Vaccines/Travelers

FDA purpose for vaccines

approves the indication demonstrated from safety and efficacy

what is active immunity?

immune system develops its OWN antibodies after exposure from

• vaccines (live and inactivated)

• infection

ACIP (Advisory Committee on Immunization Practices) purpose

provides recommendations for vaccine administration in children and adults (who gets what vaccine and what)

CDC purpose

approves ACIP recommends and publishes in CDC’s Morbidity and Mortality Weekly Report (MMWR)

Pink Book purpose

provides vaccine info and education materials for HCPs

when should a VIS be given?

prepared by CDC

handed to the patient BEFORE a vaccination is administered

what is informed consent?

patient’s ethical right to autonomy

• clear communication about benefits, risks and alternatives to care

• federal law does NOT require informed consent before imz, but states law may require (VIS)

what ingredient was thought to have caused autism from vaccines?

thimerosal (mercury-containing preservative)

• no evidence that is poses a risk for autism

• was removed from childhood vaccines in 2001

live attenuated vs inactivated vaccines

live-attenuated

• ability to replicate

• strong immune response to vaccine

• contraindicated in pregnancy and immunocompromised

inactivated

• composed of killed whole virus or bacterium or fractions of either

• immunity can diminish and supplemental booster doses may be required

examples of inactivated vaccine categpries

1. polysaccharide

   1. sugar molecules from outside layer of encapsulated bacteria

   2. do NOT produce good immune response in children <2

   3. ex. pneumococcal polysaccharide vaccine (Pneumovax 23)

2. conjugate

   1. use polysaccharides to join molecules to carrier proteins

   2. increases immune response in infants

   3. ex. Prevnar 20 (pneumococcal conjugate vaccine, Menveo (meningococcal conjugate vaccine

3. recombinant

   1. gene segment insereted into gene of another cell

   2. ex. Gardasil 9 (HPV), Flublok Quadrivalent (recombinant influenza)

4. toxoid

   1. targets a toxin produced by disease

   2. ex. diphtheria toxoid vaccine

5. mRNA

   1. gives instructions to body to produce protein specific

   2. ex. COVID-19 vaccine

Live Vaccines examples (MICRO-VY)

MMR

Intranasal influenza

Cholera

Rotavirus

Oral Typhoid

Varicella

Yellow Fever

others: TB (BCG), dengue, smallpox, ebola

Can live and inactivated vaccines be administered together?

YES

what does increasing the interval between doses of a vaccine do?

delays complete protection

what does decreasing the interval of vaccine doses do?

interferes with antibody response

what is the interval between antibody-containing and MMR/varicella-containing?

minimum 3 months and up to 11 months

how long as most live vaccines held for children?

12 months of age

maternal antibodies passed from mother to baby reduces infant’s response to live vaccines

when live vaccine is given to to infants?

Rotavirus

• prevents rotavirus-induced gastroenteritis

which inactivated vaccine is started at birth?

HepB

live vaccines can cause what result with the TST or PPD test for latent TB?

false negative

how to reduce risk of false negative TST and live vaccine?

1. give live vaccine on same day of TST

2. wait 4 weeks after live vaccine to perform TST

3. administer TST first then give live vaccine

can multiple live vaccines be given on same day?

YES

• if not, then space 4 weeks

• oral rotavirus or typhoid vaccines need NO separation

if a vaccine requires > 1 dose, can the interval be extended?

YES, but not shortened

do NOT have to restart series

interval for live vaccine 1st then antibody-containing product

2 weeks

what is recommended for post-exposure ppx of certain disease (hep A and B, rabies, tetanus)

simultaneous admin of live vaccine and antibody (IVIG)

when can systemic reactions occur after a live vaccine?

3-21 days after admin (after an incubation period)

• intranasal flu vaccine can cause mild cold-like symptoms (runny nose)

what 2 meds can help with minor allergic reactions?

diphenhydramine

hydroxyzine

severe allergic reaction sx

• urticaria (hives)

• swelling of the mouth and throat

• difficult breathing

• wheezing

• abdominal cramping and hypotension/shock

how many epi autoinjectors should be available in severe allergic rxn?

3 adult (0.3) prefilled epi auto-injectors

what is a contraindication to any subsequent doses of the SAME vaccine?

severe or anaphylactic rxn

invalid contraindications to vaccinations

may be given, if indicated, for the following situations

• mild acute illness (slight fever, mild diarrhea)

• current antimicrobial tx (except varicella, live influenza, oral typhoid)

• previous mild-moderate local skin rxn from vaccine

• allergy to penicillin or products not in vaccine

• pregnancy (except live vaccines), breastfeeding, premature birth

• recent TB skin test (live vaccines only for timing)

• immunocompromised person in household, recent exposure to disease or convalescence

• family hx of AEs to vaccine

precaution for ALL vaccines

if moderate-severe acute illness (regardless of abx use) it is reasonable to delay vaccination until condition has improved

HepB and HPV vaccine contraindication

hypersensitivity to yeast

contraindication to yellow fever vaccine

severe allergic reaction (anaphylaxis) to eggs or gelatin

vaccines admin for infants/children

• 3-dose HepB started at birth

• RSV monoclonal antibody if not admin to mother

• 2 months: PCV15 or PCV 20, DTaP, Hib, polio, rotavirus

• >12 months: live vaccines of MMR, varicella

• No polysaccharide before age 2

gvaccines admin for adolescents and young adults

• meningococcal quadrivalent vaccine (MenACWY) (Menveo or MenQuadfi)

