APhA Immunization Lectures - Final Exam

Dr. Conway

What is Innate Immunity?

Acquired Immunity?

Innate — from birth; natural, generic immunity that is built into the body

Acquired — from outside factors; active (ex. vaccines) or passive (ex. from mother to newborn)

What is the difference between Active and Passive Immunity?

Give examples of each type.

Active — exposure to a disease organism triggers the immune system to produce antibodies to that disease

• Ex. Chickenpox infection, Flu vaccination

Passive — person is given antibodies to a disease rather than producing them through his or her own immune system

• Ex. Antibodies in breast milk, Antivenom injection, Immune globulin infusion

How long does it take for a patient to generally build immunity after receiving a vaccination?

Around 2 weeks to build immunity

What is a Live Vaccine?

Inactivated Vaccine?

Which has more contraindications?

Live Vaccine — vaccine that contains only a small amount of live virus that is given to provoke immunity

Inactivated Vaccine — vaccine that does NOT contain any amount of live virus

Live vaccines have more contraindications

Which vaccines are Live Attenuated Vaccines?

You need to know these!

Live attenuated Vaccines include:

• MMR*

• Varicella*

• Rotavirus*

• MMRV*

• Live Attenuated Influenza

• Oral Typhoid Capsules

• Yellow Fever

• Chikungunya

* Part of Childhood Series

What are Adjuvants?

Things that can be added to vaccines to enhance the immune response

What specific population are Pure Polysaccharide Vaccines NOT recommended in?

Why?

Which vaccine is a good example of having a Polysaccharide version?

Children less than 2 years of age

Immune response in these children is typically not mature enough to respond to a Polysaccharide

Pneumococcal Vaccine has a polysaccharide version

What is the minimum interval for giving two inactivated vaccines?

Inactivated and live vaccines, simultaneously?

Two live vaccines, if not given simultaneously?

Two Inactivated — no minimum

Multiple Inactivated and Live, simultaneously — no minimum

Two Live — 28-day MINIMUM interval

What is the minimum interval for giving Inactivated vaccines and Antibodies?

Live Vaccines and subsequent Blood Products?

Blood Products before Live Vaccines?

Inactivated and Antibodies — no minimum

Live and Blood Products — 2 weeks

Blood Products before Live — varies (look up specific interval)

What is the minimum interval for giving a Live Vaccine followed by a PPD Skin Test?

PPD Skin Test followed by a Live Vaccine?

Live then PPD — 28-day minimum

PPD then Live — administer Vaccine after PPD skin test is read

What is the general rule of thumb for Co-Administration of Vaccines, if not one of the special cases?

What are the best practices when Co-Administering Vaccines?

General rule of thumb is that multiple vaccines can be administered in the same day, if not one of the special cases mentioned

Best practices include:

• Using separate syringes for separate vaccines

• Administering vaccines in different limbs if possible

  • Helps reduce possible local injection site reactions

  • Try and separate by at least 1 inch if not possible in different limbs

What is the Grace Period?

What is counted as “On Time”?

Which type of vaccines have NO Grace Period?

Period inside of the stated “Minimum Interval” in which a vaccine is okay to give

“On Time” is when it is within 4 days of the minimum interval

• Some states do not recognize Grace Periods

Live Vaccines have NO Grace Period and you must stick to the stated interval

What happens if the interval between vaccine doses in a series is decreased (before the stated time)?

What happens if the interval between vaccine doses in a series is increased (after the stated time)?

Interval is decreased — considered invalid, still must receive next dose on stated date

Interval is increased — its fine, just go get the next dose when you can; acts as a boost to the initial dose

What is the universal contraindication for all vaccines?

What are temporary contraindications?

Universal contraindication for all vaccines is when there are severe allergies to a vaccine or component following a previous dose (risk for Anaphylaxis)

Temporary Contraindications are situations that temporarily delay vaccination for a period of time

• Ex. Pregnancy or Immunosuppression

What are examples of False Contraindications?

Minor illness (fever, URI, diarrhea, etc.; as long as not bad enough to go to doctor or hospital)

Allergies to products not in vaccine

Allergies that are not immediate and life-threatening

Pregnancy in the household

Breastfeeding

Premature birth (do not adjust for gestation)

What is the general rule of thumb for Vaccines and Pregnancy?

