VACUNAS EN SITUACIONES ESPECIALES

Macarena sobarzoBecada de inmunologaVACUNAS EN SITUACIONES ESPECIALESTemarioAdolescentesAdultos y Tercera EdadEmbarazadasNios De Pre-TrminoReaccin Anafilctica Al HuevoInmunosuprimidos Vih +Trasplantados (MO Org. Slidos)AspleniaTratamientos InmunosupresoresPatologas Crnicas: Ir, Dm, Dao Heptico Crnico, EtcVacunas En El ViajeroPersonal De Salud

Vacunas en el adolescenteActualizar vacunas incompletasRecomendadas para todos

www.cdc.gov/vaccines/schedules/hcp/child-adolescent.htmlSin evidencia de Inmunidad2 dosis sep . Por 4 sem Historia Laboratorio.< 13 aos: 2 dosis sep. 3 meses> 13 aos: 2 dosis sep. 1 mes.PNI: 8vo.PNI: 4to (9aos).

Minimum age: 6 weeks for MenHibrix [Hib-MenCY], 9 months for Menactra [MenACWY-D], 2 months for Menveo [MenACWY-CRM])Polio: Inactivated poliovirus (IPV) vaccine:A fourth dose is not necessary if the third dose was administered at age 4 years or older and at least 6 months after the previous dose. If both oral polio vaccine (OPV) and IPV were administered as part of a series, a total of 4 doses should be administered, regardless of the child's current age. IPV is not routinely recommended for US residents aged 18 years or older.Varicela se recomienda en cdc al ao y en primero basico. Se recomienda en este grupo In accord with the Centers for Disease Control and Prevention and American Academy of Pediatrics, we recommend annual influenza immunization for all persons six months of age and older (Grade 1A). When vaccine supply is limited, immunization efforts should focus on children and adolescents who are at risk for severe or complicated influenza and household contacts and out-of-home caregivers of children 0 to 59 months of age and other individuals who are at increased risk of severe or complicated influenza (table 4). (See'Indications'above.)The choice of vaccine for an individual child depends upon age and risk factors for severe or complicated influenza. IIV is indicated for individuals 6 months, including those who cannot receive LAIV. The following groups should receive IIV, rather than LAIV (table 5):Children 6 through 23 months of ageChildren (of any age) with asthma and children two through four years of age with a history of recurrent wheezingChildren with medical conditions that increase the risk for severe or complicated influenza infectionChildren who are close contacts of severely immunocompromised individuals (eg, hematopoietic stem cell transplant recipients)

(See'Choice of vaccine'above and'Contraindications and precautions for LAIV'above.)Individuals older than 2 years and younger than 50 years who are not among of the categories listed above may receive either IIV or LAIV. Given the potential advantage of broader and more durable immunity with LAIV, we suggest LAIV for such patients if they are not pregnant (Grade 2A). (See'LAIV compared with IIV'above.)

3Vacunas en el adulto y adulto mayor

http://www.cdc.gov/vaccines/schedules/hcp/adult.htmlHSHTdap: Si no a 11 aos (8vo)Sin antecedentes /incompleto Td: 3 dosis (1 Tdap)Sarampion y Paperas:1 dosis: estudiantes de instituciones superiores, centros de atencin mdica, viajes internacionales.2 dosis: vacuna inactivada. Rubeola: 1 dosis: mujeres edad frtil sin historia inmunidad.

Vacunas en el embarazoContraindicadas: Virus vivos> 4 semanas de embarazo.Screnning PrenatalVaricela, Rubeola: PostpartoVZIG: exposicin en no inmunes. (VAR 5m despes)HBsAg: Profilaxis postparto.

http://www.cdc.gov/vaccines/schedules/hcp/adult.html http://www.cdc.gov/vaccines/adults/rec-vac/pregnant.html.27-36 semanas. (si no, postparto)Mas de 1 pareja < 6 mesesPareja HBsAg +Drogas ev

5Vacunas en el prematuroVacunados de acuerdo con su edad cronolgica, (No EG ni peso) Debe coincidir con la del calendario vacunacin normal, comenzando a los 2 meses de EC.Si nio hospitalizado clnicamente estables. Fase de crecimiento sostenido,Sin necesidad de ventilacin mecnica o terapia para infecciones graves,Sin alteraciones metablicas, renales, cardiovasculares o respiratorias significativas. Slo diferir la vacuna de polio oral hasta el momento del alta (por su riesgo de diseminacin nosocomial) o bien administrarles vacuna anti polio inactivada. Efectos adversos:Prematuros ( 2000g o 2 mesesMenor Inmunogenicidad monovalente (0, 1 y 6m). Retrasar > 1m. < 34 sem o 2000 gr puede requerir dosis adicional. INFLUENZA INACTIVADAdosis: 2,4,6 y 15-18Enf. Respiratoria CrnicaROTAVIRUS (6sem 2000g o 1m (Monovalente)Habitual.Desconocidovacuna monovalente HBIG < 12hrs (Sin no resultado disponible)

vacuna monovalente < 12hrsHBIG (< 7 das si HBsAg +)

