Immunizations Flashcards
1
Q
What are the goals of immunization programs? (2)
A
- Protect individuals & communities from disease
- Prevent, control and/or eliminate transmission
- e.g. eradication of smallpox
2
Q
What are the 2 Canadian (national) and 1 Saskatchewan vaccine guidelines?
A
Canadian:
1. National Advisory Committee on Immunization (NACI)
2. Canadian Immunization Guide (CIG)
Sask:
1. Saskatchewan Immunization Manual (SIM)
3
Q
Define immunogen/antigen
A
The substance that stimulates or triggers an immune response
4
Q
Define immunoglobulin/antibody
A
Proteins produced in response to antigens which protect the body from disease
5
Q
What is the adaptive immune system?
A
Develops as a result of infection or following immunization
- Defends vs. a specific pathogen
- Immunology memory
6
Q
What is the innate immune system?
A
A physical barrier (skin); does not produce immunologic memory
7
Q
What is herd immunity? (3)
A
- Can be established by adequate vaccination rates
- Required to prevent person-to-person transmission of infectious diseases
- Indirectly protects individuals:
- Unvaccinated/undervaccinated e.g., infants
- Unable to mount a robust immune response to vaccines e.g., immunosuppressed
8
Q
What % of the population needs to be vaccinated to prevent transmission of measles?
A
~95%
9
Q
Vaccines produce an immune response by predominately activating the:
a. Adaptive immune system
b. Circulatory immune system
c. Endocrine immune system
d. Innate immune system
A
a.
10
Q
What does it mean to be a monovalent vaccine?
A
One immunizing antigen vs. one disease e.g., Hep A vaccine
11
Q
What does it mean to be bivalent, trivalent, quadrivalent, etc.?
A
Multiple immunizing antigens vs more than one serotype of the same disease
12
Q
Examples of immunizing antigens vs. more than one vaccine preventable diseases include? (2)
A
- Measeles, mumps, rubella +/- varicella vaccine (MMR or MMRV)
- Diptheria, tetanus, pertussis vaccine (DTap)
13
Q
What is a live (attenuated) vaccine?
A
Whole, weakened bacteria or viruses that replicates, inducing an immunologic response similar to natural infection (but very mild because vaccine strains are attenuated or weakened)
- Long-term immunity
- Immunity obtained in most with one dose (2nd dose given to ensure all are protected)
14
Q
Live (attenuated) vaccines are replicating. Why might that be a problem and for who?
A
Very small risk of infection and contraindicated/caution in immunocompromised patients
15
Q
What is a killed (inactivated) vaccine? (2)
A
- Whole or parts of an inactivated (killed) bacteria or viruses;
toxoids; parts of bacteria or virus obtained via recombinant technology - Boosters required to maintain adequate titres after primary series
16
Q
Killed (inactivated) vaccines are non-replicating. Meaning?
A
Cannot cause disease they are designed to prevent
- Safe for immunocompromised patients
17
Q
What are the 5 replicating (live) vaccines to know? (Meaning if it’s not on this list, then it’s a non-replicating vaccine, so only need to memorize these 5)
A
- MMR
- Varicella
- MMRV
- Rotavirus
- Typhoid (oral)
18
Q
What is actually in a vaccine? (6)
A
- Antigen - infectious agent itself (or piece of it)
- Suspending fluid - e.g., sterile H2O for injection, 0.9% NaCl
- Stabilizers - e.g., gelatin
- Preservatives - e.g., thimerosal
- Antibiotics - prevent bacterial growth e.g., neomycin
- Adjuvants
19
Q
What do adjuvants do? (2) Examples?
A
- Increase immunogenicity or antigenicity
- Prolongs antigen absorption
E.g.,
- Aluminum salts in Adacel, Boostrix, or Gardasil-9
20
Q
What are some factors that affect vaccine response? (7)
A
- Viability of the antigen
- Antigen Dose
- Age
- Immune status
- Route & site of administration
- Timing
- Vaccine Storage
21
Q
A patient asks you why they need SO MANY doses of the COVID-19 vaccine. What advice do you provide?
a. The COVID-19 vaccine is inactivated or “dead,” so multiple doses are required. This is similar to the tetanus vaccine
b. The COVID-19 vaccine is inactivated or “dead,” so multiple doses are required. This is similar to the measles vaccine
c. The COVID-19 vaccine is live, weakened, so multiple doses are required. This is similar to the tetanus vaccine
d. The COVID-19 vaccine is live, weakened, so multiple doses are required. This is similar to the measles vaccine
A
a.
22
Q
What are the 3 ways in which vaccines can be given?
A
- Intramuscular (IM) - most; vaccines with adjuvants
- Subcutaneous (SC) - live vaccines; MMR, varicella, polio (IPV)
- Oral
23
Q
If giving multiple vaccines during the same visit, then how should they be spaced out?
A
- If possible, give in separate anatomic sites (different limbs)
- If not, separate >1 inch
24
Q
How do you give multiple live vaccines?
A
Either have to on the same day or wait at least 4 weeks between live vaccines
e.g., childhood immunizations, MMR, and Varicella vaccines given at the same time
25
Are vaccines interchangeable?
- Most vaccines can be used interchangeably to complete series if the vaccine is not available
- Ideally, complete vaccine series with the same product
26
Which vaccines are not interchangeable?
- Pneumococcal vaccines
- Some meningococcal vaccines
27
True or False? When a vaccine schedule is interrupted, the person must restart the immunization
False - series do not need to be restarted regardless of time between doses
28
You are following up with an adult pt (not immunized in childhood). He was given the MMR vaccine today, but the Varicella vaccine wasn't in stock. When is the earliest he could receive it?
a. 2 weeks
b. 4 weeks
c. 6 weeks
d. 8 weeks
b.
