VACCINE PREVENTABLE DISEASES (PART 1) CONT'D

Question 1

GUILLAIN-BARRÉ SYNDROME (GBS)

Answer 1

GBS is an illness that affects the nervous system
* rare – general risk is about 10-20 cases per 1,000,000 people
* characterized by loss of reflexes and symmetric paralysis usually beginning in the legs
* results in complete or near complete recovery in most cases
paralysis in the extremities,
you’re watching out for long term is kind of tingling in my fingers, tingling my toes. That’s progressive. It seems to spread any kind of loss of motion
it can result in complete or near-complete
paralysis but it’s generally completely reversible and treatable we use steroids and time.

It is thought that GBS may be triggered by an infection
* The infection that most commonly precedes GBS is the Campylobacter
jejuni bacteria.
* Other respiratory or intestinal illnesses and other triggers may also precede an episode of GBS, including Cytomegalovirus, Epstein-Barr virus and Mycoplasma pneumoniae

Risk of GBS associated with influenza infection greater
than that of immunization

Recommended to NOT provide influenza immunization
to people diagnosed with GBS within 6 weeks of
previous influenza immunization

Question 2

OCULORESPIRATORY SYNDROME (ORS)

Answer 2

• These symptoms were subsequently described as Oculorespiratory Syndrome
  (ORS).
  Case definition of ORS – (onset within 24 hours of immunization)
• onset of bilateral red eyes
  and/or
• respiratory symptoms (cough, wheeze, chest tightness, difficulty breathing,
  difficulty swallowing, hoarseness, or sore throat) with or without facial swelling

Only occurs w flu shots

Question 3

ORS DECISION TREE

Answer 3

how severe were the ORS symtpoms?
mild –> may receive the influenza vaccine
moderte –> may receive the influenza vaccine
severe –> non-lower resp symptoms –> may receive the influenza vaccine
lower resp symptoms –> case should be reviewed by MOH before receiving subsequent influenza vaccine

Question 4

INFLUENZA CONTRAINDICATIONS

Answer 4

TIV/QIV (Inactivated)
- < 6 months of age
- Anaphylactic reaction to previous dose of influenza
- Known hypersensitivity to any component of the vaccine with the
exception of egg
- Diagnosed with Guillain-Barré syndrome within 6 weeks of a previous dose of influenza vaccine
- Experienced severe Oculorespiratory Syndrome (ORS) within 24 hours of receiving after influenza immunization should be assessed further prior to immunizing

LAIV (Live-attenuated)
- < 2 years of age
- Anaphylactic reaction to previous dose of influenza
- Known hypersensitivity to any component of the vaccine
- Immune compromising conditions
- Children with severe asthma (or medically attended wheezing in 7 days prior to vaccination.
- Children/adolescents receiving aspirin

Question 5

EGG ALLERGY AND INFLUENZA VACCINES

Answer 5

Egg allergy - immediate symptoms within 1-2 hours after
exposure, such as urticaria and angioedema, respiratory,
gastrointestinal or cardiovascular symptoms plus
confirmatory allergy tests (skin test or egg-specific IgE).
* Egg allergy is no longer considered a contraindication for
the influenza vaccine
* Egg allergic individuals may be vaccinated against
influenza using TIV/QIV/LAIV, without a prior influenza
vaccine skin test and using the full dose, irrespective of a
past severe reaction to egg
* Flucelvax – Is grown on mammalian cell culture which uses
no egg in its production

Question 6

INFLUENZA
VACCINATION
IN CHILDREN

Answer 6

Children less than 9 who are receiving the
Influenza vaccine for the first time will
receive 2 doses 1 month apart.
* If do not return for a second dose will only
receive one dose next year
* The First dose is considered a priming dose
* Would just mean no protection for that first
year

• Okay. So the next year we’re just going to give them one dose, and they’re going to be protected. All it means is last year, when she got her first dose, her child is either sub optimally or not protected at all.

