IC11 Immunization, Malaria, Surgical Prophylaxis

Question 1

List the 14 Vaccines required in NCIS

Answer 1

1. MMR (Measles Mumps Rubella)
2. VAR (Varicella)
3. IPV (Inactivated Poliovirus)
4. Hepatitis B (HepB)
5. Diphtheria, Tetanus, Acellular Pertussis (DTaP)
6. Tetanus, reduced Diphtheria, Acellular Pertussis (TdaP)
7. Bacillus Calmette-Guerin (BCG)
8. Pneumococcal Conjugate (PCV10 or PCV13)
9. Pneumococcal Polysaccharide (PPSV23)
10. Haemophilus Influenzae Type B (Hib)
11. Influenza (INF)
12. Human Papillomavirus (HPV2 or HPV4)

Question 2

Characteristics and Distinctions among live attenuated vaccines and inactivated vaccines (including polysaccharide vaccines, toxoid vaccines and recombinant vaccines)

Answer 2

Live Attenuated Vaccines
- Weakened viruses that replicate in the body
- Efficacy – Stronger immune response + Lifelong immunity
- Safety – Immunocompromised patients should not receive
- Storage – Refrigeration

Inactivated Vaccines
- Present foreign antigens of pathogen but cannot replicate
- Efficacy – Weaker immune response + Require several doses
- Safety – Low risk of adverse reactions / cause disease
- Storage – Easier to store

Question 3

4 Precautions for use of live attenuated vaccines

Answer 3

Pregnancy & Infancy (< 1 year old) ⇒ Possible fetal infections

Severe immunocompromised patients (e.g. HIV CD4 < 200)

28 day period from 1st live vaccine

3-10 month period from administration of Antibody products (Ig, blood transfusion)

Question 4

What is Herd immunity? What is it for? Percentage depends on?

Answer 4

Sufficiently immunized population (%) ⇒ Contain transmission

Protection of both vaccinated and unvaccinated individuals

The extent to which the disease is contagious ⇒ Percentage immunization needed for herd immunity

Question 5

Purpose of Booster doses?

Answer 5

Antibody concentration wanes over time

Question 6

NAIS has everything in NCIS except which 5?

Answer 6

DTaP, BCG, IPV, PCV10, Hib

Question 7

Efficacy of vaccine depends on? (4 points)

Answer 7

Patient response (Varies)

Site of injection (Deltoid vs Gluteal – Depth and amount of muscle)

Age and immune status (80 y.o. Vs 60 y.o.)

Cold Chain problems (Temperature affects quality)

Question 8

List of ADRs of vaccines

Answer 8

Pain, red, swell at injection site; headache, myalgia (Mild, common)

Fever, hematoma (Uncommon)

Anaphylaxis, hypersensitivity (Severe, rare)

Question 9

Contraindications for vaccine use?

Answer 9

1. Allergy
2. Fever > 38
3. Bleeding risk precaution & IM administration
4. Pregnancy (Live vaccine)
5. Immunocompromised (Live vaccine)

Question 10

Are simultaneous vaccine administrations safe? Which vaccines should not be administered together?

Answer 10

All efficacious/safe when simultaneously administered

Exceptions: PCV and Meningococcal conjugate vaccine in Functional or anatomic asplenia ⇒ Should have 4-week interval apart

Question 11

Can live vaccines be administered on the same day?

Answer 11

Live vaccines (IM, SC) CAN BE ADMINISTERED ON SAME DAY, Else ⇒ 28 days apart after the first

Question 12

What happens if you miss a dose of vaccine?

Answer 12

Just take ASAP, additional dose not needed

Question 13

4 Recommended resources to provide advice on preventing infections in travelers

Answer 13

CDC Health Information for International Traveler
CDC Yellow Book
WHO Travel Advice
MFA Travel Restrictions and Requirements

Question 14

Pre-travel consultations should be done _____ weeks before departure

Answer 14

4-6

Question 15

Outline the structured and sequenced approach to address the necessary preventive and educational interventions for medical advice before international travel.

