Vaccines / Travel Flashcards
(73 cards)
1
Q
What are vaccine resources and information for patients and providers?
A
- FDA: approves indication
- Advisory Committee on Immunization Practices (ACIP): recomendations for vaccine administration
-May differ from the FDA - CDC: approves ACIP’s recommendations and publishes Morbidity and Mortality Weekly Report (MMWR and The Pink Book (epidemiology and prevention of vaccine-preventable diseases)
- Immunize.org: provides vaccine info and education for HCPs
- Vaccine Information Statements (VIS): prepared by CDC for pt info on benefits and risks (federal law requires this to be handed to pt before administration)
2
Q
Vaccine Types: Live Attenuated vs. Inactivated
-List live vaccines
A
Live attenuated: weakened (attenuated) via modifying a disease-producing (wild) virus or bacterium with ability to replicate and produce immunity, but usually will not cause illness (strong immune response, but CI: immunocompromised, pregnancy)
-COZY IV RM –> Cholera, Oral Typhoid, Zoster (Zostavax), Yellow Yever, Intranasal Influenza, Varicella, Rotavirus, MMR
Inactivated: either killed whole virus or bacterium or fractions (immunity can diminish w/ time and supplemental doses may be needed)
3
Q
Types of Inactivated Vaccines and Provide Examples: mRNA, toxoid, recombinant, polysaccharide, and conjugate
A
mRNA: vaccine gives instructions to bdoy’s cells in form of mRNA to produce protein specific to prathogen (ex. COVID-19 vaccines)
Toxoid: vaccine targets a toxin produced by disease (ex. tetanus)
Recombinant: gene segment of protein from organism is inserted into gene of another cell (ex. yeast cell) where it replicates (ex. HHP - Gardasil 9, recombinant influenza - Flublock Quadrivalent)
Polysaccharide: sugar molecules taken from outside layer of encapsulated bacteria (do NOT produce a good repsonse in children <2 yo) - ex. Pneumovax 23
Conjugate: uses polysaccharide (sugar) molecules from outside layer of encapsulated bacteria and join molecules to carrier proteins (conjugation increases immune response in infants) - ex. Prevnar 20, Menveo
4
Q
Timing of Vaccines:
1. Can vaccines be given simultaneously?
- Does increasing the interval between doses of vaccines diminish effectiveness?
- The minimum interval between an antibody-containing product and a MMR vaccine is __________ and can be up to ______ depending on the product OR give MMR ________ time before antibody-containing product.
A
- Most live and inactivated vaccines can be administered simultaneously on the same day or same visit
-Live vaccines can be given on same day, but IF NOT then space 4 weeks apart - No, but it delays complete protection and can interfere with antibody response
-do NOT shorten interval (inadequate antibody response) - 3 months; 11 months; 2 weeks
5
Q
Timing of Vaccines
1. Why are most LIVE vaccines held until a child is 12 months of age?
- What is the issue with tuiberculin skin tests (TSTs) and live vaccines? What can be done to resolve this?
- When are antibody products recommended to give simulataneously to vaccines?
A
- Maternal antibodies reduce infant’s response to vaccines (exception: rotavarius - shown to be effective despite prescence of maternal antibodies) –> inactivated vaccines given at 2 months or older except HepB
- Live vaccines can give false negative TST results. Reduce risk by
-Giving live vaccine on same day as TST (antibodies won’t form quick enough)
-Waiting 4 weeks after live vaccine to perform TST
-Administer TST first and wait at least 24 hours after reading test to give live vaccine. - Postexposure prophylaxis of certain diseases (ex. hepatitis A and B, rabies, and tetanus)
6
Q
Vaccine Adverse Reactions:
1. Patients should be screened for precautions and CIs pior to vaccine administration and then monitored for at least _____ minutes post vaccination. If an adverse event occurs, it should be reported to _________ and __________.
- Define: local vs. systemic reactions
- Allergic reaction management
A
- 15 minutes; pt’s HCP; FDA’s Vaccine Adverse Event Reporting System (VAERS)
2.
-Local rxns: common reactions that occur near injection site (pain, swelling, redness)
-Systemic rxns: fever, maliase, myalgia, HA, loss of appetite, or mild ilness similar to disease being prevented (live vaccines: mild systemic rxns can occur 3-21 days after; intranasal flu vaccine can replicated cold-like symptoms)
3.