Question 7

SARS-COV-2

Answer 7

• RNA virus (Coronaviridae family)
• Includes MERS-CoV(MERS), SARS-CoV-1 (SARS)
• Transmission: primarily by droplets spread through coughing, sneezing or talking; lesser degree via contaminated surfaces
• Common symptoms – fever, cough, shortness of breath (additional symptoms
  = include weakness, fatigue, nausea, vomiting, diarrhea, changes to taste and smell)
• Complications include impaired function of the heart, brain, lung, kidney and coagulation system
• Long COVID?
• ~17-35% of hospitalized patients treated in an ICU

Question 8

LONG COVID OR POST COVID CONDITIONS

Answer 8

• Include a wide range of symptoms that can potentially last weeks to years post
  exposure
• Financial burden of these patient sis not yet well understood
• More common in those who had severe COVID
• Some data suggest that those vaccinated who get COVID may be less at risk
• Symptoms
• Fatigue that interferes with daily activities
• Symptoms worsen with physical or mental activity
• Fever
• Cough with shortness of breath
• Chest pain
• Heart palpitations
• Headaches
• Sleep problems
• GI issues
• Joint and muscle pains

Question 9

COVID VARIANTS

Answer 9

• Variants are a concern with ongoing widespread infection.
• Many cases increase the risk of mutation
• Well over 100 new variants were isolated in 2022 alone
• What we watch for are variants that impact:
• Transmissibility
• Immunity to vaccines
• Infection Severity
• WHO divides variants into:
• Variants of concern
• Variants of interest

Question 10

COVID-19
VACCINES

Answer 10

Emerging infectious diseases have stressed the need for
novel development and manufacturing platforms that
can be readily adapted to new pathogens

Vaccine development has focused predominantly on the
viral structural spike (S) protein of SARS-CoV-2
Facilitates entry into the cell and is
located on the surface of the virion
Was identified within weeks of first
identification of cases

Question 11

VACCINE DEVELOPMENT

Answer 11

• Over 242 vaccine candidates are still in development worldwide (as
  of Dec 2 2022)
• 50 vaccines approved for use in a variety of countries
• Variety of different platforms used worldwide
• 1 DNA vaccine
• 19 Protein Subunit
• 9 mRNA
• 11 inactivated
• 9 non replicating viral vector
• 1 virus-like particle
• mRNA most common vaccine used in North America

Question 12

COVID-19
VACCINE
PLATFORMS

Answer 12

classcial platforms
next-generation platfroms

hey’ve got whole and activated vaccines that they use it’s very similar to the original polio vaccine. We have live attenuated vaccines which are similar to the Mmr ones
protein ones, which are very similar to our flu one

Virla vector is newer - basically cold virus, and they suck all the genetic material out of it. They they insert into it the genetic material for sars, and so your body gets infected with the adino virus. But when it does all it does, this ends up producing the spike protein, much like the Mrna vaccine, and you build up protection that way.

Question 13

COVID
VACCINES
IN CANADA

Answer 13

Pfizer-BioNTech mRNA vaccine
*bivalent booster dose (Pfizer-BioNTech
Comirnaty® Original and Omicron
BA.4/BA.5 in individuals age 5 years
and older
*bivalent booster dose (Pfizer-BioNTech
Comirnaty® Original and Omicron BA.1
in individuals age 12 years and older
Moderna mRNA vaccine
primary series in 6 months and
older and 18+ for booster
*Bivalent COVID-19 vaccine
(Original/Omicron BA.4/5)
*Bivalent COVID-19 vaccine
(Original/Omicron B.1.1.529 (BA.1))
AstraZeneca Vaxzevria viral
vector for 18 plus 2 doses
Janssen Jcovden viral vector for
18 plus (note is 1 dose only)
Medicago Covifenz plantbased virus-like particle for 18-
64, 2 doses
Novavax Nuvaxovid Protein
based vaccine 12+ primary
series (2 doses) and 18+ for
booster dose (1 dose)