HEPATITIS B DEPENDE DEL PESO8Vacunas en el prematuroOtros:Palivizumab (Synagis) IgG1 dirigido contra la protena de fusin F del VRSReduce las hospitalizaciones en 80% en prematuros sanos y 39% en nios con patologa respiratoria crnica. Indicaciones en Lactante menor de 6 meses con: Displasia BroncopulmonarOxigenodependiente (ingresado o propuesto al Programa de Oxigeno Ambulatorio)EG Menor 32 semanas o peso menor a 1500 gr al nacer. Contactos.Hermanos < 6 aos: calendario al da. Padres, cuidadores y hnos: influenza anual. Madre embarazada o puerperio: influenza, Tdap.Capullo: TdapPersonal neonatologa: influenza anual, Tdap c/10 aos, Hep B y Varicela (Si requiere)Pacientes con Alergia al Huevo

Prick test con vacuna previo a la administracin- : Monitorizacin 30+: Dosis graduales o via IDMeasles and mumps vaccines and one type of rabies vaccine are grown in chick embryo fibroblast cultures and containnegligible or no egg protein.46,47. reaccion es a gelatina. Administering influenza vaccine to recipients withegg allergyInfluenza vaccines are grown on embryonated chicken eggs, leading to concern that residual egg protein (ovalbumin) could10

Adverse reactions to vaccines practice parameter 2012 update. J Allergy Clin Immunol. 2012;130(1):25.Adverse reactions to vaccines practice parameter 2012 update. J Allergy Clin Immunol. 2012;130(1):25.

11Pacientes con alergia al huevo y Vacuna InfluenzaPacientes con alergia al huevo deben evaluarse por alerglogo para estudio, sin retrasar vacunacin.Segura incluso en anafilaxia al huevo.Test cutneo con vacuna influenza no predice reaccin y no se recomienda.Vacuna debe administrase con observacin de 30 minutos y lugar equipado.

Adverse reactions to vaccines practice parameter 2012 update. J Allergy Clin Immunol. 2012;130(1):25.Vacunas en Inmunosuprimidos Generalidades:Momento:Previo a una inmunosupresin si esta es planeada. Virus vivos 4 semanasVacunas inactivadas 2 semanas.

Contactos: Seguras: inactivadas y organismos vivos.Polio oral NO! Evitar manipular paales por 4 semanas si recibi rotavirus.Evitar contacto con lesiones cutneas post VAR o ZOS hasta desaparicin.Influenza : Inactivada 6 mesesVirus vivo: Sano, no embarazada y edad 2-49 aos.. NO si IC: < 2 meses TMO, GVHD, SCID 7 das

Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2014; 58:e44.Vacunas en IDPDficit de complemento

Vacuna neumoccicaPCV13 + PPSV23 PPCV13: 2-5 aos:1 dosis +: si esquema completo 2 dosis + sep 4 sem si incompleto> 6 aos: 1 dosis +PPSV23:> 2 aos: 1 dosis al menos 8 sem post PPCV13 y otra dosis 5 aos despes. Vacuna meningoccica:6 Sem- 18 meses: 4 dosis vacuna bivalente + Hib (2,4,6 y 12-15m)9m-55 aos:2 dosis MCV4> 55 aosMPSV4Revacunacin c/5 aosVacuna influenza anual

Sin contraindicaciones.Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2014; 58:e44.Vacunas en IDPDficit Fagocitos:Inactivadas: Sin CIInfluenza anualPneumoccica:PCV13: Dosis extra 2-5 aosPPSV23: Terapia ISVivas atenuadas:BCG: CIFiebre tifoidea: CIResto no CI en EGC ni neutropenia ciclica/congenitaSi en LAD y Chediak HigashiDficit de anticuerposDeficit menores (IgA, Ac polisac. Especficicos)Recomendadas por edadVacunas vivas sin CIOPV: no en IgADeficit Ac.Polisacr. Espec.Dficit Mayores (Agammaglo. IDCV)IGIV: No inactivadasInfluenza anual siNo vivas atenuadas