Encourage vaccination before pregnancy, if possible

If the vaccine has a temporary contraindication during pregnancy, defer until after birth

Any deferred vaccines should be given once the pregnancy condition is terminated

What are some examples of vaccines recommended during pregnancy?

What are examples of vaccines that have temporary contraindications during pregnancy?

Examples recommended during pregnancy:

• Tdap for EVERY pregnancy (ideally 27 to 36 weeks)

• Inactivated Flu Vaccine

• Bivalent RSVPreF (Abrysvo; 32 to 36 weeks in RSV Season)

Examples of temporary contraindicated vaccines:

• Any inactivated vaccines not mentioned as recommended

• Live vaccines

What is the good rule of thumb for immunocompromised patients?

Avoid live vaccines, but inactivated vaccines are fine (may have less effectiveness, but still are okay!)

How is Contraindication level determined based on level of Immunosuppression?

Low-Level Immunosuppression = not generally regarded as contraindication

High-Level Immunosuppression = generally not safe for live vaccines or a specific vaccine; considered Contraindication

How should we approach vaccination with immunosuppressed individuals?

Try and give vaccines before immunosuppression (in cases where it has a guideline time period)

• 4 weeks minimum, if Live

• preferred 4 weeks but 2 weeks minimum, if Inactivated

If there is any uncertainty, contact the patients healthcare provider to discuss patients condition further

What is the general rule of thumb regarding giving vaccinations to people who have an immunocompromised individual in the household?

Can receive inactivated and most live vaccines, so long as they are not:

• Rotavirus (must caution handling diapers)

• Varicella or Zoster (avoid contact with skin lesions)

What does the color Yellow indicate on a Vaccine Schedule, in regards to age?

Yellow with Spots?

Green?

Purple?

Gray?

Blue?

Yellow — recommended for all who meet age requirement, lack documentation of vaccine, or lack evidence of immunity

Yellow with Spots —recommendation for when vaccination can begin in this age group, following the general schedule

Green — recommended ages for catch up

Purple — maybe, for some but not for all; recommended ages for certain high-risk groups, additional risk factors, or another indication

Gray — no guidance / not applicable

Blue — recommended for all, based on shared clinical decision-making (warrants discussion)

What does the color Yellow indicate on a Vaccine Schedule, in regards to medical conditions?

Blue?

Purple?

Brown?

Orange?

Red?

Gray?

Yellow — recommended for all

Blue — recommended for all, based on shared clinical decision-making

Purple — not recommended for all, but for some based on either age OR increased risk outcomes

Brown — recommended for all age-eligible; additional doses may be needed based on medical condition or other indications

Orange — precaution; vaccine may be indicated if benefit outweighs risk of adverse reaction

Red — not recommended / contraindicated

Gray — no guidance / not applicable

What is the typical onset of symptoms after exposure to Influenza?

How long is the individual considered contagious?

Typical onset of symptoms is 2 days after exposure (ranges 1-4 days)

Considered contagious for generally 1 day before symptoms and 5-7 days after onset

What groups are at higher risk for developing serious complications due to Influenza?

Adults aged 50+

Children aged 6-59 months

People with chronic medical conditions

Pregnant women

What does the IIV3 abbreviation mean in Flu Vaccines?

IIV3-HD?

ccIIV3?

RIV3?

aIIV3?

LAIV3?

IIV3 — trivalent inactivated influenza vaccine

IIV3-HD — high-dose trivalent inactivated influenza vaccine

ccIIV3 — cell culture-based trivalent inactivated influenza vaccine

RIV3 — recombinant trivalent influenza vaccine

aIIV3 — adjuvanted trivalent inactivated influenza vaccine

LAIV3 — trivalent live attenuated influenza vaccine

What is an easy way to remember which Flu Vaccine is Cell-Cultured?

Which Flu vaccines are Non-Egg Based?

FluCELvax

Non-Egg Based Flu vaccines are Flucelvax (ccIIV3) and Flublok (RIV3)

Which Flu Vaccines are approved for ages 6 months and older?

9 years and older?

65 years and older?

6 months and older:

• Afluria (IIV3)

• Fluarix (IIV3)

• FluLaval (IIV3)

• Fluzone (IIV3)

• Flucelvax (ccIIV3)

9 years and older:

• Flublok (RIV3)

65 years and older:

• Fluzone High-Dose (IIV3-HD)

• Fluad (aIIV3)

What is our one Live Attenuated Flu Vaccine?