Answer 15

1. Risk Assessment
   - Health background
   - Trip details
2. Standard In-Office Interventions (Pharmacological)
   - Travel Immunizations
   - Malaria Chemoprophylaxis
   - Traveler’s Diarrhea
3. Focused Education before trip (Non-pharmacological)
   - Major routes of transmission
   - Travel-related illness
   - Medical Kit / Insurance
4. Post-travel Advice
   - Malaria Chemoprophylaxis
   - Self-assessment of abnormal symptoms

Question 16

5 Major routes of Transmissions and Vector Borne Diseases?

Answer 16

1. Food and Water Borne Pathogens (Fecal-oral route)
2. Insect Vector Borne Infections
3. Transcutaneous Spread (Contact / Droplet)
4. Respiratory Spread (Airborne / Droplet)
5. Blood and Body Fluids (Sexually transmitted / Needles Sharing)

Question 17

Match the travel vaccines to each route of transmission

Answer 17

1. Food/Water (Fecal oral) - HepA, Typhoid, Cholera, Poliomyelitis
2. Vector borne - Yellow fever, Japanese Encephalitis
3. Transcutaneous spread - Tetanus, Rabies
4. Respiratory - Influenza, Meningococcus, MMR
5. Blood & Body fluids - HepB

Question 18

Which travel vaccines are mandatory in some countries?

Answer 18

Meningococcus and Poliomyelitis vaccines

Question 19

6 inactivated / recombinant viral travel vaccines

Answer 19

Influenza, HepA, Poliomyelitis, Japanese Encephalitis, HepB, Rabies

Question 20

3 live attenuated viral travel vaccines

Answer 20

MMR, Cholera, Yellow fever

Question 21

For last minute travel, at least how long do you need to elicit protective vaccine response before travel?

Answer 21

2 weeks

For urgent travel, accelerated immunization schedules, risk avoidance counseling or drug prophylaxis

Question 22

5 Plasmodium species

Answer 22

Prevalent – P falciparum (Most dangerous), P vivax

P malariae, P ovale, P knowlesi (New)

Question 23

Transmission Mode of malaria

Answer 23

Female Anopheles Mosquito infected by plasmodium

Question 24

Malaria symptoms

Answer 24

Fever, chills, sweats, headache, body aches, weakness, N/V/D

Severe = Sepsis, organ failure, death

Question 25

Occurrence of Malaria is highest in _______ climate and _____ regions?

Answer 25

Tropical and Subtropical Climate Highest in Africa South of Sahara & Oceania (Papua New Guinea)

Question 26

3 Phases of plasmodium life cycle

Answer 26

Liver Phase (Exo-erythrocytic cycle) - Multiply in Liver cells → No symptoms - Dormancy for P vivax, P ovale Blood Phase (Erythrocytic cycle) - Multiply in RBCs and Differentiation (Gametocytes) → Clinical Symptoms Mosquito (Sporogonic cycle)

Question 27

Risk Factors for Malaria

Answer 27

Night biters – Dusk to dawn Less risks in colder season/region Less risks in deserts Risk in urban areas of Africa and India Less risks at high altitudes More risks after rainy season

Question 28

ABCDEs of Malaria Prevention Strategies

Answer 28

• Awareness – of risk, the possibility of delayed onset, and the main symptoms. • Bite prevention – stay away from mosquitoes, especially between dusk and dawn. Use chemical or physical repellents. • Chemoprophylaxis – adhere closely to antimalarial preventive medications when prescribed • Diagnosis – early recognition and seek treatment • Environments – keep off mosquito breeding places, such as swamps or marshy areas, especially in late evenings and at night.

Question 29

Drugs used for malaria chemoprophylaxis?

Answer 29

• Atovaquone + Proguanil (Malarone®) • Chloroquine • Doxycycline • Mefloquine

Question 30

Considerations for choosing an antimalarial chemoprophylaxis

Answer 30

1. Travel itinerary of utmost importance - chloroquine and/or mefloquine resistance in some areas of the world 2. Traveler’s medical history: - Medical conditions like pregnancy, G6PD deficiency, allergies, comorbidities - Medications - check for drug-drug interactions 3. Traveler’s preferences that may affect adherence - Regimen may be taken daily or weekly - Cost consideration 4. Travel departure date and duration - Regimen may need to be started as much as 2 weeks, some the day before

Question 31

Risk and Prevention Types

Answer 31

Non-Falciparum (Type B) – Any 4 drugs Falciparum (Type C) – All EXCEPT Chloroquine

Question 32

Atovaquone 250mg / Proguanil 100mg (Malarone) Dose, Regimen, CI, ADR, DDI

Answer 32

Dosing – 1 tab daily with food or milk Regimen – Start 1-2 days before trip, End 7 days after return Contraindications – Hypersensitivity, Renal (CrCl < 30 ml/min) ADR – Less side effects, N/V/D, stomach pain, headache, dizzy DDI – Rifampicin, Metoclopramide, efavirenz

Question 33

Atovaquone 250mg / Proguanil 100mg (Malarone) should be avoided in ____________________________

Answer 33

pregnancy, lactation, baby < 5kg

Question 34

What category of sales are each malaria agents under?

