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Primary Prevention

Prevent the onset or acquisition of a given disease.

Goal: to spare individuals the suffering, burden, and cost associated with the clinical condition.

Primary prevention is the first level of healthcare.


Secondary Prevention

Identify and treat asymptomatic persons who have risk factors for a given disease or in preclinical disease.


Flu symptoms, adults (7)

abrupt onset of signs and symptoms including:





nonproductive cough,

sore throat, and




Flu symptoms, children (10)

Adult symptoms:





nonproductive cough,

sore throat, and



acute otitis media,

nausea and vomiting


Flu symptoms resolve in

The worst symptoms in most uncomplicated cases resolve in about 1 week,

the cough and malaise often persist for 2 or more weeks.


Flu spreads ...

Primarily erson-to-person

Respiratory droplet,

primarily through a cough or sneeze.


Incubation and transmission periods of the flu, adults vs children

In an immunocompetent patient:

- Adults: Short incubation period, with a range of 1 to 4 days (average of 2 days).

- Adults pass the illness on 1 day before the onset of symptoms and continue to remain infectious for approximately 5 days after the onset of the illness.


- Children can shed the virus before the onset of symptoms and remain infectious for 10 or more days after the onset of symptoms.


People who are immunocompromised can remain infectious for up to 3 weeks.


H1N1 aka ...

Swine Flu


H5N1 aka ...

Avian flu


LAIV is ok for ...

Healthy people aged 2 to 49 years.


LAIV no-nos:

Individuals who should not receive LAIV include:

- children younger than 2 years;

- adults older than 49 years;

- patients with a health condition that places them at high risk for complications from influenza, including chronic heart disease, chronic lung disease such as asthma or reactive airways disease, diabetes or kidney failure, and immunosuppression;

- children or adolescents receiving long-term high-dose aspirin therapy; - people with a history of Guillain-Barré syndrome;

- pregnant women; and

- people with a history of allergy to any of the components of LAIV.


Rubella typically causes ...

a relatively mild, 3- to 5-day illness with little risk of complication to the person infected.


Rubella, reason for vaccination...

Prevention of: congenital rubella syndrome


While rubella typically causes mild disease, the effects on the fetus can be devastating. 


Pneumococcal disease ... caused by ... results in ...

Pneumococcal disease,

caused by the gram-positive diplococcus Streptococcus pneumoniae,

results in significant mortality and morbidity.


Differences between Pneumovax and Prevnar

-  Pneumococcal polysaccharide vaccine (Pneumovax®, PPSV23) contains purified polysaccharide from 23 of the most common S. pneumoniae serotypes.


- Pneumococcal conjugate vaccine (Prevnar®, PCV13) contains purified capsular polysaccharide from 13 serotypes of pneumococcus.


- Use of PCV13 is associated with greater immunogenicity when compared with PPSV23, but it does not provide protection against as many pneumococcal serotypes, and is routinely used in childhood.


Purpose of vaccination with pneumococcal vaccines...

the pneumococcal vaccine primarily protects against:

- Invasive disease such as meningitis and septicemia associated with pneumonia and disease caused by S. pneumoniae.


This organism is the leading cause of death from community-acquired pneumonia (CAP) in the United States.


The polysaccharide form (Pneumovac, PPSV 23) protects from approximately 90% of the bacteremic disease associated with the pathogen, whereas the conjugate form (Prevnar, PCV 13) is protective from approximately 70%.


Prevnar 13 (PCV 13) and Pneumovac 23 (PPSV 23) do not protect against ...

Protect against infection with Streptococcus pneumoniae, but not against anything else including:

- Mycoplasma pneumoniae;

- Chlamydophila (formerly Chlamydia) pneumoniae;

- Legionella species;

and gram-negative respiratory pathogens such as:

- Haemophilus influenzae,

- Moraxella catarrhalis, and

- Klebsiella pneumoniae.


Risk of severe, potentially life-threatening adverse reactions to PPSV 23 and PCV 13 is



PCV 13 and PPSV 23 vaccination recommendations:

Based on risk levels:

- Average risk: <65 years of age without any chronic medical conditions; no pneumococcal vaccination is needed.

- Increased risk: those ≥19 years and <65 years, cigarette smokers, or with chronic medical conditions (e.g., diabetes, lung disease, cardiovascular disease, liver disease, or kidney disease [except end-stage kidney disease or nephrotic syndrome]) but without immune compromise. These individuals should receive vaccination with PPSV23 and should be revaccinated with PPSV23 after 5 years.