29
There are very few true contraindications to being vaccinated. What are those CIs? (4)
1. Anaphylactic reaction to previous vaccine
2. Anaphylactic reaction to egg (yellow fever or RABAVERT rabies vaccine)
3. **Pregnancy, immunocompromised (live vaccines)**
4. Guillian-Barre syndrome (GBS) <=6 weeks of immunization
30
What are the expected local adverse effects of vaccines? (4)
1. Tenderness
2. Redness
3. Swelling
4. Pain at injection site
31
What are the expected systemic adverse effects of vaccines? (6)
1. Fever
2. Irritability/fussiness
3. Drowsiness
4. Decreased activity
5. Decreased appetite
6. Syncope
32
Do adverse events from a vaccine need to be reported? (2)
Depends:
1. Minor/expected reactions do not need to be reported
2. Serious, rare, or unexpected AEs thought to be caused by a vaccine, yes
33
What are some distraction techniques used to help with pain during vaccination? (5)
1. Deep relaxation breathing
2. Use technology
3. Shift attention
4. Pay attention to another part of your body
5. Rapid fire questsions
34
Specific examples of vaccines associated with more injection site pain are? (3)
Prevnar-20; MMR, HPV vaccines
35
Give most painful vaccine first or last if giving multiple?
Last
36
Numbing creams for vaccine injection pain. Yay or nay?
Yay
37
Acetaminophen to a child following a vaccine (or prophylaxis) to help with pain. Yay or nay?
- Nay - no evidence it helps apparently.
- Concern that antipyretics may reduce immune response
- Can give in first 1-2 days post vaccine if required for fever or pain
38
What are 2 vaccine DIs to be aware of?
1. Immunosuppressants e.g., DMARDs, prednisone >20mg/d x 2 weeks
- Killed - give >=2 weeks before starting therapy, if possible; but safe if given while on therapy
- Live - give >=4 weeks before starting therapy or delay until after treatment is discontinued +/- waiting period
2. Antithrombotics - caution, bleeding risk
39
Describe the process of infection via Corynebacterium diphtheria
Releases toxin --> inhibit cell protein synthesis and membrane formation
40
How is diptheria transmitted?
Respiratory droplets (e.g., sneezing or coughing)
41
What are signs and symptoms of diptheria? (3)
1. Upper respiratory infection - mild fever, sore throat, lymphadenopathy
2. A grayish white membrane appears in the throat within 2 to 3 days
3. Can lead to acute respiratory distress & systemic complications e.g. myocarditis
42
What is the mortality of diptheria?
Unimmunized 5-10%, highest in very young/old individuals
43
How does the diptheria vaccine work? (3)
1. Toxoid vaccine
2. Contains detoxified diphtheria toxin (antigen), so immune system produces antibodies towards the toxin
2. Vaccine protects against effects of the toxin, but not infection/ transmission
44
True or False? Diphteria is only available as a combo vaccine
True
45
Diphtheria is labelled as either D or d. Why?
D = pediatric formulation (higher concentration antigen)
- e.g., DTap-IPV
d = adolescent/adult formulation (reduced concentration antigen)
- e.g., Tdap
46
What is the diptheria vaccine schedule in childhood? (2)
WE GET THIS ON EXAM
ROUTINE IMMUNIZATION
1. SK Primary Series (“D”): 4 doses (2,4,6,18 months), then
2. Booster (“d”): 4-6 years & in Grade 8
47
According to NACI - what is the diptheria booster schedule in adults?
WE GET THIS ON EXAM
Td booster every 10 years (routine)
- Can also get if serious cuts/deep wounds & last tetanus vaccine was more than 5 years ago
- Should receive Tdap x 1 to replace Td booster
48
Diphtheria and pregnancy. What to know?
Should receive Tdap vaccine in EACH pregnancy
49
How is tetanus transmitted? (2)
1. Wound contamination with soil, feces, or dust
2. NOT SPREAD PERSON-TO-PERSON
50
What are the signs and symptoms of tetanus? (2)
Onset 3-21 days
- Painful muscle spasms beginning with jaw muscles (tetanus also known as “lockjaw”)
- Complications: convulsions, respiratory failure
51
What is the mortality of tetanus?
Unimmunized 10-80%, highest in very young/old individuals
52
How does the tetanus vaccine work? (2)
- Toxoid vaccine
- Contains detoxified tetanus toxin (antigen), so immune system produces antibodies towards the toxin
53
True or False? The tetanus vaccine is a standalone vaccine
False - only available as a combo vaccine
e.g., DTap-IPV, Tdap, Td
54
What is the tetanus vaccine schedule in childhood? (2)
WE GET THIS ON EXAM
ROUTINE IMMUNIZATION
1. SK Primary Series: 4 doses (2,4,6,18 months), then
2. Booster: 4-6 years & in Grade 8
55
Accoriding to NACI - what is the tetanus booster schedule in adults?
WE GET THIS ON EXAM
Td booster ever 10 years (routine)
- Can also get if serious cuts/deep wounds & last tetanus vaccine was more than 5 years ago
56
Tetanus vaccine and pregnancy. What to know?
Should receive Tdap vaccine in EACH pregnancy
57
How does Clostridium tetani cause tetanus? (2)
1. Found in the soil and feces
2. Releases a neurotoxin
58
How does Bordetella pertussis cause pertussis?
Produce toxin --> paralyze respiratory cell cilia
59
How is pertussis transmitted? (2)
1. Respiratory droplets (e.g., sneezing or coughing)
2. Close face-to-face contact (highly contagious)
60
When is pertussis (whooping cough btw) most contagious?