Vacuna neumoccicaPCV13 + PPSV23 PPCV13: 2-5 aos:1 dosis +: si esquema completo 2 dosis + sep 4 sem si incompleto> 6 aos: 1 dosis +PPSV23:> 2 aos: 1 dosis al menos 8 sem post PPCV13 y 2 dosis 5 aos despus.Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2014; 58:e44.Vacunas en IDPSCID Inactivadas:Previo IGIV. Si existe alguna produccin de anticuerpos se puede administrar vacuna influenza inactivada anual. Vivas atenuadasSindrome DiGeorge CD3500/mm3, CD8 200 y respuesta normal a mitgenos:Vacuna trivrica y varicela

Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2014; 58:e44.Pacientes VIHVacunas inactivadasSegn calendario anualVacunas vivas atenuadasContraindicadas si CD4 muy bajos (< 15% si 5a)Respuesta es mejor siTARV 3 mesesCD4 15%CV < 1000 Pacientes VIH

- Vacuna alta dosis (40ug)Medir antiHBs + Hep A > 12 a anti HBc y DNA (-): 3 dosisHIV-infected adults should receive inactivated seasonal influenza vaccine and tetanus toxoid, reduced diphtheria toxoid, with or without acellular pertussis toxoid vaccine as recommended for the general population (figure 3). (See'Influenza vaccine'above and'Tetanus toxoid, diphtheria toxoid, and acellular pertussis vaccines'above.)The human papillomavirus (HPV) vaccine should be given to HIV-infected individuals through age 26 years who did not get any or all doses when they were younger; it is not a live vaccine (figure 3). HPV DNA screening is not recommended prior to immunization. (See'Human papillomavirus vaccine'above and"Recommendations for the use of human papillomavirus vaccines", section on 'Immunosuppressed or immunocompromised hosts'.)In adults, HIV-infection is an indication for pneumococcal vaccination, with both the 13-valent conjugate (PCV13) and polysaccharide (PPSV23) vaccines (figure 3). (See'Pneumococcal vaccine'above and"Pneumococcal immunization in HIV-infected adults".)In adults, HIV-infection is an indication for hepatitis B virus (HBV) vaccination if the patient is not already immune (figure 3). Strategies to improve antibody response to the HBV vaccine include using a double dose of vaccine, checking for vaccine response, and revaccinating non-responders. (See'Hepatitis B vaccine'above and"Prevention of hepatitis B virus infection in the HIV-infected adult".)HIV-infected adults who have chronic liver disease or are at increased risk for hepatitis A infection should receive thehepatitis A vaccine, if not already immune (figure 3). These candidates include patients with chronic hepatitis B or C, injection drug users, men who have sex with men, and hemophiliacs. (See'Hepatitis A vaccine'above.)Meningococcal conjugate vaccine (Menactra or Menveo) is recommended for HIV-infected individuals who have a specific indication for meningococcal vaccination, such as functional or anatomic asplenia, age between 11 and 18, and travel exposure (table 2andfigure 3). In addition, outbreaks of invasive meningococcal disease among men who have sex with men (MSM) have prompted recommendations to vaccinate certain MSM at risk. (See'Meningococcal vaccine'above and"Meningococcal vaccines", section on 'In adults'.)Although HIV-infected patients have a significantly increased rate of infection withH. influenzae, most infections involve non-typable strains for which the vaccine is not protective. Thus, this vaccine is not recommended for adults infected with HIV who do not have other specific indications (eg, asplenia) for vaccination (figure 3). (See'Haemophilus influenzae vaccine'above.)Bacillus Calmette Guerin (BCG) vaccine is utilized in developing countries to reduce the risk of developing tuberculosis. Since there is a risk of disseminated tuberculosis disease after vaccination, and the efficacy of BCG vaccine is unknown, BCG immunization is not recommended in HIV-infected patients. (See'BCG vaccine'above.)Use of UpToDate is subject to theSubscription and License Agreement.

zoster vaccineVaricellazoster vaccinewas tested in a trial (ACTG 5247) of 295 HIV-infected individuals with CD4 cell counts 200cells/microLand virologic suppression on antiretroviral therapy (ART) and appeared safe and immunogenic [7]. Individuals with CD4 cell counts >350cells/microLhad the highest zoster antibody levels post-vaccination. However, there were higher rates of injection site reactions in the zoster group (42 versus 12.4 percent in the placebo group).Although these data are promising, it is not yet clear which HIV-infected individuals at what age should receive the zoster vaccine. It is reasonable to vaccinate those with CD4 counts >200cells/microLwho are aged 60 years or older [4]. Zoster vaccineis specificallynotrecommended for HIV-infected patients with a CD4 cell count 4 semVacunas inactivadas > 2 semNo en beneficio receptorPost TMOConsideran como nunca vacunadosAgentes vivos contraindicadas en GVHD/ IS