-Record all vital signs and administered medications
-Minor allergic rxn (swelling, pruritus): diphenhydramine, hydroxyzine
-Major allergic rxn (swelling of mouth/throat, difficulty breathing, wheezing, abdominal cramping, hypotension/shock): aqueous epinephrine 1mg/ML (1:1000 dilution) IM or 0.01mg/kg (max dose: 0.5mg) –> pharmacies should have at least three adult (0.3mg) auto-injectors administered Q5-15 minutes, call 911
-Place pt in supine position (flat on back) unless difficulty breathing (can elevate heard); if low BP, elevate legs only
7
Q
CIs and Precautions to ALL vaccines
A
CIs: severe allergic rxn to vaccine or vaccine component after previous dose
Precautions: illness (mild: give vaccine and CAN when pt receiving ABXs; moderate/severe: delay vaccine until improvement)
8
Q
CIs and Precautions to Live Vaccines
A
-CIs: pregnancy (do NOT attempt to become pregnant until 4 weeks after receiving vaccine), immunosuppression
-Precautions: recent administration of antibody-containing blood product
9
Q
CI and Precautions to Diphtheria, tetanus, and pertusis vaccines
A
-CIs (pertussis-containing vaccines): encephalopathy that is NOT attributable to another cause within 7 days after receving a previous pertussis-containing vaccine
-Preacuations: guillain-barre syndrome (GBS) within 6 weeks of previous diphtheria, tetanus, and pertussis vaccine (for DTaP and Tdap only: infantile spasms, uncontrolled seizures)
10
Q
CI to HepB / HPV Vaccines
A
hypersensitivity to yeast
11
Q
CIs to Live Attenuated Influenza Vaccines (LAIV4)
A
- Pregnant
- Immunosuppressed
- Use of ASA-containing products (children and adolescents)
- Recent use of influenza antiviral medications (oseltamivir and zanamivir within past 48 hours, permaivir within 5 days, or baloxavir within last 17 days)
- Children age 2-4 yo w/ asthma or wheezing episode in past 12 months
- Close contact w/ immunocompromised person
12
Q
Precautions to Influenza Vaccines
A
-ALL: hx of guillain-barre syndrome (GBS) within 6 weeks of previous influenza vaccination
-LAIV4: asthma in any pt >/= 5yo, underlying conditions that predispose to influenza complications (ex. chronic lung, heart, renal, hepatic, neurologic, hematologic, and metabolic disorders including DM)
13
Q
Precautions to RSV Vaccine
A
pregnancy and breastfeeding - consider delaying vaccine
14
Q
CIs and Precautions to Varicella Vaccine
A
-CIs: hx of severe allergic rxn to gelatin or neomycin
-Precaution: use of acyclovir, famiciclovir, or valacyclovir in past 24 hours before vaccination - avoid antivirals after 14 days of vaccination
15
Q
CIs and Precautions to Rotavirus Vaccine
A
-Cis: hx of intussusception (part of intestine slides into adjacent intestine part, blocking fluids/food)
-Precautions: chronic GI disease
16
Q
CI to Yellow Fever Vaccine
A
severe allergic rxn to eggs
17
Q
What is a consideration of latex allergies with vaccines?
A
Latex on vial stoppers or prefilled syringes (CI): latex allergy that results in severe rxns (most sensitivities do NOT prohibit vaccine administration)
18
Q
Recommended vaccinations/schedules for: Infants and Children
A
At birth: 3-dose hepatitis B, RSV (if mother NOT vaccinated during pregnancy)
Started at 2 months: PCV15 or PCV20, DTaP, Hib, polio, rotavirus
Start at 12 months or older: live vaccines
Polysaccharide vaccines: NONE before age 2 yo
19
Q
Recommended vaccinations/schedules for: Adolescents and Young Adults
A
Tdap: first dose at 11-12 yo
HPV: recommended at age 11-12 yo, 2-3 doses depending on age at start
Meningococcal quadrivalent vaccine (MenACWY) - Menveo or MenQuadfi
-2 dsoes: 1 dose at age 11-12 yo and 1 dose at 16 yo
-First-year college students in residential housing (if NOT previously vaccinated): 1 dose
20
Q
Recommended vaccinations/schedules for: Healthcare Providers
A
- Annual influenza vaccine - often required by employers
- HepB, varicella, and MMR - if NO demonstrated immunity (via vaccination hx or blood test)
21
Q
Recommended vaccinations/schedules for: Sickle cell disease and other causes of asplenia
A
- H. influenzae type b (Hib) vaccine
- Age 19-64 yo: Pneumococcal either PCV20 x1 OR PCV15 then PPSV23 8 weeks later
- MenACWY and MenB
22
Q
Recommended Vaccinations in Immunodeficiency
-Who counts as immunodeficient?
A
- Age 19-64 yo: PCV20 x1 OR PCV15 then PPSV23 8 weeks later
- Age 19 yo and older: Shingrix 2 doses 2-6 months apart
- HIV:
-MenACWY
-Hepatitis A and B
-Hib?