Question 14

IMMUNOGENICITY

Answer 14

• Neutralizing Ab titers (NtAb) is the most common correlate of
  protection
• Results of monoclonal Ab studies support the strong correlation
  between NtAb and protection from the virus
• Target is the spike protein regardless of vaccine type
• In studies NtAb titers above 160 in convalescent patients
• mRNA vaccines give titers in range of 360-654
• Various other vaccines give titers in the range of 50-300

Question 15

comparison

Answer 15

2 doses of the vaccine are highly productive against the delta variant.

from 2 doses of vaccine it was super effective over 80%, reducing all hospitalizations and hospitalizations related to the Delta virus.

So people who have a shorter interval. So 3 to 4 weeks the vaccine was not necessarily as effective for them. Where, if we go out to people having the vaccine 16 plus weeks apart, was 93% effective.

eople who are at high risk
probably better get them vaccinated really quickly, and get them to doses really quickly, but lower risk people. We might want to stretch it out for low risk ppl

ote is the adverse effects is that they’re like 95% mild to moderate local like most of the side effects from these vaccines are like a flu shot. They’re going to have a reaction at the site. They’re going to have minor fever

Question 16

NACI COVID RECOMMENDATIONS
pregnancy ro breastfeeding

Answer 16

NACI recommends that the COVID-19 vaccine should be offered to
individuals in the authorized age group without contraindications to
the vaccine.
* For moderately to severely immunocompromised adults who have not yet been immunized, it is recommended a primary series of 3 doses of an mRNA vaccine should be preferentially offered. For these individuals who have previously received a 1- or 2-dose COVID-19 vaccine, it is
recommended that an additional dose of an mRNA COVID-19 vaccine
should be offered.

• Pregnancy/Breastfeeding:
• Infection in pregnancy may increase the risk of complications requiring hospitalization and intensive care, as
  well as poorer pregnancy outcomes including premature birth, stillbirth, and caesarean delivery.
• During pregnancy, an mRNA vaccine is preferred due to reassuring published data on the safety of these
  vaccines in pregnancy. However, the protein subunit COVID-19 vaccine or VLP COVID-19 vaccine may be
  offered to individuals in the authorized age group without contraindications to the vaccine who are not able
  or willing to receive an mRNA COVID-19 vaccine.

Question 17

NACI COVID RECOMMENDATIONS cont’d

Answer 17

• NACI recommends COVID-19 vaccine may be offered to
  individuals in the authorized age group without
  contraindications to the vaccine who have had
  previously PCR-confirmed SARS-CoV-2 infection.
• NACI continues to recommend that bivalent Omicron-containing mRNA COVID-19 vaccines are the preferred booster products for the authorized age groups.
• Going forward, any of the bivalent Omicron-containing mRNA boosters are preferred over the original formulation boosters for authorized age groups (18 years of age and older for
  Moderna bivalent vaccines and 12 years of age and older for Pfizer-BioNTech bivalent vaccines).
• NACI recommends that for individuals 6 months of age and older, COVID-19 vaccines may be given concurrently (i.e., same day), or at any time before or after, non-COVID-19 vaccines (including live and non-live vaccines).

Question 18

NACI COVID RECOMMENDATIONS

Answer 18

• NACI recommends that a booster dose of a Pfizer-BioNTech Comirnaty (10 mcg) COVID-19
  vaccine may be offered ≥6 months after completion of a primary series or previous SARSCoV-2 infection to all children 5 to 11 years of age who do not have underlying medical
  conditions that could place them at higher risk of severe illness due to COVID-19.
• NACI recommends that a booster dose of a Pfizer-BioNTech Comirnaty (10 mcg) COVID-19
  vaccine should be offered ≥6 months after completion of a primary COVID-19 vaccine series
  or previous SARS-CoV-2 infection to children 5 to 11 years of age with an underlying
  medical condition that places them at high risk of severe illness due to COVID-19 (including
  those who are immunocompromised and who received a 3-dose primary series).