Contagious during the catarrhal stage (1-2 weeks) and the first two weeks after cough onset
61
True or False? You can contract pertussis more than once
True, immunity wanes over time
62
Complications of pertussis is seen most in which population? What are the complications (3)?
Most in infants
- Pneumonia
- Seizures
- Encephalopathy
63
Pertussis vaccine is aP or ap. What does that mean?
Only available as acellular preparation in a combination vaccine
aP = pediatric formulation (higher conc)
ap = adolescent/adult formulation (reduced conc)
64
DTaP is intended for children up to age _, while Tdap is a booster for ___________ and ______
6; adolescents and adults
65
What is the pertussis vaccine schedule in childhood? (2)
WE GET THIS ON EXAM
ROUTINE IMMUNIZATION
1. SK Primary Series: 4 doses (2,4,6,18 months), then
2. Booster: 4-6 years & in Grade 8
66
According to NACI - what is the pertussis booster schedule in adults?
WE GET THIS ON EXAM
Td booster every 10 years (routine)
- Can also get if serious cuts/deep wounds & last tetanus vaccine was more than 5 years ago
- Should receive Tdap x 1 to replace Td booster (vaccinate for pertussis once in adulthood)
67
A 20-year old patient asks you the following, "My pregnant sister wants me to get vaccinated for whooping cough. I got all my vaccines in school, but nothing else since. Do I need this?" What advice would you give?
a. No. Family members are not recommended to get vaccinated
b. No. You don't need a booster for whooping cough
c. Yes. Family members are recommended to get vaccinated
d. Yes. You need a whooping cough booster every 10 years
c.
b. is also partially correct - you only need the ONE booster in adulthood
68
A 40-year-old patient is scheduled for a Tdap booster with public health. They ask you the following, "I was vaccinated and had whooping cough as a kid, why do I need this?" What advice would you give?
a. Booster doses are common with these types of vaccines (inactivated)
b. It's recommended that all adults get vaccinated for whooping cough once as an adult
c. Whooping cough immunity wanes over time
d. All of the above
e. None of the above
d.
69
How is polio (IPV) transmitted?
Fecal-oral
70
What are the signs and symptoms of polio? (2)
1. Flu-like symptoms e.g. fever, headache, sore throat, N/V, weakness
2. Can lead to meningitis, limps, post-polio syndrome paralysis
71
What polio vaccine is used in Canada?
Inactivated poliomyelitis vaccine (IPV)
72
Polio vaccine is available as a _____ and _________
combo (Tdap-IPV); individual (IPV IMOVAX Polio)
73
What is the polio vaccine schedule in childhood? (2)
WE GET THIS ON EXAM
ROUTINE IMMUNIZATION IN CHILDREN HERE
1. SK Primary Series: 4 doses (2,4,6,18 months), then
2. Booster age 4-6 years
74
What is the polio vaccine schedule in adults?
There is none. There is no routine booster. Can check the SK Adult Immunization schedule (18+) - booster for those with increased risk of polio exposure e.g., travel to areas with outbreaks
75
A patient was looking at a polio vaccine handout and tells you the following. Please select the statement which is most accurate.
a. Most adults need a polio booster
b. Polio can lead to pneumonia
c. Polio is transmitted through stool of infected individuals
d. Polio is not routinely vaccinated for in children
c.
76
How is Hib transmitted?
Respiratory droplets (e.g., sneezing, coughing)
77
True or False? Haemophilus influenzae type b is the same as the "flu"
False - it's a bacterial infection caused by a bacteria
78
In Canada, who is most infected with Hib?
Children <5 years old
79
What are the signs and symptoms of Hib? (6)
1. Acute otitis media
2. Meningitis
3. Pneumonia
4. Bacteremia
5. Epiglottitis
6. Death rate up to 5% and deafness up to 20% (secondary to meningitis)
80
What are the two types of Hib vaccine?
Available as combo vaccine e.g., DTap-IPV-Hib or
Individually e.g., Hib (Act-HIB brand)
81
What is the Hib vaccine schedule in childhood?
WE GET THIS ON EXAM
SK Primary Series: 3 doses (2, 4, 6 months), then 1 booster (18 months)
82
Adult booster for Hib. Yay or nay?
Nay - no routine booster
83
A father asks you about vaccines for his infant. What advice do you provide about Haemophilus influenzae?
a. Can sometimes lead to acute otitis media infections
b. Transmitted through skin-to-skin contact
c. Mostly commonly affects children 7 years of age or younger
d. Is only administered to individuals at high risk of disease
a.
84
How is rotavirus transmitted?
Fecal-oral route
85
What are the signs and symptoms of rotavirus?
1. Appear 1-3 days after a person has become infected --> fever, vomiting, diarrhea, stomach pain
2. Diarrhea can last from 3-8 days
86
How long is rotavirus contagious?
Contagious - before the individual becomes ill and for 24 hours after diarrhea stops
87
What type of vaccine is the rotavirus vaccine?
Live attenuated oral vaccine
88
Rotavirus vaccine is contraindicated in what population?
Immunosuppressed infants
89
What are the 2 types of rotavirus vaccines available?
Pentavalent (ROTATEQ 3 doses) or monovalent (ROTARIX 2 doses)
90
The pentavalent ROTATEQ (or Rot-5) rotavirus vaccine is the one given in children in SK. What's the schedule?
WE GET THIS ON EXAM
3 doses at 2, 4, 6 months (2 mL po)
91
Can babies eat before or after receiving the rotavirus vaccine?