Immunodeficiency:
-Chemotherapy/bone marrow transplants drugs
-Strong immunosuppressant drugs for autoimmune conditions or cancer
-HIV w/ CD4 count <200cells/mm3 (AIDS)
-Transplant pts taking immunosuppressant drugs
-Systemic steroids >/=14 days (does NOT include inhaled, topicals, or intrarticular) at >/=20mg or 2mg/kg predinisone daily or equivalent
23
Q
Recommended Vaccines in Pregnancy
A
- Inactivated influenza vaccine in any trimester
- RSV vaccine at weeks 32-36 during RSV season
- Tdap x1 with each pregnancy during weeks 27-36
24
Q
Recommended Vaccines in Older Adults
A
- Age 50 yo and older: Shringrix 2 doses 2-6 months apart
- Age 65 yo and older: PCV20 x1 OR PCV15 then PPSV23 12 months at least later
25
*Recommended Vaccines in DM*
1. Age 19-64 yo: PCV20 x1 OR PCV15 then PPSCV23 12 months or later (>/=8 weeks if immunocompromised)
2. Age 60 and older: hepatitis B if not previously vaccinated
26
*Route Vaccination schedule for Adults: Influenza and Tetanus*
Influenza: annually
Tetanus: Tdap Q10 years
27
*Routine Vaccination Schedule for Adults: Shingles*
Age 50 yo and older (immunosupressed or expected to be immnosupressed: 19 yo and older)
-Two doses 2-6 months apart (can shorten to 1-2 months if immunocompromised)
-Vaccine even if hx of chickenpox or shingles or received Zostavax (wait at least 8 weeks)
28
*Routine Vaccination Schedule for Adults: HPV*
26 yo or younger who did NOT complete series (up to 45 yo w/ clinical decision making)
29
*Routine Vaccination Schedule for Adults: Meningococcal*
-Serogroup B (MenB: Bexsero, Trumenba): give if complement component deficiency, taking eculiziumab or ravulizumab, asplenia, microbiologist w/ exposure to N. meningitidis, serogroup B meningococcal disease outbreak exposure
-Quadrivalent conjugate (MenACWY: Menveo, MenQuadfi): same groups as MenB + HIV, travelers/residents to countries in which disease is common, military recruits, first-year colege students in living in residential housing, if NOT up-to-date
30
*Routine Vaccination Schedule for Adults: Pneumocococcal*
Age 65 yo and older (specific medical condition: age 19-64 yo)
-If never received: PCV20 x1 OR PCV15 then PPSV23 12 months or more later (>/=8 weeks if immunocompromised)
31
*Routine Vaccination Schedule for Adults: Hepatitis B*
If NOT previously vaccinated, all adults 19-59 yo (risk factors: 60 yo and older)
-Risk factors: chronic liver disease, HIV, exposure via sexual activitiy, IV drug use, incarcerated, travel to an endemic area, blood exposure (healthcare personnel, DM, dialysi)
-Give alone or with hepatitis A (Twinrix)
32
*Routine Vaccination Schedule for Adults: Hepatitis A*
Adults traveling to endemic area, household members or close contacts of adopted children newly arriving from countries w/ moderate-high infection risk, liver disease, hemophilia, men who have sex with men, illict drug use. homeless, HIV
33
COVID-19 Vaccine:
-Available formulations
-Storage requirements
-Administration (IM or SQ?)
-Vaccine schedule
Available as:
-mRNA vaccines: Comirnaty (Pfizer-BioNtech), Spikevax (Moderna)
-protein subunit vaccine: Novavax COVID-19
Storage: varies per product
Administration: IM
*Schedule*: age 12 yo and older (immunocompromised: <12 yo --> for schedule, see CDC)
-If previously unvaccinated: 1 dose of Moderna or Pfizer or 2-dose series of Novavax (given at 0 and 3-8 weeks)
-If previously vaccinated: 1 dose of any vaccine at least 8 weeks after most recent vaccine
-Pts should receive the updated formulations of the vaccine designed to protect aginst most likely circulating variants
34
Diphtheria Toxoid, Tetanus-toxoid, and acellular Pertussis-containing Vaccines:
-Available formulations
-Difference between DTaP and Tdap or Td
-Storage requirements
-Preparation requirements
Available formulations:
-DTaP: Daptacel, Infanrix
-DTaP-IPV: Kinrix, Quadracel
-*DTaP-HepB-IPV: Pediatrix*
-DTaP-IPV / Hib: Pentacel
-DTaP-IPV-Hib-HepB: Vaxelis
-Td: Tenivac, TDVax
-*Tdap: Adacel, Boostrix*
*Differences*:
-DTaP: pediatric formulations with 3-5 times more diphtheria than adult formulations
-Tdap or Td: adult formulations with lower-case d
Storage: refrigerator
Preparation: shake vial or prefilled syringe before use
35
Diphtheria Toxoid, Tetanus-toxoid, and acellular Pertussis-containing Vaccines:
-Administration (IM or SQ?)
-Routine Vaccine schedule
-When to give additional doses of tetanus
Administration: IM
*Schedule:*
-DTaP (for under 7 yo): routine series of 5 doses at age 2, 4, 6, 15-18 months and 4-6 years
-Td or Tdap: booster given at age 11-12 yo; adults: routine booster Q10 years
Additional doses:
1. *Each pregnancy to prevent pertussis in infants <2 months*
2. *Close contacts of infants younger than age 12 months if NOT up-to-date*
3. Healthcare personnel with direct pt contact if NOT up-to-date
4.* Wound prophylaxis if deep or dirty wounds that it has been more than 5 years since last dose --> tetanus immunoglobulin (TIG) may be required if NO previous tetatnus vaccines have been given)*
36
Haemophilus influenza Type B (Hib)-containing vaccines:
-Available formulations
-Storage requirements
-Preparation requirements
-Administration (IM or SQ?)
-Vaccine schedule
Available as:
-Hib: ActHIB, Hiberix, PedvaxHIB
-DTaP-IPV / Hib: Pentacel
-DTaP-IPV-Hib-HepB: Vaxelis
Storage: refrigerator --> do NOT freeze
Preparation: shake vial or prefilled syringe before use
Administration: IM
Schedule:
-Hib: routine childhood vaccine given between ages 2-15 months
-AcHIB and Hiberix are a 4-dose series, PedvaxHIB is a 3 dose series
-*Given to adults with asplenia*
37
Hepatitis-containing vaccines:
-Available formulations
-Storage requirements
-Preparation requirements
-Administration (IM or SQ?)