Question 19

MRNA VACCINE MYTHS

Answer 19

• “The vaccine was developed too fast!”
• mRNA vaccines have been in the works for years. Only the massive funding and urgency allowed them to cut out time between research stages. mRNA vaccines are also much easier to design and roll out than traditional vaccines.
• “mRNA vaccines change your DNA!”
• mRNA is simply a message that your body reads. Your cells produce millions of mRNA
  strands every day. They cannot insert into your DNA and cannot even enter the nucleus.
  *“Pfizer director admits ‘vaccine’ wasn’t tested for transmissibility.”
• Vaccines were not required to test for this when being developed. It would of added
  time to a process that was already under pressure. The focus was on preventing
  illness, hospitalization and death. It only makes sense that if you reduce infection rates transmission will also drop. Some studies in Israel and the UK did show a significant reduction in transmission (>75%)
• “mRNA vaccines have dangerous components”
• mRNA vaccines are free of preservatives. Contain only the mRNA strand
  a phospholipid layer to stabilize and allow absorption and PEG salts and
  sugars to make the solution isotonic. There are no fetal cells or other
  products as the mRNA is produced in an mRNA fabricator.
• “It’s not safe until we have more long-term data!”
• With billions of people vaccinated, many having been vaccinated
  almost a year ago with no issues. The mRNA itself is gone from your
  system 2-6 weeks after injection.

Question 20

HEPATITIS A (HAV)

Answer 20

• RNA virus (Picornaviridae family)
• Transmission: fecal-oral route
• Incubation period: average 28 days
• Cases are infectious 2 weeks before the onset of symptoms until 1 week after onset of
  jaundice
• Severity of illness increases with age (range from asymptomatic to mild illness to severe
  disabling disease lasting several months)
• Children < 6 years commonly asymptomatic
• 25% of adult cases hospitalized
• Case fatality rate ~0.5%
• NOT associated with chronic hepatitis or carrier states
• Natural infection confers immunity
• Infants and children can shed virus for up to 6 months after infection.
• Virus can survive in the environment for extended periods in harsh conditions

Question 21

HAV VACCINE

Answer 21

• Vaccine introduced in 1996
• Available as separate and in combination vaccines
• Inactivated; adsorbed to aluminium hydroxide adjuvant
• Efficacy:
• Immunogenicity – protective concentrations of Ab after 1 dose is 95% to 100% (nearly 100%
  seroconvert after 2 doses)
• Pre-exposure – 90% to 97% effective in preventing clinic HA illness
• Post-exposure –protective efficacy ~80% if used within 1 week of exposure
• Preparations available:
• AVAXIM®(adult) and AVAXIM®–Pediatric
• HAVRIX®1440(adult), HAVRIX®720 Junior
• TWINRIX® and TWINRIX® Junior (adult and pediatric; combined hepatitis A and hepatitis B)
• VAQTA®
• ViVAXIM® (combined typhoid and hepatitis A)
• Route: IM
• Series: 1 dose for primary immunization; booster dose 6 to 36 months later

Question 22

HAV VACCINE
RECOMMENDATIONS

Answer 22

• Recommendations for use:
• Pre-exposure: persons 6 months of age and older at increased risk of infection
  or severe HA
• Example: Travel
• Post-exposure: offered to household and close contacts of proven or
  suspected cases of HA (e.g., group childcare centres, clients of infected food
  handlers)
• Vaccine should preferably be given as soon as possible, and ideally within
  14 days
• Can be considered if > 14 days since last exposure (no data on outer limit
  of efficacy)
• Immunoglobulin recommended for infants < 6 months of age, people for
  who vaccine is contraindicated and if HA vaccine is unavailable

Question 23

HAV PROVINCIAL FUNDING (ALBERTA) FOR PRE-EXPOSURE

Answer 23

Must meet eligibility criteria
* Chronic liver disease (hepatitis B or C carriers)
* Candidates or recipients of liver transplants
* Residents of communities with high rates of hepatitis A infection
* Households or close contact of children adopted from hepatitis A
endemic countries
* Lifestyle risks (MSM, illicit drug use)
* Zookeepers, veterinarians and researchers who handle primates
* Residents and staff of institutions for the developmentally challenge in
which there is evidence of sustained hepatitis A transmission