Who manufactures it?

What type of Flu Vaccine is it?

What age range is it approved for?

FluMist

Manufactured by MedImmune

LAIV3

Approved for 2 to 49 years of age

For IIV3 Flu Vaccines, what is the:

• Recommended Patient Age?

• Number of Doses?

• Dose Strength?

Patient Age — 6 to 35 months, 3 to 9 years, 9 years and older

Number of Doses — 1 or 2* (6 to 35 months, 3 to 9 years), 1 dose (9 years and older)

Dose Strength — nobody cares lol

* Recommended 2 doses at least 4 weeks apart if age 6 months to 8 years

For HD-IIV3 Flu Vaccines, what is the:

• Recommended Patient Age?

• Number of Doses?

• Dose Strength?

Patient Age — 65 years and older

Number of Doses — 1 dose

Dose Strength — 0.5 mL IM

For aIIV3 Flu Vaccines, what is the:

• Recommended Patient Age?

• Number of Doses?

• Dose Strength?

Patient Age — 65 years and older

Number of Doses — 1 dose

Dose Strength — 0.5 mL IM

For LAIV3 Flu Vaccines, what is the:

• Recommended Patient Age?

• Number of Doses?

• Dose Strength?

Patient Age — 2 to 49 years

Number of Doses — 1 or 2

Dose Strength — 0.2 mL (1 spray in EACH nostril)

What is the ACIP recommendation for adults aged 65+ years old, in regards to Influenza vaccines?

They should preferentially receive any of the following:

• Trivalent HIGH-DOSE inactivated influenza vaccine (HD-IIV3)

• Trivalent RECOMBINANT inactivated influenza vaccine (RIV3)

• Trivalent ADJUVANTED inactivated influenza vaccine (aIIV3)

If none of these are available, any other age-appropriate influenza vaccine should be used

When is the general best time for Influenza vaccination for a patient who needs only 1 dose of Influenza vaccine?

In what circumstances is vaccination recommended before this time?

If only needing 1 dose, best time is September or October

Generally, vaccination should not occur during July or August, UNLESS:

• Pregnancy in the third trimester

• Children less than 9 years old who need 2 doses in one season

• Concern that vaccination later in the season may not be possible

For an individual with an egg allergy, which Influenza vaccines are recommended?

Any vaccine is fine! If there are concerns, recommend they get it at their doctor’s office just in case (and if pharmacist is not comfortable)

When should you begin to provide influenza vaccines?

How long should you provide the Influenza vaccine?

Should not be provided any earlier than September

Can be provided as long as Flu is circulating, we have stock, and stock is not expired

What is the fatality rate for cases of Tetanus caused by Clostridium tetani?

Which population makes up most of the fatal cases?

10% fatality rate

Individuals not up to date with their Tetanus-containing vaccinations

What is Whooping Cough?

How is it different from a cold?

Whooping Cough is Pertussis; struggle to breath that is highly dangerous in younger children with underdeveloped lungs

Can lead to hospitalization and respiratory arrest

What does DTaP protect against?

Tdap?

What is Tdap intended for us as?

DTap protects against Tetanus, Diphtheria, and Pertussis

Tdap protects against Tetanus and Diphtheria

• Intended for use as a booster dose for DTap in adults and adolescents

When is DTaP usually given?

Tdap?

DTaP — childhood series; less than 7 years

Tdap — adolescence and adulthood; either 10+ years (Boostrix) or 10-64 years (Adacel)

What is the ACIP recommendation for Tdap during Pregnancy?

Recommended one dose for every pregnancy because vaccination of mother transfers antibodies to fetus

• Preferred 27-36 weeks gestation

• If not during pregnancy, administer asap after birth

Recommended all family members and those around infant get vaccinated for Tdap (cocooning)

What is the recommended interval between a dose of Tdap and the last Td booster?

Every 10 years (Td component)

What ages are recommended for MMR vaccination in children?

How many doses are recommended?

2-dose series

Dose 1 — 12 to 15 months

Dose 2 — 4 to 6 years

* Reminder: MMR is a Live Attenuated Vaccine

How does age of an adult factor into MMR vaccination recommendations for non-healthcare professionals?