-Vaccine for dialysis pts
Available as:
-*Hepatitis A: Havrix, Vaqta*
-Hepatitis B: *Engerix-B (adults and pediatrics), Heplisav-B (adults), Recombivax HB (adults and pediatrics)*, PreHevbrio (adults)
-*DTaP-HepB-IPV: Pediarix*
-DTaP-IPV-Hib-HepB: Vaxelis
-Hepatitis A and B: Twinrix
Storage: refrigerator --> do NOT freeze
Preparation: shake vial or prefilled syringe before use
Administration: IM
Dialysis pts: high-dose Recombivax HB (40mcg/mL)
38
Hepatitis A: Vaccine Schedule
-Children: routine schedule of 2 doses at age 12-23 months with iminimal interval between doses of 6 months
-Adults: men who have sex with men, illicit drug use, chronic liver disease, homeless, HIV, travelers to endemic area, anyone who wants
39
Hepatitis B: Vaccine Schedule
-Children: routine schedule of 3 doses at age *0 (starting within 24 hours after birth)* 1-2, and 6-18 months
-Adults (if NOT previously vaccinated): *age 19-59 yo or 60 yo and older w/ risk factors (chronic liver disease, HIV, blood exposure - healthcare workers, DM, dialysis)*, IV drug use, sexual exposure risk (men who have sex with men, multiple partners), incarcerated, traveling to endemic area
-Energix-B, Recombivax HB, and PreHevbrio: 3 dose series given at months 0, 1, and 6 (can be completed in 4 months if necessary, but may require booster at 1 year)
-Heplisav-B: 2 dose series given at months 0 and 1
40
Combined Hepatitis A and B: Vaccine Schedule
3 dose series at months 0, 1, and 6 (can be completed faster if needing tro travel to high-risk area)
41
Human Papillomavirus Vaccine:
-Available formulations
-Storage requirements
-Preparation requirements
-Administration (IM or SQ?)
-Vaccine schedule
-Cautions/CIs
-Purpose of vaccine
Available as: HPV9 (9-Valent) - Garasil 9
Storage: refrigerator --> do NOT freeze
Preparation: shake vial or prefilled syringe before use
Administration: IM
*Schedule:*
-Routine vaccination at age 11-12 yo (may be started at 9 yo - hx of sexual abuse and up to 26 yo - immunocompromised, men who have sex with men)
-If started before age 15 yo, 2 doses at months 0 and 6-12
-If started at age 15 yo and older or immunocompromised: 3 doses at months 0, 1-2, and 6
Cautions/CIs:
-Caution: fainting (though incidence is similar to other vaccines) --> administered to seated pt and monitor after vaccination
-CI: severe yeast allergy
*Purpose:* prevents cervical, vulvar, vaginal, oropharyngeal, penile, and anal cancers and genital warts
42
*Influenza Vaccines:*
1. Annually for all pts ________ and older
2. Give two doses if age _____ to ______ and NOT previously vaccinated. Give these two doses ________ days apart.
3. Recommendations in pts with egg allergy
1. 6 months
2. 6 months-8 yo; 28 days
3. Even in severe allergy, can receive any age-appropriate vaccine --> no additional observation period required beyond the 15 minutes
-Egg-free products: Flublok (18 yo and older) and Flucelvax (age 6 months and older)
43
*Influenza Vaccines:*
1. Recommendations in pregnancy
2. Recommendations in pts 65 yo and older
3. Influenza A subtype vaccines are based on ________.
1. Can receive any age-appropriate inactivated influenza vaccine --> do NOT aminister live vaccine (FluMist)
2. Preferred: Fluzone High-Dose, Fluad, or Flublok
3. Surface antigens (hemagglutinin, neuraminidase)
44
*Quadrivalent Inactivated Influenza Vaccines (IIV4):
Vaccines for 6 months and older
-Which ones are egg-free?*
Afluria, Fluarix, FluLaval, Fluzone
Egg-free: Flucelvax (grown in cell culture, ccIIV4)
45
*Quadrivalent Inactivated Influenza Vaccines (IIV4):
Vaccines for age 18 years and older and 65 years and older
-Which ones are egg-free?*
-Age 18 yo and older, egg-free: Flublok (recombinant, RIV4)
-Age 65 yo and older: Fluzone High-Dose, Fluad
46
Quadrivalent Inactivated Influenza Vaccines (IIV4):
-Storage requirements
-Preparation requirements
-Administration (IM or SQ?)
-Vaccine schedule
-What does quadrivalent cover?
Storage: refrigerator --> do NOT freeze
Preparation (Afluria): can be given w/ a needle-free jet injector
Administration: IM
*Schedule*: annually given as soon as available (prefereably before October, but can be vaccinated later --> outbreaks usually peak in February)
*Covers*: two different influenza As and two different Influenza Bs
47
Quadrivalent Live Attenuated Influenza Vaccine (LAIV4):
-Available formulations (age indicated)
-Storage requirements
-Administration
-CIs
Available as: *FluMist for healthy individuals 2-49 yo*
Storage: refrigerator --> do NOT freeze
*Administration:* intranasal as 0.2mL divided between two nostrils
CIs:
-*Pregnancy
-Immunocompromised*
-Recently taken influenza medications (oseltamivir or zanamivir within 48 hours, peramavir in past 5 days, or baloxavir in past 17 days)
48
Measles, Mumps, and Rubella-Containing Vaccines:
-Available formulations (type)
-Storage requirements
-Administration (IM or SQ?)