Answer 34

1. Malarone - POM with exemption 2. Chloroquine & Mefloquine - Pharmacy only 3. Doxycycline - POM

Question 35

Chloroquine Phosphate 250mg (150mg base) Dose, Regimen, CI, ADR, DDI

Answer 35

Dosing – 2 tab weekly with or after meals Regimen – Start 1-2 weeks before trip, End 4 weeks after return Contraindications – Hypersensitivity, Region resistance ADR – N/V, stomach pain, skin rash/itch DDI – QTc prolonging CYP3A4 inhibitors (clarithromycin, voriconazole)

Question 36

Chloroquine should be taken with precaution in

Answer 36

Exacerbate psoriasis, myasthenia gravis, auditory damage, liver impairment, seizure disorders

Question 37

Doxycycline 100mg Dose, Regimen, CI, ADR, DDI

Answer 37

Dosing – 1 capsule daily with full glass of water, 30min upright Regimen – Start 1-2 days before trip, End 4 weeks after return Contraindications – Hypersensitivity, special populations ADR – GI discomfort, sunburn, vaginal candidiasis DDI – Multivalent ions

Question 38

Doxycycline should be avoided in ________

Answer 38

< 8 y.o., pregnancy, lactation

Question 39

Mefloquine 250mg Dose, Regimen, CI, ADR, DDI

Answer 39

Dosing – 1 tablet weekly after meals Regimen – Start 1 week before trip (preferred - 2-3 week), End 4 weeks after return Contraindications – Hypersensitivity, ADR – GI discomfort, dizzy, fatigue, headache, insomnia, vivid dreams, neuropsychiatric disorder DDI – Ketoconazole

Question 40

Non-pharmacological protection examples

Answer 40

Barrier protection – Clothing / Light color clothing / Avoid dusk to dawn / Permethrin Impregnated Bed Net Insect Repellent DEET (Alpine) – 20-50% for 6-12h protection Picaridin (Kiwi) – 20% Oil of Lemon Eucalyptus (OLE) or PMD IR3535 2-undecanone

Question 41

Define surgical site infections (SSIs)

Answer 41

Healthcare-associated Infection Within 30 days after surgical operation or within 1 year for implants left affecting the incision or deep tissue at operation site

Question 42

Indications for SAP

Answer 42

Clean surgery = Healthy skin incised (Sites not usually traversed) only when: 1. Prosthesis or implant will be inserted 2. SSI poses catastrophic risk / Immunocompromised Clean-contaminated surgery = Penetrated under controlled conditions without unusual contamination (Respiratory, alimentary, genitourinary) Contaminated ⇒ Antibiotic treatment not prophylaxis

Question 43

Antibiotic of choice should be ______ spectrum, based on ________________

Answer 43

Narrow spectrum Local resistance pattern, Site with expected pathogen, MDR bacteria and CDAD risks, MRSA Risks, Beta Lactam Allergy

Question 44

For those with MRSA risk, SAP with _______ +/- _______ is suitable

Answer 44

Vancomycin, Cefazolin

Question 45

When to administer antibiotic for surgeries?

Answer 45

30-60 min before surgical incision – Complete infusion 1h before incision for fluoroquinolones and vancomycin – Longer infusion time needed

Question 46

Factors requiring intraoperative redosing

Answer 46

Procedure Duration > 2 half-lives of drug Intraoperative Blood loss > 1500mL Extensive burns

Question 47

Antibiotic duration should be how long?

Answer 47

< 24h (CDAD and AKI risk for > 24h)

Question 48

List non-antimicrobial strategies recommended to reduce the risk of SSI

Answer 48

Hair removal only if it interferes with operation – NO RAZOR, use clipper, depilatory agent Blood glucose control postoperative < 180 mg/dL (10 mmol/L) Postoperative temperature > 35.5oC Postoperative supplemental oxygen Preoperative alcohol-containing skin preparatory agents Plastic wound protectors (GI, biliary surgery) WHO checklist Surveillance Feedback