If born before 1957, they are considered immune

If born in 1957 or after AND there is no evidence of immunity, give at least one dose

What are the contraindications for the MMR vaccine?

If the patient is allergic to any component of the vaccine

Pregnancy

Immunosuppression

Receipt of Blood Products

* Reminder: MMR is a Live Attenuated Vaccine

What special populations have unique recommendations for MMR vaccination?

Students entering Post-High School Training:

• All students with no evidence of immunity should receive 2 doses at least 4 weeks apart

Healthcare Personnel:

• If born during or after 1957 with no evidence of immunity, should receive 2 doses at least 4 weeks apart

• If born before 1957 with no evidence of immunity should consider 2 doses at least 4 weeks apart (special consideration for outbreaks)

What are the target groups for MMR vaccination?

1. All children

2. All special populations at high risk (health care personnel, college students, international travelers, etc.)

3. Adults born in 1957 or later who have no evidence of immunity / vaccination

Should a patient with provider-diagnosed MMR be considered immune?

Maybe, but it is preferred there is some form of documentation (titers or proof of vaccine)

What happens to MMR vaccination recommendations in the event of an outbreak?

MMR vaccinations CAN be given in event of an outbreak to children as young as 6 months old if at high risk of exposure

However, if given BEFORE 12 months of age, it cannot be counted towards the 2-dose series

Contact local health departments for guidance

How is Chicken Pox (Varicella) transmitted?

When is an individual considered contagious?

Where does the rash appear?

How long does the rash typically last?

Transmitted via respiratory droplets or contact with Varicella lesions; VERY contagious

Individual is considered contagious 1-2 days before the rash and 4-5 days after onset of rash

Rash appears on the head first, then is concentrated on the trunk for a duration of 5-10 days

What ages are recommended for Varicella vaccination in children?

How many doses are recommended?

What if there is no evidence of immunity in children older than these recommended ages?

2-dose series

• Dose 1 — 12-15 months

• Dose 2 — 4 to 6 years

* Reminder: MMR is a Live Attenuated Vaccine

If there is no evidence of immunity and the child is:

• 7 to 12 years old, we give 2 doses that are 3 months apart

• Older than 13 years, we give 2 doses 4 to 8 weeks apart

Should a patient who provides a verbal history of Chickenpox be considered immune?

How can a patient demonstrate immunity?

No, unless patient was born before 1980 where it is assumed there was exposure

Can draw titers or present proof of vaccination

What is Shingrix?

What types of presentation is it available in?

What is it FDA approved for?

Recombinant, adjuvanted Zoster Vaccine

Available as:

• Powder and AS01B Adjuvant Suspension

• Prefilled Syringe

FDA approved for prevention of Herpes Zoster in:

• Adults 50+ years, including those who previously received Zostavax

• Adults 18+ (19+ by ACIP) who are at increased risk due to immunodeficiency

What are the most common high-risk types of HPV Valances?

Low-risk types?

What do the high-risk types help protect against?

Low-risk types?

High-Risk Types — 16, 18, 31, 33, 45, 52, 58

• Protect against 90% of cervical cancers

Low-Risk Types — 6, 11

• Protect against 90% of genital warts

What are the general dosing recommendations based on age for the HPV vaccines?

Immunocompetent 9 to 14 years:

• 2-dose series (3 if immunocompromised)

• Doses 0, 6 to 12 months

Age 15 to 26 years:

• 3-dose series

• Doses 0, 1 to 2, 6 months

Age 27 to 45 years:

• If not already vaccinated, may be vaccinated with 3-dose series using shared clinical-decision making

What are the four different Pneumococcal Vaccines on the market?

1. PCV15 — 15-valent pneumococcal conjugate vaccine

2. PCV20 — 20-valent pneumococcal conjugate vaccine

3. PPSV23 — 23-valent pneumococcal polysaccharide vaccine

4. PCV21 — 21-valent pneumococcal conjugate vaccine

When is PPSV23 recommended?

In children 2-18 years with certain underlying conditions after fill PCV13 or PCV15 series + additional PCV15

• Single dose

In adults 65+ of 18+ years with certain underlying conditions

• Single dose 1 year after PCV15

• Alternative option is to give PCV20 alone and no PPSV23

When is PCV15 recommended?

