children infected with HIV

 

19.

Which of the following statements are true concerning Haemophilus influenzae type b vaccine (Hib)?

I. One dose of Hib is recommended for all infants over the age of 15 months if they have not received a previous dose.

II. Standard dosing for Hib vaccine is 2, 4, 6, and 12-15 months of age.

III. The 6-month dose is omitted if PedvaxHIB is used for the first two doses.

IV. Hib vaccine is not routinely recommended for children 5 years of age and older.

A. I only

B. I, II, and III

C. II, III, and IV

D. II and III

E. All are correct.

 

20.

Which of the following vaccines available in the United States is a live, attenuated virus vaccine?

A. Polio (IPV)

B. Haemophilus influenzae vaccine (Hib)

C. DTaP

D. Varicella vaccine

E. Pneumococcal vaccine

 

32-6. Answers

1.

E. Routine vaccinations in the adult are a yearly influenza vaccine, Td vaccine every 10 years, and a single pneumococcal vaccine for patients with select chronic illnesses (such as diabetes). Meningococcal and hepatitis vaccines are recommended only for certain indications.

 

2.

D. Routine revaccination with pneumococcal vaccine is not recommended. Revaccination is recommended for select high-risk groups and everyone 65 years and older who received an initial dose under the age of 65 and if more than 5 years have elapsed since the previous dose.

 

3.

A. Injected influenza vaccine is an attenuated, split-virus vaccine. The LAIV is administered intranasally.

 

4.

E. With the recent availability of a conjugate meningococcal vaccine, the ACIP recommended including all adolescents ages 11-12 among the other recommendations.

 

5.

C. DTaP is indicated for children under the age of 7. Because of adverse effects of DTaP in children 7 years of age and older, Td or Tdap is used.

 

6.

B. Polysaccharide pneumococcal vaccine (23-valent) is indicated for those over the age of 2 years and conjugated polysaccharide vaccine (7-valent) is approved for ages 2 months to 7 years. A meningococcal conjugate vaccine has recently been approved, and the polysaccharide vaccine will be removed from the market once supplies of the conjugate vaccine are adequate.

 

7.

A. OPV is no longer recommended in the United States, and vaccination with IPV will continue until poliovirus is eradicated worldwide.

 

8.

B. Hepatitis B vaccine is a recombinant hepatitis B surface antigen vaccine.

 

9.

E. Pneumococcal vaccine is not recommended for a healthy individual until the age of 65.

 

10.

A. The hepatitis A vaccine alone will protect a healthy individual between 1 and 40 years of age who has previously been exposed to the virus.

 

11.

B. High-risk groups targeted for influenza vaccination include persons age 6 months to 18 years and persons > 50 years old. Also included are persons age > 19 years with chronic pulmonary disease (e.g., emphysema, chronic obstructive pulmonary disease); cardiovascular disease (e.g., congestive heart failure, post-myocardial infarction, heart anomalies); metabolic disease (e.g., diabetes); renal dysfunction; hemoglobinopathies (e.g., sickle cell), and immunosuppression (e.g., HIV infection, chemotherapy). Other groups that should receive the vaccine include residents of long-term care facilities, people 24 months to 18 years old on aspirin chronically, pregnant women in all trimesters, hospital and outpatient employees, nursing home employees with patient contact, home health care providers working with high-risk persons, household members of high-risk persons, and persons desiring to avoid influenza infection.

 

12.

A. Complications of rubella may include arthritis, arthralgias, encephalitis, and hemorrhaging; however, the major complication is congenital rubella syndrome, which occurs in the offspring of a woman who had rubella during pregnancy. Babies born with CRS have major birth defects that can affect many organs.

 

13.

B. Live-virus vaccines will be killed if antibodies have been administered recently. The length of time that must separate these two products depends on the dose and type of antibody-containing blood product being used.

 

14.

C. Local reactions are the most common type of adverse reaction, and include pain, swelling, and redness at the site of injection. These reactions usually occur within minutes to hours of the injection and are usually mild and self-limiting. Systemic adverse reactions include fever, malaise, myalgias, and headache and are more common following live vaccines.

 

15.

E. All the other listed vaccines are first given at 2 months of age. Hepatitis B vaccine is recommended at birth to decrease the incidence of hepatitis B in infants of hepatitis B-infected mothers.

 

16.

C. Asplenic patients require protection against the encapsulated bacteria (pneumococcus, meningococcus, and Haemophilus), as well as common viral infections. Previous series completions of routine vaccines, such as measles, varicella, and polio, are adequate for protection. Td vaccines should be repeated every 10 years.