2 AOS post TMO en seronegativos.- Sin GVHD, IS y si IGIV (8-11m)DT: diphtheria toxoid, tetanus toxoid; DTaP: diphtheria toxoid, tetanus toxoid, acellular pertussis; GVHD: graft-versus-host disease; HCT: hematopoietic cell transplant; R: recommended - administer if not previously administered or current; such patients may be at increased risk for this vaccine-preventable infection; Td: tetanus toxoid, reduced diphtheria toxoid; Tdap: tetanus toxoid, reduced diphtheria toxoid, and reduced acellular pertussis; U: usual - administer if patient not current with recommendations for dose(s) of vaccine for immunocompetent persons in risk and age categories; X: contraindicated.* Indicates recommendation for a course of action that deviates from recommendations of the Advisory Committee on Immunization Practices, United States Centers for Disease Control and Prevention (CDC).These live vaccines should not be administered unless the vaccine is otherwise indicated based on the annually updatedCDC recommendations AND the patient is not immunosuppressed AND there will be an interval of 4 weeks prior to transplant. Administer to adolescents and adults (strong, low) and to children (strong, moderate) if measles seronegative, the timing is 24 months after transplant, no GVHD is present, and the patient is not receiving immunosuppressive medication. Two doses should be administered.If not previously administered. Administer if varicella seronegative, the timing is 24 months after transplant, no GVHD is present, and the patient is not receiving immunosuppressive medication. Two doses should be administered (strong, low). Consider if the patient is not severely immunosuppressed AND the patient is varicella immune as defined by documentation of age-appropriate varicella vaccination, serologic evidence of immunity, documentation of varicella or zoster infection, or birth in the United States before 1980[1]AND there will be an interval of 4 weeks prior to transplant.References:PretransplantPrior to hematopoietic cell transplant (HCT), HCT candidates who are not already immunocompromised should receive the vaccines that are indicated for immunocompetent individuals based upon age, vaccination history, and exposure history [10]. HCT candidates should receive live virus vaccines 4 weeks prior to the initiation of the conditioning regimen and inactivated vaccines 2 weeks prior to the initiation of the conditioning regimen.Nonimmune HCT candidates 12 months of age should receive thevaricella vaccine(a live virus vaccine) if they are not immunocompromised and if the interval until initiating the conditioning regimen is 4 weeks [10]. If there is sufficient time prior to HCT, two doses of the varicella vaccine should be given; for individuals 1 to 12 years of age, the doses should be separated by at least three months and, for individuals 13 years of age, the doses should be separated by at least four weeksPosttransplantHCT recipients should be immunized against a number of pathogens such as pneumococcus,Haemophilus influenzae, tetanus, and others once they are likely to mount an immune response. Live virus vaccines are avoided altogether during the first 24 months following HCT, but certain ones (eg, measles, mumps, and rubella vaccine) are indicated 24 months following HCT in patients who donothave active graft-versus-host disease and who arenotreceiving immunosuppressive agents [2,10]. The approach to immunization is summarized in the following Table (table 1). Specific recommendations for each vaccine are presented below.INACTIVATED VACCINESTetanus, diphtheria, and pertussisThe 2013 Infecti

20Pacientes con TOSMltiples factores que contribuyen a un E de inmunosupresin: disfunciones, fenmenos de rechazo y terapia IS. Vacunas inactivadas seran seguras en pacientes tx (3-6m)Recomendaciones de acuerdo a guas nacionales.Vacunas vivas atenuadas estn contraindicadas posterior al tx Programa previo al procedimiento (4s), segn corresponda.Idealmente evaluacin respuesta serolgica 4s post vacunaNo se asocia a mayor episodios de rechazo

Danziger-Isakov et al. Am J Transpl. 2013; 13: 311-317Pacientes Adultos con Trasplante rgano SlidoVacuna Hib no se recomienda porque ttulos son adecuados.