In children at ages 2, 4, 5, and 12 to 15 months

In children with high-risk medical conditions

• CDC recommends PCV15 as an alternative option with PPSV23

Adults age 50+ and 19 to 49 years with certain underlying conditions

• Single dose of PCV15 + a dose of PPSV23 1+ year later

When is PCV20 recommended?

In children ages 2, 4, 6, and 12 to 15 months

In children with high-risk medical conditions, IF no documentation of PCV20

In adults age 50+ and 19 to 49 years with certain underlying conditions

When is PCV21 recommended?

What are some adverse effects of this vaccine?

(Capvavixe) Approved in adults 18+ years of age

Recommended by ACIP in adults 50+ and 19 to 49 years old with certain underlying conditions

Adverse effects:

• Injection site pain

• Headache

• Fatigue

Which vaccine does not follow the general trend of older vaccine versions being sufficient coverage, meaning that experts recommend getting newer versions?

Pneumococcal

If you had PPSV23 or PCV15 before, they recommend waiting at least a year then getting the new PCV20 or PCV21

What is the ACIP recommendation for the Hepatitis A vaccination?

For all children 1 to 2 years old

• 2-dose series through 18 years old, with a minimum of 6 months apart

Adults if the risk factor is present or if there is desire for immunity

What is the ACIP recommendation for the Hepatitis B vaccination?

Infants:

• 3-dose series

• Birth, 1 to 2 months, 6 months; NO EARLIER THAN 24 WEEKS

Adolescents:

• 3-dose series

• 0, 1, 6 months

HEPLISAV-B:

• 2-dose series, 1 month apart

• For adults 18+

PreHevbrio:

• 3-dose series

• 0, 1, and 6 months for adults 18+

* ESSENTIALLY RECOMMENDED FOR EVERYONE

What is the ACIP recommendation for the RSV Vaccination in Infants?

If the infant younger than 8 months is born during or entering their first RSV season:

• Should receive 1-dose of Nirsevimab OR Clestrovimab

• October through March in U.S

• ONLY if:

  • Mother did not receive RSV during pregnancy

  • Mother’s RSV vaccination status is unknown

  • Infant was born less than 14 days after maternal RSV vaccination

Children aged 8 to 19 months who are at increased risk of severe RSV and entering their second RSV season:

• Should receive 1-dose of Nirsevimab

Which RSV vaccine is approved for Pregnancy?

When should it be given?

What are some potential adverse effects?

Abrysvo

Given 32 to 36 weeks gestational age of the pregnancy, September through January

Potential adverse effects:

• Injection site pain

• Headache

• Nausea

• Pre-eclampsia

• Pre-Term Birth

Which RSV products can be administered to infants and some young children?

During pregnancy?

To some older adults?

Infants + Young Children:

• Infant RSV Antibody ONLY

• Do NOT administer Abrysvo, Arexvy, or mResvia

During Pregnancy:

• Abrysvo ONLY

• Do NOT administer RSV Antibody, Arexvy, or mResvia

Older Adults:

• Abrysvo, Arexvy, or mResvia

• Do NOT administer RSV Antibody

What is the ACIP recommendation for the RSV Vaccination in Adults?

All adults 75+ and adults 50 to 74 years who are at increased risk of severe RSV disease should receive a 1-dose RSV vaccine

• Any product is fine ig

What is the ACIP Recommendation for the Poliomyelitis Vaccination?

Infants (childhood series):

• 4-dose routine series

• 2, 4, 6 to 18 months, 4 to 6 years

Adults 18+ who are known or suspected to be unvaccinated or incompletely vaccinated against Polio

• Complete primary vaccination series + IPV

Adults who have received a primary series of tOPV or IPV in any combination and are at increased risk of Polio

• May receive another dose of IPV

What are the severe adverse events associated specifically with COVID-19 vaccines?

Myocarditis and Pericarditis (seen more in male adolescents)

What is the ACIP recommendation for the COVID-19 Vaccine?

Essentially, recommended for all 6 months and older with shared clinical decision-making

What is the ACIP Recommendation for the Mpox vaccine?

Recommended for adults 18+ at risk for Mpox

Includes gay, bisexual, and other men who have sex with men, transgender, or nonbinary people who have had certain characteristics in the past 6 months

Which vaccine is the exception to the ‘catch up’ rule?

When is the cutoff?

Rotavirus

Cutoff is 8 months due to the risk ending after the first year of life