immunizations for adults stephen j. gluckman, m.d

Immunizations for Adults

Stephen J. Gluckman, M.D.

Immunizations

Where do the recommendations come from? Advisory Committee on Immunization

Practices Approved by:

American Academy of Family Physicians American College of Obstetricians and

Gynecologists American College of Physicians

Definitions

Active Toxoid Live, Attenuated Killed, Inactivated Recombinant

Pre-Exposure

Passive Immune Globulin Specific high titer

preparations

Post-Exposure

General Rules: Administration

Give it the way it is recommended. The buttock is generally not recommended. Recommended intervals between doses are

the minimal ones. Shorter may lead to decreased antibody levels Longer will not

Can administer most vaccines simultaneously.

General Rules:Contraindications and Precautions

The live vaccines are measles, mumps, rubella, yellow fever, oral polio, varicella, zoster, oral typhoid, BCG Pregnant woman Immunocompromised patients

Vaccines made in eggs are measles, mumps, influenza - both, yellow fever True egg allergy

Vaccines containing neomycin are measles, mumps, rubella, zoster None contain penicillin

General Rules:Misconceptions I

The following are not contraindications to vaccination

Local or mild-moderate reactions to previous vaccination

Mild acute URI or gastroenteritis Current antimicrobial therapy Breast Feeding

Personal history of “allergies” Family history of adverse reactions to an

immunization Pregnancy, unless live vaccine Pregnancy in a household member of

vaccinee

General Rules:Misconceptions II

General Rules:Misconceptions III

Mercury Thimerosal in vaccines since the 1930’s No evidence that it has caused any harm

Ethyl mercury not methyl mercury Essentially removed from all vaccines today

Trace amounts in some formulations of Influenza, Td, TDaP

Autism Fraudulent study Poorly supported anecdote

REPORT SEVERE REACTION TO PROPER AUTHORITIES

http://vaers.hhs.gov/index 1-800-822-7967

Immunization record

The patient’s chart should contain a notation including the: Date Type of Immunization Dose Site Lot number Manufacturer Identification of the person who administered

Pre-Exposure Immunization All Adults

Tetanus/Diphtheria (Td) Every 10 yearsOne of these should be: tetanus, diphtheria, acellular pertussis (Tdap) This should be given if no Td within 5 years

Many Adults Measles, Mumps, Rubella, Influenza, Pneumococcus,

Hepatitis B, Varicella, Hepatitis A, HPV, Zoster

Selected Groups Travelers, Health Care Workers, College Students, Nursing

Home Residents

Post-Exposure Immunizations

Hepatitis A

Hepatitis B

Tetanus

Rabies

Varicella

MMR Measles and Mumps

Made in Eggs, Live One dose indicated for all persons born after 1956 unless

One or more documented prior immunizations (+) serology HCW documented disease Medical contraindication

Second dose Recently exposed HCW International traveler College Student

Rubella

Rubella Live, no eggs One dose indicated for

All women of child bearing potential All HCW’s unless

History of vaccination (+) serology

» A history of rubella is not reliable

Rubella:Vaccine

Live attenuated virus is shed but there is no transmission

Adverse reactions: Arthralgias and arthritis Fever Rash

Rubella

What if pregnant at the time of immunization?

“The risk of vaccine associated with defects is so small as to be negligible and should not ordinarily be a reason to interrupt pregnancy”

- CDC Registry

Rubella

Can a breast feeding woman get Immunized?

Yes

Can a household member of a pregnant woman get immunized?

Yes

Influenza Two Types of Vaccines - equal efficacy

Live Vaccine (FluMist®) Advantages

No injection Disadvantages

Expensive Nasal stuffiness, rhinitis Shed virus Only approved for 18-49 year olds No contact with immunocompromised persons

Inactivated Vaccine Parenteral

Latex free» Fluzone®, Fluvirin®

Contains latex» Fluarix®

Influenza:Vaccine

Changes from year to year based on the “best guess” of which strains will be circulating

Patients need to know About 70% efficacy Prevents influenza, a bad disease, not URI’s

Influenza:Whom to Vaccinate with the Seasonal Vaccine?

All adults Particularly indicated for:

Otherwise healthy persons > 50 years of age Adults chronic cardiopulmonary disorders Adults with chronic metabolic diseases Pregnant women Health care workers Persons with HIV infection Residents of chronic care facilities

Pneumococcal Vaccine

PPV

23 capsular polyvalent polysaccharide antigens of 90% of bacteremic infections

Healthy adults respond to 80% of the serotypes

PCV

Conjugated vaccine for infants and children (Prevnar®)

Pneumococcal Vaccination

Whom to vaccinate? All adults 65 and over and those high risk groups

at any age CSF leaks and cochlear implants Asplenic Chronic cardiopulmonary, alcoholism or metabolic

diseases Revaccination?