Danziger-Isakov et al. Am J Transpl. 2013; 13: 311-317HgadoesplenectomaAlta dosisInfluenza anualHepatitis b en hd y alta dosis 3 dosis.. Receptores renales o hepaticos.22Pacientes con terapias inmunosupresoras

A guide to prepare patients with inflammatory bowel diseases foranti-TNF- therapy. Med Sci Monit.2014 Mar 26;20:487-98Pacientes con tratamiento inmunosupresores No se debe retrasar la inmunosupresin para facilitar la inmunizacin. Las vacunas inactivadas se deben administrar segn calendario anual de pacientes inmunocompetentes. Vacuna influenza inactivada de forma anual Vacuna neumoccica ( PCV13 + PPSV23)Vacunas vivas atenuadas no deben administrarse. Vacuna varicela 4 semanas previasPosterior si es que de baja intensidadVacuna zoster 4 semanas previasMayores de 60 aos o con edad entre 50-59 aos e historia positiva de varicela Posterior si es que de baja intensidad.No hay evidencia que las vacunas exacerben la enfermedad crnica, por lo que no deben evitarse.

Prednisona: < 20mg/da o < 2mg/kg (nios)MTX:< 0,4mg/kg/semanaAZA: 14 das previoPCV + PPSV23MCV4Hib (no vac. >5a) > 14 das postRepetir 8 sem despus si antes.IS 3 meses

Vacuna neumoccicaPCV13 + PPSV23 PPCV13: 2-5 aos:1 dosis +: si esquema completo 2 dosis + sep 4 sem si incompleto> 6 aos: 1 dosis +PPSV23:> 2 aos: 1 dosis al menos 8 sem post PPCV13 y 2 dosis 5 aos despus.mmunizationsThe spleen is the dominant site for the production of IgM antibodies required for opsonizing encapsulated pathogens. Thus, whenever elective splenectomy is considered, patients should undergo appropriately timed preoperative immunization againstStreptococcus pneumoniae(pneumococcus),Neisseria meningitidis(meningococcus), andHaemophilus influenzaetype b. Vaccination recommendations for asplenic patients are presented in the following Table (table 1) [4].Timing of immunizationsVaccines should be administered at least 14 days prior to scheduled splenectomy. If this is not possible, immunizations can be given after the 14thpostoperative day. This recommendation is based in part upon a study comparing pneumococcal vaccination 1, 7, and 14 days after splenectomy in 59 trauma patients compared to 12 adult controls [5]. Postvaccination immunization titers were not significantly different from control patients. However, opsonophagocytic function of the antibodies was diminished in patients vaccinated before the 14-day point. In another study, splenectomized patients who needed pneumococcal revaccination due to low antibody responses were significantly more likely to have received their initial vaccination fewer than 14 days before or after splenectomy [6].If postoperative vaccine administration is performed prior to postoperative day 14, it is reasonable to repeat the postsplenectomy vaccines eight weeks after the initial doses. In patients undergoing immunosuppressive chemotherapy or radiotherapy, immunization should be delayed for at least three months after completion of therapy [4]. (See"Immunizations in patients with cancer", section on 'Timing of immunizations'.Estos pacientes deben recibir las vacunas recomendadas en segn calendario anual para pacientes inmunocompetentes incluyendo la PCV13 en menores de 2 aos. No hay contraindicacin de vacunas, salvo la vacuna influenza virus vivo. La PCV13 debe administrarse al complemento con PPSV23 en mayores de 2 aos segn lo descrito previamente. Si es que aun no se ha realizado la esplenectoma la PPSV23 debe administrarse al menos 2 semanas previo o posterior al procedimiento. Una dosis de vacuna Hib debe administrarse para las personas no vacunadas mayores de 5 aos. La vacuna meningococica debe administrarse para pacientes mayores de 2 meses. La MCV4-D no debe administrarse en pacientes menores de 2 aos por la interferencia con algunos serotipos de la vacuna neumococica cuando se administran simultneamente. La revacunacin con MCV4 o MPSV4 para los mayores de 55 aos que no la han recibido previamente se recomienda cada 5 aos. ImmunizationsIf a patient has anatomic or functional asplenia, we recommend immunization with pneumococcal (table 4andtable 3), meningococcal (table 6), andHaemophilus influenzaetype b vaccines (table 5). (See'Immunizations'above.)If a patient will be undergoing elective splenectomy, we recommend that the pneumococcal, meningococcal, andHaemophilus influenzaevaccines be administered at least 14 days prior to surgery. If it is not possible to administer these vaccines prior to splenectomy, they can be given after the 14thpostoperative day. (See'Timing of immunizations'above.)We recommend that asplenic individuals receive an inactivated influenza vaccination annually, as well as other routine vaccines according to age-based recommendations (table 1). (See'Influenza vaccine'above.)