Question 24

PRE-IMMUNIZATION SEROLOGY FOR ANTIHAV (IGG)

Answer 24

• Considered for:
• Individuals born prior to 1945
• Individuals from an endemic country
• People with history of hepatitis or jaundice that may have been
  caused by HA
• Individuals diagnosed with hepatitis B and/or hepatitis C infection

Question 25

HEPATITIS B (HBV)

Answer 25

• DNA virus (Hepadnaviridiae family)
• Transmission: blood, semen, vaginal fluids
• Initial infection may be asymptomatic (adults 50%, children 90%)
• Individuals who are able to successfully clear the virus in the first 6 months
  (acute infection) become immune
• Risk of chronic infection varies inversely with age (10% of adults; highest risk
  in infants exposed during child birth)
• may develop liver disease or liver cancer
• Worldwide – estimated to be > 300 million HBsAg carriers
• 2018 Carriers: Alberta - 663; Edmonton – 262
• 2018 Acute Cases: Alberta – 20; Edmonton - 12

Question 26

HBV VACCINE

Answer 26

• Vaccine available in 1982 in Canada; school-based programs started in
  1987
• Available as separate and combination vaccines
• Purified HBsAg produced from the genetically engineered yeast strain
• Antigen adsorbed onto aluminum hydroxide
• Efficacy:
• Pre-exposure – 95% to 100% effective in preventing chronic infection (3
  doses of vaccine)
• Post-exposure – highly effective in preventing HBV when given to
  exposed infants, within one week of percutaneous exposure or within 2
  weeks of sexual exposure

Question 27

HBV prep avail

Answer 27

Preparations available:
* ENGERIX®-B (adult) and ENGERIX®-B –Pediatric
* RECOMBIVAX HB®(adult), RECOMBIVAX HB®-Pediatric, RECOMBIVAX HB®-
Adult dialysis
* TWINRIX® and TWINRIX® Junior (adult and pediatric; combined hepatitis A
and hepatitis B)
* Route: IM
* Series: varies
* Recommendations for Use:
* Infants and children: routine immunization (age varies by jurisdiction)
* Adults: all susceptible people who wish to decrease their risk should be
encouraged to be vaccinated (response rate decreases with age and
overall health); publicly funded vaccine for those with increased risk of
exposure or complications

Question 28

INDICATIONS FOR PROVINCIALLY FUNDED
HBV VACCINE (ALBERTA)

Answer 28

• See complete list:
  https://open.alberta.ca/dataset/aip/resource/b697265e072f-4e49-9fc6-c8693a9e7d2a/download/AIP-BP-HepatitisB.pdf
• For those not vaccinated in childhood, provincially funded
  HBV vaccine available for (list is not all-inclusive):
• Adults and children who have immigrated to Canada from areas with high
  prevalence of HBV
• Healthcare workers, occupational risk
• Lifestyle risks (e.g. people who use illicit drugs with blood exposure, MSM,
  multiple sexual partners or STIs)
• Hemophiliacs
• Chronic renal disease or hemodialysis patients
• Household contacts of HBV-carrier
• Sustained a needlestick, percutaneous, or permucosal exposure
• Persons living with HIV

Question 29

HBV PRE-IMMUNIZATION SEROLOGY

Answer 29

Pre-immunization serology
recommended for:
* Individuals with HIV, chronic
liver disease, lifestyle risks
(e.g., high risk sexual
practices, seeking STI
treatment, unprotected sex
with new partners), use illicit
drugs, non-immune adults
who have immigrated to
Canada from endemic
areas
* anti-Hbs, HBsAg, antiHBc

Serology Interpretation
anti-HBs positive**
HBsAg negative
anti-HBc negative
Considered
immune

anti-HBs positive**
HBsAg negative
anti-HBc positive
Considered
immune

anti-HBs negative
HBsAg negative
anti-HBc negative
Susceptible

adults who have immigrated to Canada from an endemic area, because they might not have been exposed in the endemic country.

anti hbs means antibodies to the surface protein
Anti-hbc means antibodies to the core protein
HbsAg means that we’re looking for antigen. So this is surface entity, which means the person has circulating surface antigens.