-Vaccine schedule
-CIs
Available as: *LIVE attenuated*
-MMR: *M-M-R II*, Priorix
-MMRV (MMR + Varicella): *ProQuad*
Storage:
-Refrigerator: Priorix, *diluents (or at room temp)*
-*Freezer: ProQuad (due to varciella component)
-M-M-R II: refrigerator or freezer*
*Administration*: SQ (M-M-R II and ProQuad may be given IM)
Schedule:
-Children: routine 2 dose series at 12-15 months and 4-6 years (ProQuad: for age 12 months - 12 years)
-Adults: 1 dose if NO evidence of immunity (adults born before 1957 are considered immune generally)
-Give 1-2 doses 4 weeks apart if NO evidence of immunity in: *healthcare workers*, HIV w/ CD4 count >/=200 cells/mm3 for at least 6 months, nonpregnant pts of childbearing age w/ no evidence of immunity to rubella, international travelers, household contacts of immunocompromised people and students in postsecondary educational institutions
Is: pregnancy or immunocompromised
49
MenACWY (Quadrivalent Meningococcal) Vaccines:
-Available formulations
-Storage requirements
-Preparation requirements
-Administration (IM or SQ?)
Available as:
-Age 2 yo and older: *MenQaudfi*
-Age 2 months - 55 yo (can be 56 yo and older if needed): *Menveo*
Storage: refrigerator --> do NOT freeze
Preparation (Menveo):* both vials (powder and liquid) contain vaccine --> use only the supplied liquid for reconstitution*
Admnistration: IM
50
MenACWY (Quadrivalent Meningococcal) Vaccines:
-Routine Vaccine schedule
-Special populations to vaccinate
*Routine vaccination:* 2 doses at 11-12 years and 16 years
Special populations to vaccinate:
1. *Travelers to certain countries (ex. African meningitis belt)*; proof of vaccination required for: Saudi Arabia for Haji and Umrah pilgrimages
2. *Two months and older w/ asplenia or sickle cell disease, HIV infection*, complement component deficiencies, or use of eculizumab or ravalizumab
3. *Lab workers with N. meningitidis exposure*
4. *First-year college students* living in residential housing if not up-to-date
5. Military recruits
*Number of dosease and timing will depend on age and specific risk --> ongoing risk should be revaccinated Q5 years
51
MenB Vaccines:
-Available formulations
-Storage requirements
-Preparation requirements
-Administration (IM or SQ?)
-Vaccine schedule
Available as:
-*MenB: Bexsero, Trumenba
-MenABCWY: Penbraya* (for age 10-25 yo when all serogroups indicated)
Storage: refrigerator --> do NOT freeze
Preparation *(Penbraya):prefilled syringe contains MenB and vial contains MenACWY - use of both components required*
Administration: IM
Schedule:
-*Age 10 yo or older and high risk (asplenia/sickle cell disease*, complement component deficiences or use of eculizumab or revalizumab, *lab workers w/ N. meninigitidis exposure, during an outbreak*):
-Bexsero or Penbraya 2 doses given 1 month apart
-Trumenba: 2 doses given 6 months apart (if high risk or during outbreak): 3 doses at 0, 1-2, and 6 months
-NOT at high risk: *optional* for those 16-23 yo who want vaccine (preferred in age 16-18 yo)
52
Pneumococcal Vaccines:
-Purpose
-Available formulations
-Storage requirements
-Preparation requirements
-Administration (IM or SQ?)
*Purpose:*
-Children: risk of common infections w/ S. pnuemoniae (ottitis media, pneumonia, meningitidis, and bloodstream infections)
-Also at risk: chronic conditions of altered immunocompetence
*Available as:*
-Conjugate vaccines: Prevnar 20 (PCV20), Vaxneuvance (PCV15)
-Polysaccharide vaccine: Pneuomovax 23 (PPSV23)
Storage: refrigerator --> do NOT freeze
Preparation: shake vial or prefilled syringe before use
Administration:
-PCV15, PCV20: IM
-*PPSV23: IM or SC*
53
Pneumococcal Vaccine Schedule
Children *< 5 yo: PCV15 or PCV20* as 4 doses at 2, 4, 6, and 12-15 months
-*PPSV23: <2 yo will NOT produce adequate antibody response*, indicated in 2-18 yo after PCV15 or PCV20 series completion with select medical conditions
Adults age *19-64 yo with specific medical conditions OR 65 yo and older routinely*
-Specific medical conditions: alcohol use disorder; cigarrette smoking; DM; chronic heart, lung, or liver disease; *immunocompromised* - chronic renal failure, asplenia/sickle cell disease, HIV, malignancy, solid organ trasnplant, immunosuppressive drugs
-*PCV20 x 1 OR PCV15 followed by PPSV23 12 months later (>/=8 weeks if immunocompromised)*
-Previously had PCV13 or PPSV23: consult CDC recommendatoins
54
Poliovirus-containing vaccines:
-Available formulations
-Storage requirements
-Preparation requirements
-Administration (IM or SQ?)