Babies can breastfeed, eat and drink any time before or after receiving the rotavirus vaccine
92
What happens if an infant spits up or regurgitates the rotavirus vaccine?
If infant spits up or regurgitates, a replacement dose should NOT be administered
93
Rotavirus sheds in stool for up to __ days. Who is cautioned in this situation?
10;
Handwashing; immunocompromised household members should avoid changing diapers for the period
94
What are the common adverse effects of the rotavirus vaccine? (6)
1. Fever
2. Diarrhea
3. Irritability
4. Loss of appetite; some may get flatulence
5. Abdominal pain
6. Dermatitis
95
What is a rare adverse effect of rotavirus vaccine?
Intussusception (bowel obstruction)
96
A mother is wondering about routine childhood immunizations. Which diseases are prevented that are transmitted via the fecal-oral route?
a. Rotavirus, polio
b. Rotavirus, diphtheria
c. Polio, diphtheria
a.
97
A father is wondering about routine childhood immunizations for his 2-month old. He [the dad] has ankylosing spondylitis and is taking infliximab (remicade). What advice would you provide related to rotavirus vaccine?
a. Rotavirus vaccine is contraindicated b/c of paternal immunosuppressive use
b. Rotavirus vaccine can be given as usual with no special precautions
c. Rotavirus vaccine can be given as usual, and he should avoid diaper changes (if able)
c.
98
How is meningococcus transmitted? (3)
1. Respiratory droplets
2. Close contact with respiratory secretions/saliva (kissing, sharing of vapes, lipstick, food/drink, toothbrushes, etc)
3. Risk factors: crowded housing (military barracks, post-secondary residence)
99
What does meningococcus cause? (2) What are the associated complications? (5)
Meningitis & bacteremia
Complications:
1. Limb amputations
2. Hearing loss
3. Brain damage
4. Seizures
5. Skin scarring
100
True or False? Adults get a routine booster for meningococcus
False - no routine booster
101
Men-C-C vaccine is ____valent
mono
102
Men-C-ACWY-135 is ______valent
quadri
103
A parent is wondiering about routine childhood immunizations. Which type of meningococcocal vaccine(s) are typically given?
a. Serogroup ACWY-135 meningococcal vaccine
b. Serogroup B meningococcal vaccine
c. Serogroup C meningococcal vaccine
d. A&B
e. A&C
f. B&C
g. All of the above
e.
104
A parent is wondering about routine childhood immunizations. What type of disease or complication does the meningococcal disease prevent?
a. Pneumonia/myocarditis
b. Pneumonia/seizures
c. Seizures/hearing loss
d. Seizures/lockjaw
c.
105
How is measles transmitted?
Respiratory droplets; highly infectious
106
The leading cause of vaccine-preventable deaths in children worldwide is?
Measles
107
What are the signs and symptoms of measles? (5)
1. Fever
2. Sore throat
3. Cough
4. Runny nose
5. Red rash
108
What are the complications caused by measles? (4)
1. Otitis media and pneumonia
2. Encephalitis
3. Seizures, deafness, or brain damage
4. Death
109
How are mumps transmitted?
Respiratory droplets
110
What are the signs and symptoms of mumps? (3)
1. Fever
2. Respiratory symptoms
3. Parotitis (swelling of parotid gland)
111
What are the complications caused by mumps? (3)
1. Meningitis or encephalitis
2. 3/10 males develop swollen testicles and 1/20 females develop swollen ovaries
3. Congenital malformations or abortion in pregnancy
112
How is rubella transmitted?
Respiratory droplets
113
What are the signs and symptoms of rubella? (4)
1. Rash
2. Lymphadenopathy
3. Arthralgia
4. Fever
114
What problems can rubella cause in pregnancy?
Congenital malformations or miscarriage
- Infection during pregnancy can lead to congenital rubella syndrome in the infant (heart disease, cataracts, deafness)
115
How is varicella transmitted? (3)
1. Respiratory droplets
2. Direct contact with blister fluid
3. Vertical transmission
116
What are the signs and symptoms of varicella? (2)
1. High fever
2. Red itchy rash (begins at scalp and moves towards trunk)
- Rash begins as red spots that become fluid-filled blisters that gradually crust over
117
What complications are caused by varicella? (3)
1. Skin and soft tissue infections
2. Pneumonia
3. Herpes Zoster or Shingles - reactivation of varicella virus
118
What type of vaccine is MMR/MMRV/V vaccines?
Live, attenuated
119
Who is MMR/MMRV/V vaccines contraindicated in?
CI in pregnancy and immunocompromised individuals
- Deferred until 12 months of age (maternal antibodies decline at this point)
120
MMRV contains trace amounts of what?
Neomycin and gelatin - so be cautious in those with severe allergies
121
Efficacy of MMR/MMRV/V vaccines increases with age. Why?
1. Maternal antibodies can decrease live vaccine replication & impact efficacy
2. MMR+/-V is deferred until 12 months of age when maternal antibodies have declined
122
MMR/MMRV routine booster in adults. Yay or nay?
Nay
123
IF an adult needs an MMR or MMRV vaccination b/c not vaccinated as a child, what would they be given?
1. MMRV not indicated in adults, use MMR and V (if required)
2. Varicella (V) vaccine only indicated to 49 years of age
124
What are the common reactions to the MMR vaccine? (4)
1. Soreness
2. Redness and swelling at injection site
3. Mild subclinical infection occurring 1 week after (~5%)
4. Possible joint aches from the rubella component may occur in teenage and adult women
125
What are the adverse effects of the varicella vaccine? (3)
1. Swelling and redness
2. Possible low grade fever
3. A varicella-like rash (blisters) at injection site may develop
126
A patient is inquiring about the vaccination for MMRV. The MMR+/-V is generally contraindicated/not given to individuals...
a. Who are immunocompromised
b. Who are pregnant
c. Who are six months old
d. All of the above
d.