- Highest risk: those ≥65 years, or with immune compromised conditions, including those due to disease (e.g., malignancy, HIV, end-stage kidney disease), iatrogenic causes (e.g., use of steroids, immunomodulators, transplant recipients), or functional or anatomic asplenia. For those ≥65 years, individuals should receive PCV13 followed by PPSV23 1 year later. For younger adults with high-risk conditions, individuals should receive PCV13 followed by PPSV23 ≥8 weeks later.


HIV and invasive pneumococcal disease prevention....

the risk of pneumococcal infection is up to 100 times greater in people with HIV infection than in other adults of similar age. Once the diagnosis of HIV infection is made, the patient should receive both PCV13 and PPSV23 vaccines as soon as possible:

-  PCV13 is given first, followed by PPSV23 8 weeks later.

- A second dose of PPSV23 should be administered at least 5 years after the initial dose, and

- A third dose should be administered at age 65 years if the person was younger than age 65 years at the time of HIV diagnosis.


Who should be revaccinated and with what ...

- Those between 19 but < 65 at increased risk of serious compliciations.  In other words, cigarette smokers and those having chronic medical conditions (e.g., DM, lung disease, cardiovascular disease, liver disease, kidney disease (except end-stage kidney disease or nephrotic syndrome).  They should receive PPSV 23 and should be re-vaccinated with PPSV 23 after 5 years.

- Those at highest risk, >= 65 or with immune compromised conditions (d/t disease, iatrogenic causes, asplenia):

- Younger adults:  PCV 13, then PPSV23 >= 8 weeks later and repeat the PPSV 23 in 5 years

- Older adults, >= 65:  PCV 13, then PPSV 23 one year later.


Hepatitis B infection is caused by ...

the small double-stranded DNA hepatitis B virus (HBV) that contains an inner core protein of hepatitis B core antigen (HBcAg) and an outer surface of hepatitis B surface antibody (HBsAg).


Hepatitis B transmission...

The virus is usually transmitted through an exchange of:

blood and body fluids, including semen, vaginal secretions, and saliva, via percutaneous and mucosal exposure.


Risk factors for hepatitis B virus (HBV) transmission:

Groups at particular risk for HBV acquisition include:

- Sex partners of people with HBV infection;

- Sexually active persons who are not in a longterm, mutually monogamous relationship (>1 sex partner during the previous 6 months);

- Men who have sex with men;

- Injection drug users; - Household contacts of persons with chronic HBV infection;

- Patients receiving hemodialysis;

- Residents and staff of facilities for people with developmental disabilities;

- Travelers to countries with intermediate or high prevalence of HBV infection;

- Healthcare and public safety workers at risk for occupational exposure to blood or blood-contaminated body fluids, and at particular risk.

- Infants born to mothers with HBV infection .


Hepatitis B prevention ...

- Limit percutaneous and mucosal exposure to blood and body fluids

- Immunization


Hepatitis B Vaccine - recombinant hepatitis B vaccine

- Does not contain live virus

- Well tolerated

- Contraindicated:

h/o anaphylactic rx to baker's yeast


Reason to delay any vaccination

Only in the face of serious or life-threatening illness


Recombinant hepatitis B vaccine is a

3-injection series given with appropriate spacing


Offer Hepatitis vacinnation to:

- Those born before 1982 (year of introduction)

- Healthcare and public safety workers

- Chronic liver disease patients

- HIV patients

- DM patients

- Anyone seeking protection from Hepatitis B


Acute hepatitis B is a serious

illness that can lead to acute hepatic failure, particularly in those with underlying liver disease.


Number of acute hepatitis B patients that develop chronic hepatitis B



Considerations for those wtih chronic hepatitis B

- Appears clinically well, but can transmit the illness.

- Potent risk factor for hematoma developement or primary hepatocellular carcinoma and hepatic cirrhosis.


Infants and HBV 

Pregnancy and HBV

- 40% transmission rate (between moms confirmed with Hepatitis B and their infants.

- ~25% of infected infants with die of chronic liver disease

- Screen all pregnant women for HBsAg at first prenatal visit


 Anaphylactic reactions and what not to vaccinate with:

Anaphylactic Reaction History

Immunizations to Avoid

Neomycin - IPV (polio), MMR, Varicella

Streptomycin, polymyxin B, neomycin - IPV, vaccinia (smallpox)

Baker’s Yeast - Hepatitis B

Gelatin, neomycin - Varicella zoster

Gelatin - MMR


Smallpox is caused by

The variola virus.  


Small pox is a serious, contagious, and sometimes fatal infectious disease.  Variola major is the most common and severe form with a fatality rate of about 30%.


Smallpox is spread by



direct deposit of infective droplets onto the nasal, oral or pharyngeal mucosal membrane or in teh alveoli of the lungs


Direct and faily prolonged face-to-face contact is required.