26Pacientes con Enfermedades Crnicas

CECCurr Gastroenterol Rep.2013 Jan;15(1):300. Immunizations in chronic liver disease: what should be done and what is the evidence.Dilisis: ttulos subptimosVacunar etapa tempranaDoblar dosisBooster TSOTSOErc menos respuesta a vacunas por la inmunuspresion dada por la uremia. Ademas pacientes en dialisis menor titulos de ac y falla en mantener ac en elt iempo.Patients with end-stage renal disease (ESRD) have a reduced response to vaccination because of the general suppression of the immune system associated with uremia. Compared with vaccination in patients without ESRD, dialysis patients have a lower antibody titer and an inability to maintain adequate antibody titers over time. (See'Introduction'above.) Patients with end-stage renal disease (ESRD) have a reduced response to vaccination because of the general suppression of the immune system associated with uremia. Compared with vaccination in patients without ESRD, dialysis patients have a lower antibody titer and an inability to maintain adequate antibody titers over time. (See'Introduction'above.)Although the development and, especially, the duration of protective antibody titers in response to vaccine administration in dialysis patients are often suboptimal, recommendations are to vaccinate ESRD patients against hepatitis B. The antibody response to hepatitis B may be improved by vaccinating early in the course of chronic kidney disease (CKD), doubling the dose of vaccine administered, giving an additional dose, and giving an early booster dose with a fall in antibody titer. Adjuvants to boost the immune response may prove useful, but are not yet widely available or used. (See'Hepatitis B virus vaccine'above.)The response to pneumococcal vaccine is diminished among patients with CKD, particularly maintenance of adequate antibody titers. Despite this, pneumococcal vaccination is recommended in patients with ESRD. (See'Pneumococcal vaccine'above.)The required shorter duration of influenza antibodies suggests that all dialysis patients should receive an influenza vaccine on a yearly basis. Limited evidence suggests that H1N1 vaccine is safe and effective in hemodialysis patients. (See'Influenza vaccine'above.)There is little information about other vaccines in the dialysis population, but vaccinations for human papilloma virus (HPV) and herpes zoster should be considered, especially in patients on transplant waiting lists. (See'Human papillomavirus vaccine'above and'Varicella-zoster virus vaccine'above.)

Cases of HBV infection in hemodialysis units have also prompted the Centers for Disease Control (CDC) to reiterate its recommendation that all dialysis patients receive hepatitis B vaccination [19,20]. The CDC suggested that the cost of vaccinating patients is mitigated by the reduced need for monthly surveillance of antigen and antibody status in those who develop specific antibodies [19].The number of dialysis patients who have received hepatitis B vaccination has increased significantly over the last several decades. As an example, the percentage of dialysis patients who had received at least three doses ofhepatitis B vaccinehad increased from 5.4 percent in 1983 to 56 percent in 2002 [15]. Dialysis facility or preprinted chart orders for vaccination may improve vaccination rates for hepatitis, as well as pneumococcus, in dialysis patients [21].Because of the generally low response rate among patients with ESRD, multiple attempts have been made to enhance the immune response tohepatitis B vaccine. These include [3,22-31]:Doubling the dose of vaccine.Giving booster doses of vaccine in response to a fall in antibody titer.Attempting to increase the immune response either by changing the mode of injection (intradermal versus intramuscular) or by adding immunostimulants or adjuvants [32-35]. As an example, one multicenter study randomly assigned 300 patients with CKD to four doses of hepatitis B ASO4 vaccine (zero, one, two, and six months) or three doses of hepatitis B ASO2V vaccine (zero, one, and six months) [34]. The two vaccines are associated with different adjuvants. At 12 months, the ASO2V vaccine, compared with the ASO4 vaccine, was associated with a significantly more rapid and robust response, with seroconversion rates of 77 and 39 percent at two months and 94 and 79 percent at 12 months, respectively. Thus, three doses of the hepatitis B ASO2V vaccine provide rapid and persistent protection against HBV among patients with CKD. At present, this vaccine is not available in the United States.Giving a combined hepatitis A and B vaccine [36].Data exist to support the following strategies to improve antibody production tohepatitis B vaccinein patients with ESRD [20]:Double the vaccine dose suggested for patients without ESRD (ie, 40mcg/dosein patients with ESRD).Administer the vaccine in the deltoid muscle.Give additional doses to patients with ESRD (eg, Heptavax 40 mcg intramuscular [IM] at zero, one, and six months or Engerix 40 mcg IM at zero, one, two, and six months).Begin the vaccination series as soon as CKD is recognized and the patient is known to be hepatitis B surface antigen (HBsAg) and antibody negative; the clinician should not wait until the patient is dialysis dependent to begin the vaccination protocol [3].Since spurious seropositivity for HBsAg may occur shortly after vaccination, it has been recommended that testing of serum for HBsAg be avoided within three weeks of vaccination [37].Administer an additional three-dose series to dialysis patients who failed to respond to the initial series, which is defined as antibody titers 10 int.unit/Lone to two months after completion of the first series [2].Administer a single booster dose of 40 mcg if the antibody titer falls to 10 int.unit/Lin the patient who initially developed an antibody response to vaccination or after natural infection [38,39]. There appears to be no benefit to repeated boosters in those whose antibody titers remain 10 int.unit/L.