127
What causes herpes zoster?
Viral infection caused by reactivation of varicella zoster virus
128
What are the signs and symptoms of herpes zoster? (2)
1. Prodromal pain can precede the rash by days to weeks in most individuals
2. Maculopapular vesicular rash (painful, itchy) occurring along 1 or 2 dermatomes (usually thoracic) that does not cross the midline (unilateral)
- Usually lasts ~7-10 days
129
What complications are caused by herpes zoster? (4)
1. Disseminated zoster: ophthalmic (10-15%), CNS, pulmonary & hepatic involvement
2. Association with increased risk of cerebrovascular event within ~1 year post herpes zoster infection (?↑ cardiac event)
3. <10% of individuals 65yrs + will be hospitalized
4. Mortality is uncommon
130
What is the herpes zoster vaccine?
SHINGRIX - adjuvanted, recombinant subunit
131
Who is recommended to get the shingles vaccine? (3)
1. Recommended adults 50 years or older
Also recommended if:
2. Previously vaccinated with ZOSTAVAX II
3. Zoster/shingles episode
132
What's the deal with ZOSTAVAX II in Canada?
Discontinued in 2022
133
How well does the shingles vaccine work?
Decreases shingles and post-herpetic neuralgia by A LOT for roughly 9 years
134
What is the Shingrix dosage schedule?
2 doses (0, then 2-6 months)
- For individuals who are or will be immunosuppressed, the second dose can be administered 1-2 months after the first (if required)
135
A patient is inquiring about SHINGRIX. Which statement is accurate?
a. SHINGRIX is indicated in healthy inviduals 50 years of age or older
b. SHINGRIX is indicated in healthy individuals 18 years of age or older
c. SHINGRIX is indicated in immunocompromised individuals 50 years of age or older
d. SHINGRIX is indicated in immunocompromised individuals 18 years of age or older
e. A and D
f. B and C
e.
136
SHINGRIX typically given to older folk, but when might we give it to a young person? (new indication)
Recommended adults 18+ with an immunocompromising disease
137
A patient has questions regarding immunizations for you. Which vaccine preventable disease is NOT transmitted by respiratory droplets?
a. Diphtheria
b. Measles
c. Mumps
d. Polio
d.
138
A patient has questions regarding immunizations for you. Which vaccine preventable disease is NOT routinely vaccinated for in childhood immunizations?
a. Haemophilus influenzae type b
b. Herpes zoster
c. Pertussis
d. Varicella
b.
139
A patient has questions regarding immunizations for you. They received all their childhood immunizations. Which do they require a booster for as part of routine immunizations in adulthood?
a. Tetanus
b. Meningococcal
c. Measles
d. Polio
e. Varicella
a.
140
A patient is getting immunizations for hepatitis and wants to know more about the disease. What education can you provide?
a. Hep A can lead to chronic liver disease
b. Hep B can lead to chronic liver disease
c. Hep A is transmitted via blood or bodily fluids
d. Hep B is transmitted via fecal-oral particles
b.
141
A patient is getting immunizations for hepatitis and wants to know more about the disease. What education can you provide?
a. Hep A vaccination is part of routine childhood immunizations
b. Hep A vaccine is non-routine and offered to individuals at high risk of acquiring the disease
c. Hep B is part of routine childhood immunizations
d. Hep B vaccination is non-routine and offered to individuals at high risk of acquiring the disease
e. A & C
f. A & D
g. B & C
h. B & D
g.
142
A patient is wondering about HPV and immunizations. What advice can you provide about the HPV vaccine?
a. Adults require a routine HPV vaccine booster dose
b. Does not protect against other STIs
c. Is contraindicated in immunosuppressed individuals
d. Only recommended for females
e. Is only indicated in those up to 26 years
b.
143
A patient has questions related to mpox and immunizations. What advice can you provide?
a. Mpox is associated with long term sequelae and high mortality rates
b. Mpox is transmitted only via respiratory droplets
c. The mpox vaccine is contraindicated in those immunocompromised
d. The mpox vaccine is indicated in those at high-risk e.g., MSM with STI in the past year
d.
144
A 67 year old heard about the new "pneumonia" vaccine (prevnar-20, PCV20). They previously received pneumovax-23 (PPSV-23). What advice would you provide?
a. The new "pneumonia" vaccine is interchangeable with pneumovax-23
b. The new "pneumonia" vaccine is not interchangeable with pneumovax-23
c. The new "pneumonia" vaccine provides longer lasting immunity than PPSV-23 because of the way it is formulated (conjugate vaccine)
d. The new "pneumonia" vaccine provides longer lasting immunity than PPSV-23 because of the way it is formulated (polysaccharide vaccine)
e. A & C
f. A & D
g. B & C
h. B & D
g.
145
Name the two Shingrix RCTs that we need to know about and the mean ages associated with both
1. ZOE-70 (mean age ~76)
2. ZOE-50 (mean age ~62)
146
What were the Shingrix RCTs comparing?
Shingrix vaccine vs. placebo
147
What were the outcomes of the Shingrix RCTs? (2)
1. Decreases risk of shingles
2. Decreases risk of postherpetic neuralgia
148
True or False? Once infected with Hep B, the person carries it chronically?
False - most clear infection after 4-8 weeks (although some chronic carriers but it's rare)
149
How is Hep B transmitted?