Smallpox is most contagious

with the onset of rash

and contagion continues until the last smallpox scab falls off.


Incubation period of 7 - 17 days.

Prodromal stage - 2 - 4 days, temperature 101 - 104, malaise, HA, body aches, and sometimes vomiting.


Smallpox rash starts where

Appears first as small red spots on the tongue and in the mouth that develop into open sores that spread large amounts of the virus into the mouth and throat.  Period of highest contagion.


then appears on the skin, starting on the face and spreading to the arms and legs and then to the hands and feet.  Spread generally happens within 24 hours.


Varicella, aka



Varicella-zoster virus (VZV) causes



Varicella-zoster virus, transmission

Chickenpox is transmitted via:

respiratory droplet


contact with open lesions


Varicella presents

with 300 - 500 vesicular lesions, fever, itch, and fatigue.


It can be serious, especially in infants, adults, and immunocompromised patients of any age.


Varicella vaccine

Administered to children on or after their 1st birthday with a booster between ages 4 - 6.


Older children and adults, two immunizaitons, 4 - 8 weeks apart.


Pregnant women without evidence of immunity, 1st dose at completion or termination of the pregnancy.


Varicella vaccine contains

a live, attenuated virus


Vaccines with live attenuated viruses:

1.  MMR 

2. Varicella

3. Zoster (Zostavax)

4. Rotavirus (only given to young infants)


Precautions for use with live attenuated virus vaccinations

1.  Not in pregnant women b/c of theoretical risk of passing virus to unborn child.

2. Immune suppression b/c of risk of becoming ill with virus.

3. HIV - not generally given if CD4 T lymphcyte cell counts are < 200 cell/uL


Tetanus is caused by ... 

an ...

lives in ...

transmitted via

Clostridium tetani

anaerobic, gram-positive, spore forming rod

the soil, particularly if it contains manure

a contaminated wound


Diphtheria is caused by ...

a ...

transmitted from ...

Corynebacterium diphtheriae

gram-negative bacillus

person-to-person via respiratory droplets


Heptatitis A infection is caused by ...

a (type of virus)

spread via

replicates in ...

is excreted in ...

and shed in ...

Hepatitis A virus (HAV)

Small RNA virus

Fecal-oral transmission

the liver

the bile

the stool


HAV immunization is recommended for:

- Travelers to developing nations (and avoid foods generally eaten raw, including fruits and many vegetables)

- Men who have sex with men (MSM)

- Indviduals who reside or travel to areas with the disease is endemic.

- Food handlers

- Sewage workers

- Persons working with HAV-infected primates or with HAV in a laboratory setting

- Day-care workers

- Long-term care residents and employees

- Military and laboratory personnel.

- IV drug users

- Those infected with chronic hepatitis B or C or any chronic liver disease

- Individuals with clotting-factor disorders and are receiving clotting-factor concentrates who've not been previously infected.

- Family members adopting a child from a endemic area.

- Anyone who asks for it.


Polioviruses are ...

and capable of ...

Transmission is via ...

Household contact infection rate is as high as ...

Highly contagious

causing paralytic, life-threatening infection

fecal-oral route




Vaccine-associated paralytic poliomyeltisis


Because of VAPP risk the oral polio vaccine which contains a small amount of weakend virus is no longer used in the U.S.


Prochaska and DiClement change framework called the Stages of Change Model/Trnastheroretical Model (TMM) consides of five stages:

1.  Precontemplation.  No interest in change, unaware the problem exists or minimizes the problem's impact.

2. Contemplation. Considering change, looking at positive and negative aspects.  Can feel "stuck," unable to figure out how to change.

3. Preparation. Some change behaviors or thoughts are seen.  Can feel that s/he doesn't have the tools needed to proceed.

4. Action. Ready to change, has or will take concrete steps to change, but can be inconsistent with follow through.

5. Maintenance/relapse. New healthy habit has been adopted.  Relapse can occur, but patient learns to deal wtih backsliding


Brief intervention used to encourage smoking cessation

5 As:

Ask about tobacco use

Advise to quit

Assess willingness to make a quit attempt

Assist in quit attempt

Arrange follow-up, ideally beginning within the first week after the quit date.


Medications that reduce the desire to smoke:

- Bupropion (Zyban, Wellbutrin)

- Varenicline [var en' i kleen] (Chantix)


Varenicline (var en' I kleen), FDA warnings

Watch for:  depressed mood, agitation, changes in behavior, suicidal ideation, suicide.

Watch in all patients, but in particular in patients iwth anyhistory of psychiatric illness.

Monitor closely for changes in mood and behavior.