Higado cronico: BUENA R A PNEUMO. REVACUNAR EN 5 AOS. PCV13 PARA POSTTRASP. Hepatitis b mejor respuesta previo a cirrosis. En cirrosis considerar uso de doble dosis. Hep a dos dosis para evitar hep fulminante.HEP B: health care personnel and public safety workers who are potentiallyexposed to blood or other infectious body fluids;persons with diabetes who are younger than age 60 years as soon as

feasible after diagnosis; persons with diabetes who are age 60 years orolder at the discretion of the treating clinician based on the likelihoodof acquiring HBV infection, including the risk posed by an increasedneed for assisted blood glucose monitoring in long-term care facilities,the likelihood of experiencing chronic sequelae if infected with HBV,and the likelihood of immune response to vaccination;persons with end-stage renal disease, including patients receiving hemodialysis,persons with HIV infection, and persons with chronic liver diseasePneumococcal conjugate (PCV13) vaccination Adults aged 19 years or older with immunocompromising conditions (including chronic renal failure and nephrotic syndrome), functional or anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants who have not previously received PCV13 or PPSV23 should receive a single dose of PCV13 followed by a dose of PPSV23 at least eight weeks later.Adults aged 19 years or older with the aforementioned conditions who have previously received one or more doses of PPSV23 should receive a dose of PCV13 one or more years after the last PPSV23 dose was received. For adults who require additional doses of PPSV23, the first such dose should be given no sooner than eight weeks after PCV13 and at least five years after the most recent dose of PPSV23.When indicated, PCV13 should be administered to patients who are uncertain of their vaccination status history and have no record of previous vaccination.Although PCV13 is licensed by the US Food and Drug Administration for use among and can be administered to persons aged 50 years or older, ACIP recommends PCV13 for adults aged 19 years or older with the specific medical conditions noted above.Pneumococcal polysaccharide (PPSV23) vaccination When PCV13 is also indicated, PCV13 should be given first (see footnote ).Vaccinate all persons with the following indications: All adults aged 65 years or older;Adults younger than 65 years with chronic lung disease (including chronic obstructive pulmonary disease, emphysema, and asthma), chronic cardiovascular diseases, diabetes mellitus, chronic renal failure, nephrotic syndrome, chronic liver disease (including cirrhosis), alcoholism, cochlear implants, cerebrospinal fluid leaks, immunocompromising conditions, and functional or anatomic asplenia (eg, sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia, splenic dysfunction, or splenectomy [if elective splenectomy is planned, vaccinate at least two weeks before surgery]);Residents of nursing homes or long-term care facilities; andAdults who smoke cigarettes.Persons with immunocompromising conditions and other selected conditions are recommended to receive PCV13 and PPSV23 vaccines. See footnote for information on timing of PCV13 and PPSV23 vaccinations.Persons with asymptomatic or symptomatic HIV infection should be vaccinated as soon as possible after their diagnosis.When cancer chemotherapy or other immunosuppressive therapy is being considered, the interval between vaccination and initiation of immunosuppressive therapy should be at least two weeks. Vaccination during chemotherapy or radiation therapy should be avoided.Routine use of PPSV23 vaccine is not recommended for American Indians/Alaska Natives or other persons younger than 65 years unless they have underlying medical conditions that are PPSV23 indications. However, public health authorities may consider recommending PPSV23 for American Indians/Alaska Natives who are living in areas where the risk for invasive pneumococcal disease is increased.When indicated, PPSV23 vaccine should be administered to patients who are uncertain of their vaccination status and have no record of vaccination.Revaccination with PPSV23 One-time revaccination five years after the first dose of PPSV23 is recommended for persons aged 19 through 64 years with chronic renal failure or nephrotic syndrome, functional or anatomic asplenia (eg, sickle cell disease or splenectomy), or immunocompromising conditions.Persons who received one or two doses of PPSV23 before age 65 years for any indication should receive another dose of the vaccine at age 65 years or later if at least five years have passed since their previous dose.No further doses of PPSV23 are needed for persons vaccinated with PPSV23 at or after age 65 years.