Blood or bodily fluids containing HB virus
e.g., sharing injection drug equipment, sexual contact, vertical transmission
150
What are the signs and symptoms of Hep B? (6)
1. Asymptomatic in up to 50% of adults and 90% of children
2. Fatigue
3. Fever
4. N/V
5. Decreased appetite
6. Jaundice
151
What is the Hep B vaccine schedule in childhood? (2)
WE GET THIS ON EXAM
1. SK Primary Series: 2 doses in Grade 6 (0 months, 6 months)
152
Name the adult formulations of the Hep B vaccine (2)
1. ENGERIX-B
2. RECOMBIVAX HB
153
True or False. No booster vaccine is required for Hep B
True
- EXCEPTION - potentially some special populations based on serology (e.g., dialysis)
154
What does this serology tell us?
HBsAg: negative
anti-HBc: negative
anti-HBs: negative
Susceptible to Hep B
155
What does this serology tell us?
HBsAg: negative
anti-HBc: negative
anti-HBs: positive with >=10 IU/L
Immune from vaccination
156
What does this serology tell us?
HBsAg: negative
anti-HBc: positive
anti-HBs: positive
Immune from infection
157
True or False? If a [healthy] patient's anti-Hbs falls <10 IU/L then they need to get re-vaccinated for Hep B
False - if the patient is otherwise healthy; if received appropriate immunizations series, then they are considered immune/protected for life even if anti-HBs (HB surface antibody) drop <10 over time because immune memory to HB persists
- ANOTHER HB VACCINE DOSE IS NOT REQUIRED
158
When might someone be re-vaccinated for Hep B?
Some special populations (immunocompromised, CKD, etc.)
- If anti-Hbs <10, give another dose and repeat serology
159
How is Hep A trasmitted?
Fecal-oral
- Contaminated food, water, drinks, etc.
- HA virus can remain infectious in the environment for several weeks
160
What are the signs and symptoms of Hep A? (7)
1. Asymptomatic (younger)
Adolescents/adults have the following:
2. Anorexia
3. Nausea
4. Fatigue
5. Fever
6. Jaundice
7. Rarely death
161
Hep A vs. Hep B: Which CAN lead to chronic hepatitis/liver disease?
Hep B only
162
Hep B vaccine. Combo or monovalent?
Comes in both forms
163
Hep A vaccine. Combo or monovalent?
Comes in both forms
164
Hep A routine in childhood?
No, but recommended for people at risk of infection
165
If giving Hep A vaccine. How many doses?
2 doses at 0 and 6 months (interval, not age)
166
What is the Hep A and B combo vaccine called?
TWINRIX (HAHB)
167
When might HAHB vaccine (TWINRIX) be used?
If someone requires Hep A for travel and unsure if they've received Hep B series/no Hep B series documented
- Otherwise it is not routinely given in childhood vaccines and not publicly funded
168
True or False? Hep A vaccine is not publicly funded
True and False - normally not publicly funded BUT if person is high-risk then it is
169
How is HPV transmitted? (2)
1. Sexually by skin-to-skin contact (or mucosa contact)
2. Vertically
170
True or False? HPV is the most common STI
True
171
What are the signs and symptoms of HPV? (3)
1. Most infections are asymptomatic & and are eventually cleared by the immune system within 24 months
2. Some develop genital warts (HPV types 6, 11, others)
3. Some develop cancer
172
What are the 2 HPV vaccine formulations?
1. HPV-9 (GARDASIL-9) - 9 types covered obvs
2. HPV-2 (CERVARIX ) - only approved in females and not commonly used
173
What should the patient be educated on when giving the HPV vaccine?
More painful b/c adjuvanted - may give after other vaccines
174
At the moment, Sask is following the old dosing regimen for HPV vaccine. Which is?
Routine in childhood
GARDASIL-9 x 2 doses (0, 6 months) given in Grade 6
175
In what 2 scenarios is HPV vaccine publicly funded? (after childhood I guess?)
1. Individuals born female since Jan 1, 1996, up to and including 26 years old
2. Individuals born male since Jan 1, 2006 up to and including 26 years old
176
When is HPV vaccine most effective to give? Why?
HPV vaccine is most effective when given at a younger age, before exposure to HPV.
- HPV vaccine after onset of sexual activity is recommended because unlikely vaccine recipient has been infected with all HPV types in the vaccine
- Still indicated in women with abnormal pap test, cervical cancer or genital warts
177
A 24 year old woman is being seen for routine health care. She has not received any vaccinations against HPV. The patient initiated sexual activity at 18 years of age and has had three male sex partners. What would you recommend regarding HPV vaccination?
Go get it.
2 doses
178
NACI HPV vaccine guidelines differ to Saskatchewan's. How many doses do the following populations get:
9-20 years
21-26
>=27
9-20 = 1 dose of HPV vaccine (previous recommendation was 2 doses)
21-26 = 2 doses of HPV vaccine (previous recommendation was 3 doses)
>=27 = 2 doses of HPV vaccine using SDM (previous recommendation was 3 doses)
179
What does NACI say about giving the HPV vaccine in pregnancy?
May be offered (previous recommendation was to delay until post-pregnancy)
180
How many doses, according to NACI, of the HPV vaccine would a >=9 year old, immunocompromised, or HIV get?
3 (0, 2, 6 months)
181
How is mpox transmitted? (4)
1. Skin to skin contact
- Transmission NOT prevented by condoms
2. Respiratory droplets (close, sustained face-to-face contact)
3. Animal to humans (e.g., bites from rodents (Africa))
4. Low risk transmission: shared contaminated objects e.g., doorknobs, bed linens
182
What are the signs and symptoms of mpox? (6)
Systemic illness:
1. Fever
2. Chills
3. Headache
4. Myalgias
5. Rash (pimple-like/blisters, look similar to shingles but larger)
Atypical (2022 outbreak):
6. Oral, genital, and anal lesions without systemic illness
183
How long is mpox contagious?