-Vaccine schedule
Available as: *ONLY inactivated in US* (other countries provide live oral vius)
-IPV: IPOL
-DTaP-IPV: Quadracel
-*DTaP-HepB-IPV: Pediarix*
-DTaP-IPV / Hib: Pentacel
-DTaP-IPV-Hib-HepB: Vaxelis
Storage: refrigerator --> do NOT freeze
Preparation: shake vial or prefilled syringe before use
Administration (IPV): IM or SC
Schedule: routine childhood vaccine series (4 doses at age 2, 4, 6-18 months and 4-6 yo)
55
Rotavirus Vaccines:
-Available formulations
-Storage requirements
-Administration
-Vaccine schedule
Available as: *LIVE attenuated
-RSV1: Rotarix
-RSV2: RotaTeq*
Storage: refrigerator --> do NOT freeze
*Administration: PO*
Schedule:
-Routine infant series: do NOT initiate after 15 weeks
-Rotarix: 2 doses at age 2 and 4 months
-RotaTeq: 3 doses at age 2, 4, and 6 months
56
Respiratory Syncytial Virus (RSV) Vaccines and Antibodies:
-Purpose
-Available formulations
-Storage requirements
-Preparation requirements
-Administration
Purpose: prevent RSV-associated lower respiratory tract disease during RSV season in high risk populations
Available as:
-RSV Vaccines: *Abrysvo*, Arexvy
-RSV Monoclonal Antibodies: *nirsevimab (Beyfortus), palivizumab (Synagis)*
Storage: refrigerator --> do NOT freeze
Administration: IM
Schedule (RSV Vaccines):
-*Pregnant pts 32-36 weeks during RSV season (September-January): 1 dose of Abrsyvo to prevent RSV in infant <6 months old*
-Adults 60 yo and older (double check CDC: lots of changes) at increased risk ((COPD< asthma, heart failure, kidney or liver disease, DM, immunocompromised, residence in long-term care facility 1 dose of Abrsyvo or Arexvy
Schedule (RSV Monoclonal Antibodies):
-*Neonates and infants <8 months born during or entering first RSV season: 1 dose of nirsevimab (if mother NOT vaccinated during pregnancy)*
-Palivizumab: reserved for premature infants and infants at highest risk of hospitalization due to RSV infection
57
Varicella Virus containing vaccines
-Available formulations
-Storage requirements
-Preparation requirements
-Administration (IM or SQ?)
-Vaccine schedule
-Cautions/CIs
*Available as:*
-Varicella (for chickenpox): Varivax --> LIVE vaccine
-MMRV: ProQuad
Storage *(Varivax): freezer --> store diluent in refrigerator or rom temperature*
Preparation *(Varivax): reconstitute immediately upon removal from freezer and administer within 30 minutes*
Administration: *SC or IM*
Schedule:
-Routine childhood vaccine of 2 doses at age 12-15 months and 4-6 yo
-*Any adolescent or adult w/o evidence of immunity to varicella: give 2 doses four weeks apart*
Cautions/CIs:
-CI: *pregnancy, immunocompromised, hypersensitivity to gelatin or neomycin*
-Some antivirals (ex. acyclovir, valacyclovir, famciclovir) can interfere w/ Varivax (live) --> *stop 24 hours before vaccine* administration and do NOT take for 14 days after vaccination
58
Zoster Virus Vaccine: Shingrix
-Storage requirements
-Administration (IM or SQ?)
-Vaccine schedule
Storage: *refrigerator (along w/ adjuvant liquid)* --> do NOT freeze
Administration: IM
*Schedule:*
-All adults 50 yo and older or adults 18 yo and odler who are or will be immunocompromised: 2 doses at 0 and 2-6 months (if immunocompromised: 2nd dose can be given at 1-2 months)
-Vaccinate even if pt has had received Varivax or Zostavax (wait at least 8 weeks - live vaccine no longer available) or hx of zoster infection since recurrence is possible
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*Miscellaneous vaccines:*
1. The rabies vaccine, __________, may be given with post-exposure w/o previous vaccination along with one dose of __________.
2. _________ is the oral live vaccine for typhoid which prevents typhoid fever caused by __________. The capsules should be stored _____________, and the dose should be finished at least ________ prior to travel. _________ is the inactivated polysacharide vaccine given IM.
3. What is the main consideration with the Bacille Calmette-Guerin (BCG) vaccine?
1. RabAvert; rabies immune globulin (RIG)
2. Vivotif; Salmonella typhi; in the refrigerator; one week; Typhim Vi
3. It is a live TB vaccine that can cause a positive rxn to the TB skin test.
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*Miscellaneous Vaccines:*
1. Yellow fever vaccine (YF-VAX) is a _______(inactivated/live) vaccine that should be given ______(IM/SQ). How is the vaccine prepared?
2. What is the main CI to YF-VAX? What is given after vaccination?
3. Cholera vaccine (Vaxchora) is an oral _________(inactivated/live) vaccine that is for patients traveling to an active area of toxigenic __________.