For most people only a single vaccination is recommended

Consider revaccination for: high risk groups Those immunized > 5 years ago and were < 65 at

the time

Hepatitis B

Why vaccinate?

200-300,000 new cases annually

10% chronic carrier

Immediate and late mortality

Hepatitis B

Recombinant >95% of healthy adults make antibody Schedule options

0,1,4 months With hepatitis A (Twinrix):

0,1,6 months 0,7,21 days and 12 months

High dose vaccine for dialysis and immunocompromised patients

Hepatitis B: Recommendations

All Newborns All Adolescents Selected (Almost all) Adults

Occupational, e.g. Health Care Workers Hemodialysis patients Injection drug users Sexually active, Non-monogamous Sexual partner of a known carrier Inmates of long-term correctional facility Recipients of blood products Persons with chronic liver disease Household contacts

Management of non-responder? 0.1 - 0.25 ml intradermal at 0,2,4 weeks* Revaccinate with dialysis dose (40 mcg)*

Need for booster? Not recommended

Pre and post immunization serological testing? Not recommended

*Not FDA approved but supported in the literature

Hepatitis BAreas of Concern

Hepatitis A

Vaccine Formalin inactivated No antibiotics Single dose is 99% protective; second dose at > 6 months

confers more long lasting immunity Indications

All children High risk adults

International travelers Persons living in areas of high endemicity Persons working in day care centers Persons with chronic liver disease

Post exposure prophylaxis (14 days)

Hepatitis A

Three equally effective options Hepatitis A alone (Vaqta or Havrix)

0, > 6 months

Twinrix (Combined with Hepatitis B) 0,1,6 months 0,7,21 days and 12 months

Varicella Vaccine

Live, attenuated, neomycin 99% seroconversion rate after two doses Protective for at least 10 years Breakthrough infections occur, but are mild Transmission rates of the vaccine to

susceptible contacts are very low.

Varicella

Who is Susceptible? A history of varicella is very reliable A negative history of varicella is not

Cost effective to measure antibodies in a person who says that they did not have varicella

Indications All susceptible

Varicella Vaccine

Dosage and administration Children 12 mos to 13 yrs - two doses at

> 3 months apart Greater than 13 yrs - two doses at 4-8 week

intervals

Routine testing for immunity after vaccination is unnecessary

Adverse effects: local discomfort

An 18 year old woman comes to your office for pre-college immunizations. If she does NOT already have known immunity, for which of the following should she be immunized?(select all that apply)

CASE

a. Measles, mumps, rubella

b. Hepatitis B

c. HPV

d. Meningococcus

Meningococcal Vaccine

Two types Conjugate (Menactra, Menveo)

Age 2-55

Polysaccharide (Menomune) > Age 55

Meningococcal Vaccine

Only effective against serogroups A,C,Y, W-135. About 30% caused by group B – not in the

vaccine

Meningococcal Vaccine

Recommended (1 dose) All children age 11-12 1st year college students living in dormitories and

military recruits (if not given earlier) Persons at increased risk ages 2-55 years

Travelers to endemic or epidemic areas Persons on a Hajj (required) Asplenic patients Persons with terminal complement deficiencies

Relative Risks for meningococcal disease (per 100,000) Endemic risk 1-1.5 All college students 0.6 Freshman 1.7 Freshman in dorm 5.4

Meningococcal Vaccine

Human Papillomavirus (HPV)Vaccine

Indicated for women and suggested for men, 9-26 years 99% make antibodies to the serotypes

ACIP: aim at 11-12 year olds with “catch-up” of older

Two vaccines Gardasil® HPV Types 16,18: 70% of types that cause

cervical cancer HPV Types 6,11: 90% of types that cause warts 3 doses: x, x+2m, x+6m

Cervarix®

Types 16,18 3 doses: x, x+1, x+6

Human Papillomavirus (HPV)Vaccine

FAQ Should woman be screened before being

vaccinated No

What about vaccinating men? Consider to prevent warts, not cancers or

transmission Should pregnant woman get vaccinated?

No, appears to be safe but….. How long does the protection lasts?

Unknown. At least 5 years

Herpes Zoster Vaccine

Single dose Live Neomycin

Studied in 60 years old and older Prevented disease in 50% Breakthrough infections were generally milder Decreased efficacy with increasing age History of zoster is not a contraindication

Pre-Exposure, Selected Groups

Nursing Home Patients

Influenza

Pneumococcus

Tetanus/Diphtheria (Tdap)

College Students

Measles, Mumps, Rubella

Tetanus/Diphtheria/Pertussis

Hepatitis B

Meningococcal

HPV

Health Care Workers

Hepatitis B

Influenza

Varicella

Measles, Mumps, Rubella

Questions?