Pharmacists as Immunizer part 2

A patient’s vaccination needs may be determined based on:

1. Immunization history

2. Age

3. Health condition 

4. Occupation 

5. Travel itinerary 

ADULT VACCINATION SCHEDULE

• Philippine Foundation for Vaccination (PFV)

• Philippine Society for Microbiology and Infectious Diseases

PEDIATRIC PATIENTS

• Philippine Infectious Diseases Society of the Philippines

• PFV

• Philippine Pediatric Society

INFLUENZA VACCINE (PFV, 2015)

• Quadrivalent inactivated vaccine

• Trivalent inactivated vaccine

INFLUENZA VACCINE (PFV, 2015)

Recommended for all adults particularly: 

• Individuals >/= 50 years old

• Healthcare workers 

• Residents of chronic care facilities and nursing homes 

• Those with chronic disorders

• Individuals with HIV/AIDS 

• Immunosuppressed patients 

• Pregnant women in the 2nd or 3rd trimester without a flu shot in the last 12 months 

• Healthy persons providing essential and emergency community services 

• Students and other personnel in institutional settings

INFLUENZA VACCINE (PFV, 2015)

Those with chronic disorders:

1. Chronic pulmonary disease (including bronchial asthma)

2. Chronic cardiovascular/renal/liver disease

3. Neurological disorder

4. Chronic metabolic disease 

PNEUMOCOCCAL VACCINE (PFV, 2015)

• Pneumococcal Polysaccharide Vaccine (PPSV23)

• Pneumococcal Conjugate Vaccine (PCV13)

PNEUMOCOCCAL VACCINE (PFV, 2015)

Recommended for all adults particularly: 

• Adults 50 years and older 

• Adults <50 years old with …

PNEUMOCOCCAL VACCINE (PFV, 2015)

Adults <50 years old with: 

• Chronic lung disease (including bronchial asthma, TB)

• Chronic cardiovascular/renal/liver disease

• Diabetes Mellitus 

• Alcoholism

• Cochlear implants 

• CSF leaks 

• Immunocompromised conditions

• Residents of nursing homes and long term care facilities 

• Smokers

PNEUMOCOCCAL VACCINE (PFV, 2015)

Adults <50 years old with immunocompromised conditions

1. Functional and anatomic asplenia

2. Leukaemia and lymphomas

3. Generalized malignancy

4. Transplants

5. Chemotherapy/Radiation Therapy

6. HIV/AIDS

TIMING OF VACCINATION SCHEDULE

• PATIENTS RECEIVING ANTIBODY-CONTAINING BLOOD PRODUCTS

• VACCINES THAT ARE ADMINISTERED ON THE SAME DAY AND ON DIFFERENT DAYS

PATIENTS RECEIVING ANTIBODY-CONTAINING BLOOD PRODUCTS

ANTIBODY-VACCINE INTERACTION

ANTIBODY-VACCINE INTERACTION

• inactivated vaccine

• live injected vaccine

• live oral and intranasal

• live attenuated influenza and rotavirus

• products containing type-specific or negligible antibody

Inactivated Vaccine:

given any time, before, during or after receiving antibody-containing blood products

Inactivated Vaccine:

• For Post-exposure prophylaxis (Hepa B, Rabies, Tetanus) 

Giving the vaccine together with the antibody (Ig) is even recommended

Live Injected Vaccines:

Requires time interval (which is given first)

Live Injected Vaccines:

Vaccine given first

(MMR, MMRV, Varicella)

Live Injected Vaccines:

Vaccine given first : wait time

2 weeks before giving antibody

Live Injected Vaccines:

blood product given first: wait time

3 months or longer

Live Injected Vaccines:

zoster vaccine

no known interaction, so can be given anytime

Live oral and intranasal vaccines:

Ig, no known effect to oral typhoid vaccine

Live attenuated influenza vaccine and rotavirus vaccine:

not affected by the presence of antibodies

Products containing type-specific or negligible antibody

• Palivizumab (Synagis)

• Washed red blood cells

Palivizumab (Synagis)

• - monoclonal antibody used to prevent respiratory syncytial virus (RSV) infection in infants and young children

• No need to space vaccine administration.

Washed red blood cells:

• negligible antibody content

• Do not require spacing when receiving vaccines

VACCINES THAT ARE ADMINISTERED ON THE SAME DAY AND ON DIFFERENT DAYS

VACCINE-VACCINE INTERACTION

VACCINE-VACCINE INTERACTION

• Vaccines Administered on the same day:

• Combination Vaccines VS. Single Component Vaccines

• Vaccines Not Given on the same day

Vaccines Administered on the same day:

Live + Inactivated Vaccines

Combination Vaccines VS. Single Component Vaccines

Combining different vaccines in one syringe:

not recommended

Combination Vaccines VS. Single Component Vaccines

Combination vaccines:

preferred over single-component

Vaccines Not Given on the same day:

Live Vaccines NOT given on the same day:

• Live Parenteral Vaccines + Live attenuated influenza vaccine

• Live Parenteral + Live Parenteral

Live Parenteral Vaccines + Live attenuated influenza vaccine

• (given intranasal)

• spaced four (4) weeks apart

Live Parenteral + Live Parenteral

spaced four (4) weeks apart

Vaccines Not Given on the same day:

Live Vaccines NOT given on the same day: EXEMPTION

• yellow fever vaccine + measles vaccine: spacing not necessary

 Live Vaccines administered Orally

Spacing not necessary

• Oral Polio Vaccine

• Oral Typhoid

• Rotavirus Vaccine

 Live Vaccines administered Orally

Spacing not necessary

• e.g. Live parenteral + oral Live vaccines

• Live Intranasal vaccines: oral live vaccines

Others

Spacing not necessary

•  Inactivated + Inactivated vaccines

• Inactivated + Live Vaccine

VACCINES REQUIRING MORE THAN ONE DOSE AND THE TIME INTERVAL NECESSARY

MULTIDOSE VACCINES 

MULTIDOSE VACCINES 

Increasing/decreasing the interval between doses

Increasing the interval between doses:

does not reduce effectiveness 

Decreasing the interval

: may interfere with antibody response

SCREENING PATIENTS PRIOR TO VACCINE ADMINISTRATION

• provision of basic screening questions

• contraindication

• precaution

Contraindication 

• a condition in the patient that increases the chances of a serious adverse reaction to occur. If present, vaccines should not be given. 

• Risk outweighs the therapeutic benefits.

Precaution

• If benefit outweighs the risk, then, vaccine may be given

TWO TEMPORARY PRECAUTIONS TO VACCINATION

1. Moderate to severe acute illness. Vaccination delayed until recovery 

2. Recent recipient of an antibody-containing blood product (MMR, Varicella containing vaccines but not for zoster vaccine)

TWO TEMPORARY PRECAUTIONS TO RECEIVING LIVE VACCINES

• pregnancy

• immunosuppression

PREGNANCY

Live vaccines should be avoided, HPV (human papillomavirus vaccine (inactivated): until mother gives birth

IMMUNOSUPPRESSION

• Congenital immunodeficiency, leukemia lymphoma, generalized malignancy

• Steroid Use

• For asthma patients on steroid inhalers

• For HIV/AIDS infection

• For symptoms of HIV or who has AIDS

• Cancer treatment (alkylating agents, antimetabolites, radiation therapy)

Congenital immunodeficiency, leukemia lymphoma, generalized malignancy

avoid live vaccines 

Steroid Use

long term use of high dose steroid (20mg or more per day of prednisone or 2mg/Kg or more prednisone: avoid live vaccines)

For asthma patients on steroid inhalers,

not contraindicated for live vaccines

For HIV/AIDS infection

• avoid live vaccines, LAIV should be avoided 

• inactivated influenza vaccine given

For symptoms of HIV or who has AIDS

zoster and MMRV should be avoided

Cancer treatment (alkylating agents, antimetabolites, radiation therapy)

wait at least three months after the last dose before vaccination.

Yellow fever vaccine

should be avoided in breastfeeding women

Rubella vaccine

can be shed in milk, but infection of infant is rare.

FOUR PERMANENT CONTRAINDICATION TO VACCINATION

• HISTORY OF A SEVERE ALLERGIC REACTION AFTER VACCINATION

• ENCEPHALOPATHY OCCURRING WITHIN 7 DAYS OF PERTUSSIS VACCINATION

• SEVERE COMBINED IMMUNODEFICIENCY (SCID)

• HISTORY OF INTUSSUSCEPTION (SPECIFIC FOR ROTAVIRUS VACCINE)

HISTORY OF A SEVERE ALLERGIC REACTION AFTER VACCINATION

• Anaphylactic reaction (IgE-mediated) 

• generalized urticaria 

• swelling of the mouth and throat 

• difficulty breathing 

• wheezing 

• hypotension and shock

HISTORY OF A SEVERE ALLERGIC REACTION AFTER VACCINATION

• Egg protein:

Yellow fever and Influenza vaccines (prepared using embryonated chicken eggs) 

Only hives:

get flu vaccine 

Other than hives:

get flu vaccine administered in medical setting

Severed allergic rxn to flu vaccine:

contraindication

HISTORY OF A SEVERE ALLERGIC REACTION AFTER VACCINATION
Gelatin (Fluzone and MMR):

stabilizer

HISTORY OF A SEVERE ALLERGIC REACTION AFTER VACCINATION

Thimerosal (thiomersal):

preservative in some influenza vaccines

HISTORY OF A SEVERE ALLERGIC REACTION AFTER VACCINATION

Neomycin:

antimicrobial in multi dose vaccines

• Delayed-type reaction (contact dermatitis) give vaccine

HISTORY OF A SEVERE ALLERGIC REACTION AFTER VACCINATION

latex

use latex free products (vinyl or nitrile gloves)

ENCEPHALOPATHY OCCURRING WITHIN 7 DAYS OF PERTUSSIS VACCINATION

• Encephalopathy  (coma, decreased level of consciousness or prolonged seizures (DTP/DTaP)

SEVERE COMBINED IMMUNODEFICIENCY (SCID)

• Due to reported cases of rotavirus infection after rotavirus vaccine administration with SCID, it becomes contraindication for rotavirus vaccine.

HISTORY OF INTUSSUSCEPTION (SPECIFIC FOR ROTAVIRUS VACCINE)

• Intussusception -  is a serious disorder where a part of the intestines slides into an adjacent part of the intestines.

Intussusception

-  is a serious disorder where a part of the intestines slides into an adjacent part of the intestines.