1. Live; SQ; reconstitute with provided diluent
2. CI: severe allergy to eggs or gelatin; International Certificate of Vaccination (yellow card)
3 Live; Vibrio cholerae
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*Storage considerations with vaccines*
1. Keep earliest expiration date first to use
2. Keep vaccines in original packaging until use
3. Never place vaccines the in the doors of the freezer or refrigerator where temperature is unstable
4. Measure refrigerator and freezer temperatures w/ buffered temperature probe and document at least twice each workday. Keep temperature log for three years (or longer as required by individual states).
Overview of vaccine storage:
-Most are stored in refrigerator --> 35F-46F (2C -8C)
-Freezer: varicella --> -58F - +5F (-50C - -15C)
-Diluents kept at room temp or in refrigerator
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*Vaccine Administration Technique*
Never mix vaccines in syringe
IM: *use 22-25 guage needle at 90 degree angle
-Needle length: 1 inch for most adults, males >260lb or females >200lbs: 1.5 inch
-Adults: inject into deltoid muscle above level of armpit and below shoulder joint*
-Infants: inject into anterolateral mid-thigh muscle
SC: *23-25 guage needle, 5/8'' in length at 45 degree angle
-Adults: inject into fatty tissue over triceps, pinch skin to prevent injection into muscle*
-Infants: inject into thigh
Intradermal: also 90 degree angle, but given with autoinjector that has very small needle
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*General Traveler Considerations*
1. Travelers should have list of medical conditions and medications (Rx and OTC)
2. Travel vaccinations should be documented on International Certificate of Vaccination or Prophylaxis (ICVP) sometimes called the "yellow card"
3. Medications and medical supplies should be packed in carry-on luggage
4. Assess need for disease prevention and vaccines though CDC on the yellow book (considerations: does disease spread through water and food, insects, or blood/bodily fluids?)
5. Increased risk for DVT and PE from limited movement with long air travel - consider compression stockings, performing lower leg exercises when sitting, and standing up and walking
6. Prevention of altitude sickness - acetazolamide started the day before in moving up high altitudes (AVEs: photosensitivity and polyuria, CI: sulfa allergy, recommend sun protection and hydration)
-Acute cases: oxygen, inhaled beta-agonists, dexamethasone
7. See healthcare provider after return from traveling
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*Traveler's Diarrhea (TD):*
-Transmission
-Primary pathogen
-What is dysentery TD?
-Prophylaxis (non-pharm)
-Treatment (non-pharm)
Transmission: through food and water
Primary pathogen: bacterial (E. coli)
Dysentery: blood is mixed in with stool often accompanied with systemic symptoms (classified as severe)
0rophylaxis (non-pharm):
-General rule of "boil it, cook it, peel it, or forget it"
-Eat food that is cooked and served hot; avoid food that has been sitting on a buffet
-Eat raw fruits and vegetables if washed in clean water or peeled
-Use bottled water or boil for approximately one minute before drinking or using to brush teeth; avoid ice
-Keep hands clean and out of mouth, water hands often or alcohol hand-sanitizer
Treatment (non-pharm):
-Hydration with increased fluid and salt intake (oral rehydration solution)
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*Traveler's Diarrhea (TD): Pharmacological Therapy (Prophylaxis)*
-Bismuth subsalicylate (BSS) in 13 yo and older (have been used in >3 yo w/ no recent or current viral infections): 524-1050mg PO QID with meals and at bedtime
-Avoid BSS in ASA allergy, pregnancy, renal insufficiency, gout, ulcer, or anyone taking anticoagulants, probenacid, or methotrexate
-Antibiotics: should NOT be used by most travelers except those at very high risk of complications or for performance reasons (ex. proferssional athelete) --> rifaximin preferred (alternative: azithromycin and rifamycin)
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*Traveler's Diarrhea (TD): TX*
-Mild TD: loperamide 4mg after first loose stool then 2mg after each (max: 16mg/day by Rx or 8mg/day by OTC for up to 2 days - if symptoms do NOT resolve, contact HCP) or BSS (loperamide preferred)
-Moderate TD: loperamide +/- antibiotics (low resistance: azithromycin or quinolone, alternative: rifaximin)
-Severe TD (including dysentery) antibiotics +/- loperamide (preferred: aztihromycin, alternative: quinolones or rifaximin)
-Rifaximin and rifamycin: cannot use when invasive pathogen suspected
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*Typhoid Fever:*
-Transmission
-Pathogen
-Prophylaxis
Transmission: food or water contaminated by feces of someone with acute infectionor chronic asymptomatic carrier
Pathogen: Salmonella typhi
Prophylaxis:
-Safe food and water precautions
-Wash hands frequently
-Typhoid vaccines: only about 50-80% effective
-Vivotif (PO, live vaccine): complete 1 week or more before travel for 6 yo and older, revaccinated Q5 years
-Typhim Vi (IM, inactivated): complete 2 weeks or more before expected exposure for 2 yo and older, revaccinated Q2 years
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*Travel Dieases transmitted from water and food:*
1. Cholera caused by ___________ often results in __________ (symptom) that is typically mild, but can be vaccinated against with __________ which is a single dose oral live vaccine that should be done at least ____ days before travel.