27Vacunas en el ViajeroVacunas de RutinaVacuna influenza: En los trpicos Todo el ao,Hemisferio norte y sur solo en el invierno (diciembre a febrero y abril a septiembre) con algunos brotes en verano en cruceros.. Vacuna difteria, ttanos, pertussis: Todos los viajeros estn en riesgo de pertussis, por lo tanto se deben vacunar con una dosis de Tdap todos los adultos entre 19-64 aos, incluso si un booster de Td se administr recientemente. Para aquellos 65 aos deben recibirla si es que estn en contacto cercano con menores de 1 ao. Se debe administrar un booster contra el ttanos cada 10 aos, siendo el primero Tdap y luego Td.Vacuna varicela: Se recomienda para todos aquellos sin inmunidadVacuna trivrica: Los viajeros estn en riesgo de sarampin y paperas. Sarampin adquirido en vuelos internacionales. Los nios que viajan fuera de USA una dosis de esta vacuna previo al calendario habitual (min 6m) 1 ao debe haber recibido las 2 dosis de vacuna trvirica separadas por al menos 28 dias. Lugares por propsitos humanitarios con individuos enfermos: > 1964: 1 dosis< 1964: 2 dosisVacuna poliovirus:La endemia de virus polio salvaje persiste en Pakistan, Afganistan y Nigeria, y se reinfectaron pases como Somalia, Kenya, Etiopia, Siria, Camerun, Africa ecuatoria e Irak. Viajeros a estas zonas deben recibir un esquema completo segn edad. Los adultos deben recibir un booster. Aquellos adultos no vacunados deben recibir un esquema completo con IPV. (0, 4-8 sem, 6-12 meses)CDC. Yellow Book Homepage. http://wwwnc.cdc.gov/travel/page/yellowbook-home-2014Vacunas del ViajeroFiebre Amarilla

1 dosisVacuna viva atenuadaInmunidad:10 dasCDC. Yellow Book Homepage. http://wwwnc.cdc.gov/travel/page/yellowbook-home-2014Vacunas del ViajeroVacuna meningoccica

CDC. Yellow Book Homepage. http://wwwnc.cdc.gov/travel/page/yellowbook-home-2014Vacunas del ViajeroFiebre Tifoidea

CDC. Yellow Book Homepage. http://wwwnc.cdc.gov/travel/page/yellowbook-home-2014Vacunas del viajeroHepatitis A: Endemicidad alta.

CDC. Yellow Book Homepage. http://wwwnc.cdc.gov/travel/page/yellowbook-home-2014Vacunas del ViajeroHepatitis B: intermedia a alta endemicidad

CDC. Yellow Book Homepage. http://wwwnc.cdc.gov/travel/page/yellowbook-home-2014Vacunas del ViajeroOtras.Vacuna del virus de la encefalitis japonesa:Viajes a Taiwan, Japn y China, en particular si se tienen planificadas estadas prolongadas en zonas rurales. En Corea del Sur, Corea del Norte y Hong Kong el riesgo de encefalitis japonesa es ms espordico y slo limitado a ciertas reas rurales. Esta vacuna no est actualmente disponible en Chile.Vacuna anti-rbica pre-exposicin:Recomendada para viajeros a Asia del Este:prevean pasar mucho tiempo en exteriores:particulamiente en reas rurales, y actividades como ciclismo, camping otrekking.Tambin es recomendable para viajeros con significativo riesgo ocupacional (como veterinarios)Viajes muy prolongadosViajes con nios pequeos mayor riesgo de sufrir mordeduras de animales

CDC. Yellow Book Homepage. http://wwwnc.cdc.gov/travel/page/yellowbook-home-2014Vacunas en el Personal de Salud

Tdap indep. de ltima dosis Td

0,1 y 6 mAnti-HBs 2 meses (-) 3 dosis +Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep.2011 Nov 25;60(RR-7):1-45Otras vacunas: VHA, tifoidea y polio estn indicadas en trabajadores expuestos a material fecal.BCG, no tiene indicacin rutinaria. Personal de laboratorio en contacto con bacilo de Koch, y en centros donde se asiste a un elevado nmero de pacientes con tuberculosis multirresistente

35GRACIAS