~2-4 weeks (until all lesion scabs have fallen off)
184
True or False? The smallpox vaccine can be used for mpox
True - mpox virus is an orthopoxvirus that is in the same genus as variola and vaccinia viruses
185
What type of vaccine is the smallpox/mpox vaccine?
Live-attenuated, non-replicating virus (no risk of developing infection or transmission to others)
186
Who should get the smallpox/mpox vaccine?
>= 18 years at high risk for exposure
187
True or False? Gay people are at higher risk of mpox
False - "Being transgender or gender-diverse might be a risk factor, but only along with other high-risk behaviour, such as multiple sexual partners or anonymous sex. Mere identity as gay, bisexual, or gender nonconforming is not itself a risk factor, and a monogamous relationship with such a person is not considered high risk."
188
Name the mpox vaccine
IMVAMUNE
189
What is the mpox vaccine schedule?
1. PrEP: IMVAMUNE 2 doses (0.5 mL) subcut given 1 month apart (0, 1 month)
- Potential booster after 2 years
2. PEP: IMVAMUNE 1 dose ≤4 day (up to 14 days) since last exposure
- Consider 2nd dose in 1 month if ongoing exposure
190
How is pneumococcal transmitted? (2)
1. Respiratory droplets; direct oral contact or indirect contact with infectious oral secretions
2. Children <5 years in daycare have 2-3x increased risk pneumococcal disease compared to those who do not
191
What are the signs and symptoms of pneumococcal? (5)
1. Sinusitis,
2. Acute otitis media,
3. Pneumonia
4. Invasive pneumococcal disease (infection in a normally sterile site): bacteremia, meningitis
4. Mortality: increased risk IPD risk factors older adults e.g. >10% case fatality in those ≥65yrs who develop IPD
192
True or False? The pneumococcal vaccines are interchangeable
False
193
Why are there so many pneumococcal vaccines anyways?
The most common serotypes that cause disease vary across different populations and tend to change over time
194
What are the two types of pneumococcal vaccines? Which one are the newer vaccines atm?
Conjugate and polysaccharide
Newer vaccines are conjugate (although PNEUMOVAX-23 is polysaccharide but no longer stocked by public health)
195
What makes a conjugate vaccine different from a polysaccharide vaccine? (5)
Conjugate vaccine (compared to polysaccharide)
- Longer lasting immune (create long-term memory cells)
- More robust immune response – involve B & T cells
--Polysaccharide – “T cell independent”
---Infants – respond well to T-cell dependent antigens; do not respond well to T cell independent antigens e.g. previous, when pneumovax23 was used in infants at high risk of IPV, waited until 2 years of age
196
What is the pneumococcal routine adult schedule (NACI)?
WE HAVE ON EXAM (mostly)
>=65 years (& otherwise healthy), regardless of pneumococcal vaccination history with PREVNAR-13 PCV13, VAXNEUVANCE PCV15, or PNEUMOVAX-23 PPSV23 (wait ≥1 year from last pneumococcal dose)
- PREVNAR-20 (PCV20) 0.5mL IM x 1 dose
OR
- CAPVAXIVE (PCV21) 0.5mL IM x 1 dose
197
True or False? Pneumococcal vaccines are administered all at the same time
False - needs to be an interval between them (but don't worry about the specific times)
198
A patient calls you about an adverse event following vaccination one week ago. Which of the following potential AREXVY adverse events would require filling out an AEFI (adverse event following immunization)?
a. Myalgia
b. Atrial fibrillation
c. Headache
d. Lethargy
b.
199
You initiate a conversation regarding AREXVY (RSV vaccine) with a 65 year old patient. Which of the following is NOT a condition that increases risk of serious disease from RSV applicable to your patient?
a. CKD
b. COPD
c. Diabetes
d. Pregnancy
d.
200
A patient is asking you about the new COVID-19 vaccine and why they need to keep getting more doses. What advice do you provide?
a. The COVID-19 vaccine is a live vaccine so multiple doses are required
b. The COVID-19 vaccine is an inactivated vaccine so mutliple doses are required
c. The COVID-19 vaccine is updated to reflect current circulating COVID-19 strains
d. The COVID-19 vaccine is update to reflect ancestral circulating COVID-19 strains
e. A & C
f. A & D
g. B & C
h. B & D
g.
201
A 22 year old patient is unsure of their vaccination history and tell you their parents did not believe in the benefits of vaccines. What advice would you provide?
a. A blood test is necessary to see which vaccines they would need
b. They can go ahead and receive all the routine childhood vaccines they missed
c. They can go ahead and receive the vaccines given in childhood appropriate for adults
c.
202
A patient who is pregnant comes into your pharmacy and inquires about vaccinations. Which of the following diseases does she require vaccination for?
a. Pertussis
b. Pneumococcal
c. Polio
a.
203
What is the vaccine schedule for people with increased risk of IPD? What should they be getting?
≥18 years & medical or environmental IPD risk factors
(regardless of pneumococcal vaccination history with PREVNAR-13 PCV13, VAXNEUVANCE PCV15, or PNEUMOVAX-23 PPSV23):
- PREVNAR-20 (PCV20) 0.5mL IM x 1 dose
OR
- CAPVAXIVE (PCV21) 0.5mL IM x 1 dose
204
What are 3 categories of risk factors when it comes to age-based risk factor eligibility for Pneu-C-20 immunization? (age 6 weeks through 64 years at presentation) (eligible for public funding that is)
1. Chronic medical condition
2. Immunocompromised
3. Special populations
205
What are 6 special population groups that can/should get the Pneu-C-20 vaccine through age 6 months to 64 years? (Meaning, eligible for public funding)
1. Homeless
2. LTC facility - resident
3. Substance use - illicit non-injection drug use
4. Substance use - injection drug use (including steroids)
5. Personal care home resident
6. Resident in a group home
206
At what age does the proportion of people eligible for public funding of Pneu-C-20 decrease?