2. Though most people in the US are vaccinated with polio in childhood, what are CDC recommendations for travel?
3. _________ is a disease that has the highest risk of people traveling from developed countries to developing countries and can be vaccinated prior (though some experts advise against regardless of destination).
1. Vibrio cholerae; rice-water stools; Vaxchora; 10 days
2. Single lifetime booster dose of IPV at least 4 weeks prior to travel for adults have previously completed a poliovirus series and are traveling to a region where poliovirus is circulating
3. Hepatitis A
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*Which diseases are transmitted through bodily fluids and blood that should be considered with international travel? What the general recommendations for vaccine prophylaxis? *
Hepatitis B:
-Low risk in travelers that do not participate in high-risk behaviors
-Vaccination extremely important when traveler plans to receive medical care, volunteer to provide medical work, or have unprotected sexual encounters (also: obtaining piercings and tattoos)
-3-dose vaccine series can take 6 months to complete (if unable to obtain all three: receive as many doses before and complete upon return, high risk: accelerated series can be done and booster required in a year)
Meningococcal meningitis:
-Transmitted through respiratory secretions
-Vaccination recommended when traveling to area where N. meningitidis is hyperendemic or epidemic, particularly if spending a long time (high risk: meningitis belt of Africa during December-June)
-Saudi Arabia requires vaccine for traveling along Haji and Umrah pilgrimages
-Current recommendations with only Menveo and MenQuadfi; no recommendations for MenB use
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*Diseases transmitted via insect bites:*
1. Insects that transmit disease are _______. What are the primary insects tha transmit disease?
2. What are some strategies to avoid insect bites?
3. _________ is a disease from mosquito bites often in the timeframe where populations are high during rainfall that can cause severe bleeding and organ failure, and treatment is mostly supportive.
4. Japanese encephalitis is an often asymptomatic disease that causes swelling around the brain. The ______ vaccine is recommended when travelers are planning exposure to outdoors or spending at least one month in endemic area during transmission season.
1. Vectors; mosquitoes (transmit: Japenese encaphalitis, yellow fever, dengue, malaria, and Zika virus)
2.
-Stay and sleep in screened or air-conditioned rooms and use bed net which can be pre-treated w/ mosquito repllent
-Cover exposed skin with long-sleeved shirts, long pants, and hats
-Use mosquito repellant consisting of DEET on exposed skin which also covers ticks (covers only mosquitos: picaridin, oil of lemon, eucaltyptus, or IR3535) --> apply sunscreen then repellant
-Use permethrin to treat clothing, gear, and bed nets, but do NOT apply directly to skin
3. Dengue
4. Ixiaro
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*Malaria: *
-Transmission
-Primary pathogen and most deadly pathogen
-Prophylaxis options and key considerations
Transmission: Anopheles mosquito
Primary pathogen: Plasmodium vivax
Most deadly pathogen: P. falciparum
Prophylaxis: QD regimens initiated 1-2 days prior to travel
-ALL: avoid in pregnancy, and causes nausea (take CF, milk, or water)
-Doyxycline (Doryx, Vibramycin): also prevents rickettsial infections and leptospirosis (preferred in hiking/camping), avoid in children <8 yo
-Atovaquone/proguanil (Molarone): avoid in breastfeeding, severe renal impairment
-Primaquine: most effective for P. vivax, strop 1 week after travel, avoid in G6PD deficiency (required screening before) and breastfeeding (unless infant tested for G6PD deficiency)
Prophylaxis: weekly regimens initiated 1-2 weeks prior to travel
-ALL: safe in children and pregnancy, choice depends on resistance in region
-Chloroquine: resistance issues w/ P. falciparum and P. vivax, stop 4 weeks after travel, AVEs of retinal toxicity and visual changes, avoid in areas of chloroquine or mefloquine resistance
-Mefloquine: start >2 weeks before travel; stop 4 weeks after travel, avoid in underlying psychiatric conditions, seizures, arrhythmias, and areas of mefloquine resistance
-Tafenoquine: may be used for up to 6 months; avoid use in G6PD deficiency (requires testing prior), breastfeeding (unless infant tested negative for G6PD), or underlying psychiatric conditions
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*Yellow Fever:*
-Transmission
-Prophylaxis
-Treatment
Transmission: mosquitoes
Prophylaxis:
-Reducing mosquito exposure
-YF-VAX (live attenuated vaccine) prior to travel for high risk (due to serious side effects: yellow-fever vaccine-associated neurological disease)--> pt should receive ICVP ("yellow card") which is valid 10 days after date of vaccination; single dose provides lifetime protection; CI in severely immunocompromised or hypersensitivity to egg
Treatment:
-No specific TX except symptomatic relief with fluids, analgesics, and antipyretics
-NSAIDs ans ASA cannot be used due to increased risk of bleeding (in severe cases, yellow fever can cause hemorrhage)
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Zika Virus:
-Transmission
-Main concerns
-Prophylaxis
Transmission: mosquitos, possibly sexual and blood transfusion-associated
Main concern: disease itself usually asymptomatic or mild --> infants can be born with microcephaly causing significant disability and many birth defects of brain, eyes, hearing, and impaired growth
Prophylaxis:
-NO vaccine
-Avoiding mosquito bites
-Condoms during sexual contact
-CDC recommends pregnant women NOT traveling to any area with ongoing Zika Virus