 

17.

B. The minimal interval in a series for most vaccines is 4 weeks. Decreasing the interval may interfere with antibody response and protection. Usually the last dose in a series is separated from the previous dose by 4-6 months. Increasing the interval does not affect vaccine effectiveness. You never need to restart a series except for oral typhoid vaccine.

 

18.

A. Rates of pneumococcal disease are highest in children < 2 years of age, those with asplenia, patients with HIV, American Indian and Alaskan Natives, African Americans, and day care attendees. Obesity is not considered a high-risk disease for pneumococcal infection.

 

19.

E. Although all the answers are correct, Hib vaccine may be indicated for children over the age of 5 with certain chronic conditions. This vaccine is relatively complicated to use because recommendations vary among manufacturers. Please consult package inserts before administering.

 

20.

D. Varicella vaccine, LAIV, measles-mumps-rubella vaccines, and rotavirus vaccines are the only live vaccines routinely administered in the United States. Other nonroutinely administered live vaccines include oral typhoid vaccine, vaccinia (smallpox) vaccine, and yellow fever vaccine. The majority of vaccines are inactivated or killed vaccines.

 

32-7. References

Advisory Committee on Immunization Practices. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United (Part 1). MMWR. 2005;54(RR-16):1-23.

Advisory Committee on Immunization Practices. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United (Part 2). MMWR. 2006;55(RR-16):1-25.

Advisory Committee on Immunization Practices. General recommendations on immunizations. MMWR. 2006;55(RR-15):1-48.

Advisory Committee on Immunization Practices. Poliomyelitis prevention in the United States: Updated recommendations. MMWR. 2000;49(RR-5): 1-22.

Advisory Committee on Immunization Practices. Preventing pneumococcal disease among infants and young children. MMWR. 2000;49(RR-9):1-38.

Advisory Committee on Immunization Practices. Preventing tetanus, diphtheria, and pertussis among adolescents: Use of tetanus, reduced diphtheria toxoid, and acellular pertussis vaccine MMWR. 2006; 55(RR-3):1-34.

Advisory Committee on Immunization Practices. Preventing tetanus, diphtheria, and pertussis among adults: Use of tetanus, reduced diphtheria toxoid, and acellular pertussis vaccine MMWR. 2006;55 (RR-17):1-33.

Advisory Committee on Immunization Practices. Prevention and control of seasonal influenza with vaccines. MMWR. 2009;58(RR-8):1-52.

Advisory Committee on Immunization Practices. Prevention and control of meningococcal disease. MMWR. 2005;54(RR-7):1-21.

Advisory Committee on Immunization Practices. Prevention of hepatitis A through active or passive immunization. MMWR. 2006;55(RR-7):1-23.

Advisory Committee on Immunization Practices. Prevention of pneumococcal disease. MMWR. 1997; 46:1-24.

Advisory Committee on Immunization Practices. Prevention of rotavirus gastroenteritis among infants and children. MMWR. 2009;58:1-24.

Advisory Committee on Immunization Practices. Prevention of varicella. MMWR. 2007;56 (RR-4): 1-40.

Advisory Committee on Immunization Practices. Quadravalent human papillomavirus vaccine. MMWR. 2007;56:1-24.

Advisory Committee on Immunization Practices. Revised ACIP recommendation for avoiding pregnancy after receiving a rubella-containing vaccine. MMWR. 2001;50:1117.

Advisory Committee on Immunization Practices. Revised recommendations of the Advisory Committee on Immunization Practices to vaccinate all persons aged 11-18 with meningococcal conjugate vaccine. MMWR. 2007;56794-95.

Advisory Committee on Immunization Practices. Update: Vaccine side effects, adverse reactions, contraindications, and precautions. MMWR. 1996;45 (RR-12):1-35; errata MMWR. 1997;46:227.

Advisory Committee on Immunization Practices. Use of diphtheria toxoid-tetanus toxoid-acellular pertussis vaccine as a five dose series. MMWR. 2000;49 (RR-13):1-8; erratum MMWR. 2000;49(47):1074.

Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine: Preventable Diseases. 11th ed. Atlanta, Ga.: CDC; 2009.

Centers for Disease Control and Prevention. Vaccines and immunizations Web site. Available at: www.cdc.gov/vaccines/pubs/pinkbook/default.htm.

Grabenstein JD. Immunofacts: Vaccines and Immunologic Drugs. St. Louis, Mo.: Wolters Kluwer Health; 2007.

Plotkin SA, Orenstein WA, Offitt P, eds. Vaccines. 5th ed. Philadelphia: WB Saunders; 2008.