65+
207
How is RSV transmitted?
Respiratory droplets
208
What are the signs of RSV? (3)
1. URTI - mild, cold-like symptoms e.g. sore throat, cough, headache, nasal congestion, etc
2. Lower lung infections e.g. bronchiolitis and pneumonia
3. Severe - requiring oxygen and hospitalization/ICU
- Leading cause of hospitalization in infants (US)
209
What are the 2 RSV vaccines approved by NACI?
1. AREXVY
2. ABRYSVO
210
Of the 2 RSV vaccines in Canada, which one is adjuvanted?
AREXVY
211
Of the 2 RSV vaccines which are monovalent and which are bivalent?
1. AREXVY = monovalent
2. ABRYSVO = bivalent
212
Who are the 2 RSV vaccines indicated in? (3)
1. Everyone >= 75 years (esp those at increased risk of severe RSV)
2. 60-74 years long term care residents
3. 60-74 years who are at increased risk of severe RSV
213
Of the 2 RSV vaccines, which one can be used in pregnancy?
ABRYSVO (32-36 weeks - for better passive immunity to infant)
214
What was the population of the RSV vaccine study?
Medically stable 60+ who lived in community or long-term care
215
What was the intervention of the RSV vaccine study?
The vaccines, AREXVY and ABRYSVO
216
What was the comparator of the RSV vaccine study?
Placebo (therefore cannot say if one vaccine is better than the other b/c weren't studied against each other)
217
What was the outcome of the RSV vaccine study?
Lower rates of RSV related lower respiratory tract infections
218
What are 2 potential side effects of the RSV vaccination that has ongoing assessment at the moment?
1. Guillian Barre Syndrome
2. Atrial fibrillation
219
How are adverse events from vaccinations reported? Are all adverse effects reported?
1. Public Health Agency of Canada collects case reports
- Part of post-marketing safety surveillance --> ensure safety
- Data is stored in the Canadian Adverse Events Following Immunizations (CAEFI) database & used to signal AEs that require more investigations
2. Minor/expected reactions do not need to be reported
3. Serious, rare, or unexpected AEs thought to be caused by a vaccine:
- Complete a Report of Adverse Event Following Immunization (AEFI) form
220
How is COVID-19 transmitted?
Respiratory droplets
221
What are the signs and symptoms of COVID-19 (5)
Mild:
1. Sore throat
2. Cough
3. Headache
Severe:
4. Requiring oxygen
5. Hospitalization/ICU
222
What are the 2 COVID-19 vaccines?
1. COMIRNATY (Pfizer)
2. SPIKEVAX (Moderna)
223
The Canadian Immunization Guide (CIG) suggests anyone can receive a 2024-2025 COVID-19 vaccine, but the vaccine is recommended in the following populations: (3)
1. Individuals >= 65 years of age
2. Individuals >= 6 months of age who:
- Are residents of long-term care (LTC) homes
- Have underlying medical conditions that increase their risk of severe COVID-19
224
If an individuals already had a COVID-19 infection, how long until they can get the vaccine?
3-6 months
225
How long should you wait between COVID-19 vaccines?
For previously immunized individuals, the recommended period to wait is 6 months from the last COVID-19 vaccine dose. A minimum waiting period of 3 months may be considered for those at increased risk for severe disease
226
What should be done with your vaccines pre-pregnancy? (3)
1. Update as required
2. Serology may be done
- e.g. hepatitis B, rubella, varicella
3. Delay conception for 1 month after administration of live vaccine e.g. MMR, varicella
- Live, attenuated vaccines pose a ”theoretical” risk to the developing fetus and are generally contraindicated during pregnancy
227
Which trimester do we prefer to vaccinate for pertussis (Tdap)?
Third b/c maternal antibody transfer is highest here
228
What trimester do we give flu shot in?
Any is fine, as long as it's an inactivated influenza vaccine
(Attenuated vaccine is contraindicated in pregnancy)
229
What trimester do we give COVID-19 vaccine in?
Any trimester seems to be fine. mRNA vaccine preferred due to safety data
230
What trimester do we give RSV vaccine in?
32-36 weeks (third trimesterish)
Use bivalent ABRYSVO vaccine (no adjuvant btw)
231
There are a few instances when vaccination is not recommended during breastfeeding. When might that be? (2)
1. Mpox vaccine IMVAMUME - limited data, risk assessment using SDM
2. Some travel vaccines e.g., yellow fever
232
What series of shots is recommended for substance users (special population. Can be illicit non-injection drug, or injection drug use)? (8)
1. HA
2. HB
3. Pneu-C-20
4. Influenza
5. COVID-19
6. NACI - Td q10 years, Tdap once adulthood
7. HZV (Shingrix)?
8. RSV?
233
What series of shots is recommended for MSM (special population)? (8)
1. HA
2. HB
3. Mpox
4. Influenza
5. COVID-19
6. NACI - Td q10 years, Tdap once adulthood
7. HZV (Shingrix)?
8. RSV?
234
What are some chronic medical conditions where additional vaccination would be required? (5)
1. Cardiac disease
2. Diabetes mellitus
3. Lung disease
4. Liver disease
5. Renal disease