1st case: 1st one they have antibodies to surface protein, immune, prob vaccinated
2nd case: surface protein pos, core protein pos - prob got hep B and then cleared it to produce antibodies because the core protein is not given in vaccine
3rd case: neither vaccinated nor exposed + recovered = vaccinate this peron

Question 30

HBV BOOSTER DOSES AND REIMMUNIZATION

Answer 30

• After seroconversion, protection appears to persist indefinitely
• Memory cells present, despite undetectable circulating antibody
• Post-immunization serology recommended in specific circumstances
• Timing is important as titers will fall naturally over time serology is usually
  performed within 12 weeks of final dose
• Routine boosters not recommended for immunocompetent individuals
• In some select cases, booster doses may be recommended if anti-HBs titres fall below
  10 IU/L
• Again, time is important. Doing a test 5 years after the last dose that shows <10 does
  not mean a booster is necessary
• Certain groups that are negative for anti-HBs after first series, may qualify for
  second vaccine series (or higher dose Ag vaccine)

Question 31

HUMAN PAPILLOMAVIRUS (HPV)

Answer 31

• DNA virus (double stranded)
• Most common sexually transmitted infection in Canada
• ~75% of Canadians will acquire one or more vaccine HPV types in their
  lifetime
• Usually no symptoms; may cause warts
• Long-term HPV infection can lead to cancer of the cervix, vagina,
  vulva, penis, anus, mouth, and throat
• HPV is the major cause of cervical and vaginal cancer in women
• average of 1,350 cases of cervical cancer diagnosed/year in Canada with 400 deaths
• causes almost all head and neck cancers in males < 40 yrs in Alberta
• > 100 different strains
• Low-risk HPV (non-oncogenic): 6, 11
• High-risk HPV (oncogenic): 16,18

Question 32

HPV VACCINE

Answer 32

• First HPV vaccine approved in 2006 to reduce risk of cervical cancer
• Inactivated, genetically engineered vaccine
• Preparations available: Be aware of differing schedules among these
  vaccines
• Cervarix® (HPV2) – covers HPV types 16 and 18 (not approved for males)
• Gardasil® (HPV4) – covers HPV types 6, 11, 16 and 18
• Gardasil®9 (HPV9) – covers HPV types 6, 11, 16, 18, 31, 33, 45, 52, 58
• Immunogenicity > 99% after 3 doses (similar immunogenicity with 2
  doses in children 9-14 years)
• Route: IM

Question 33

HPV VACCINE RECOMMENDATIONS

School-based immunization (Grade 6) – HPV9 (2
doses)
* Student eligible to receive vaccine in Grade 6
continue to be eligible to receive the vaccine up
to and including 26 years of age
* Males and females up to and including 26 years of
age

Answer 33

• Girls and women:
• 9 to <27 years: HPV2, HPV4, or HPV9
• 27 years of age and older: HPV2, HPV4 or HPV9 may be administered if at
  ongoing risk of exposure (peak risk of HPV is within 5 to 10 years of 1st sexual
  experience, 2nd peak in women 45 years and older)
• Boys and men:
• 9 to <27 years: HPV4 or HPV9
• 27 years of age and older: no data to guide evidence-based
  recommendations; HPV4 or HPV9 may be administered if at ongoing risk of
  exposure
• Men who have sex with men:
• Disproportionately high burden of HPV, particularly types 16 and 18
• HPV4 or HPV9 recommended for men < 27 years
• Although no data in > 27 years, HPV4 or HPV9 should be strongly considered