  • 2 doses: 1 at age 11-12 and 2nd at 16 years

  • first year college students if not previously vax

• HPV

  • age: 11-12 (2-3 doses)

• Tdap

  • first dose age 11-12 yrs

pregnancy vaccines needed

• live vaccines are contraindicated

• RSV (Abrysvo) at weeks 32-36

• inactivated influenza at ANY trimester

• Tdap x 1 with every pregnancy (weeks 27-36)

older adult vaccines

• Shingrix age ≥50 yrs

• pneumococcal age ≥50 yrs

  • PCV20 × 1, PCV21 × 1, or PCV15 × 1 then PPSV23 × 1 >12 months later

• RSV age ≥75 yrs

diabetes vaccines (2)

• pneunomococcal vaccine (age 19-49yrs)

• HepB age ≥60 yrs

sickle cell disease/asplenia vaccines

1. H. influenza type B (Hib)

2. pneumococcal vaccine (age 19-49)

3. meningococcal vaccine

   1. Menveo or MenQuadfi (MenACWY)

   2. meningococcal serogroup B vaccine (MenB) (Bexsero or Trumenba)

immunocompromised vaccines

live vaccines are contraindicated

1. pneumococcal (age 19-49)

2. Shingrix age ≥19 yrs

3. HIV infection

   1. menACWY

   2. hep A

   3. hep B

COVID-19 vaccine dose and age (4)

1. previously unvaccinated and age ≥12 years

   1. 1 dose

2. previously unvaccinated and age 12-64 yars

   1. 1 dose of any vaccine administered at least 8 weeks after the most recent COVID-19 vaccine

3. previously unvaccinated and age ≥65 years

   1. 2 doses of any vaccine at months 0 and 2-6

4. age <12 yrs or immunocompromised: consult CDC website

Pediarix (3 components)

1. DTaP

2. HepB

3. IPV

who is Pediarix indicated for?

children age < 7 yrs

Tdap brand names (2)

Adacel

Boostrix

when is routine Tdap/Td boosters given?

every 10 years in adults

what special pops is Tdap/Td indicated for? (3)

1. pregnant people in third trimester of each pregnancy

2. close contacts of infants

3. HCP if not up to date

4. wound ppx: if deep or dirty wound and >5 yrs since last dose

when is haemophilus influenza Type B (Hib) given?

adults with asplenia

Havrix, Vaqta vaccine

HepA

Energix-B, Heplisav-B, Recombivax HB vaccine

HepB

which adults should receive HepA vaccine?

chronic liver disease, men or have sexual with men, illicit drug use, HIV, travelers

when is HepB vaccine given to infants?

within 24 hours after birth (3 doses at 0, 1-2, and 6-18 months)

when is HepB recommended for adults

(if previously unvaccinated)

• all ages 19-59 yrs or those ≥60 yrs with risk factors

  • chronic liver disease

  • HIV

  • blood exposure (HCPs, dialysis, diabetes)

how many doses is Twinrix?

Hep A and B

3 doses (ages 0, 1, and 6 months)

what does Gardasil (HPV9) prevent

cervical, vaginal, penile, anal cancers and genital warts

recommended age for Gardasil 9

9-26 yrs

• recommended age: 11-12 yrs (may be started at age 9)

• contraindicated with yeast allergy severe

regimens of Gardasil 9 (2)

• before age 15: 2 doses (0, 6-12 months)

• ≥15 yrs or immuncompromised: 3 doses (0, 1-2, 6 months)

what age can flu vaccines start to be given annually?

≥6 months

when should 2 doses of influenza vaccine be given on first vaccination? (or only one dose given previously in their lifetime

ages 6 months to 8 yrs old

4 weeks apart

can patient with an egg allergy receive any flu vaccine?

YES

even if severe allergy symptoms

no additional observation time is recommended beyond 15 min

brand examples of egg-free products (2)

Flublok (age >18 yrs ONLY)

Flucelvax

what 3 brand flu vaccines are preferred in older adults? (≥65 yrs)

Fluzone HD

Fluad

Flublok

inactivated influenza vaccines (IIV) (8)

1. ≥6 months

   1. Afluria, Fluarix, FluLaval, Fluzone

   2. Flucelvax (egg-free)

2. ≥18 yrs

   1. Flublok

3. ≥65 yrs

   1. Fluzone HD, Fluad

Live Attenuated Influenza Vaccine (LAIV)

FluMist

healthy people age 2-49

admin 0.2mL divided between the 2 nostrils

2 MMR containing vaccines (Live Attenuated)

MMR: M-M-R II (Priorix)

MMRV (MMR + Varicella): ProQuad

how many doses is MMR for children

2 doses (ages 12-15 months then 4-6 yrs)

how many doses is MMR in adults

1 dose if no evidence of immunity

give 1-2 doses (4 weeks apart) if no immunity to healthcare workers

how should MMR be stored?

refrigerator or freezer

How should ProQuad (MMRV) be stored?

freezerh

how should MMR be admin?

SC (MMR II and ProQuad can be given IM)

MenACWY brand names (2)

MenQuadfi age ≥2 yrs

Menveo age 2 months-55 yrs

when should MenACWY be given for adolescents?

ages 11-12 and 16 yrs (2 doses)

special populations that should get MenACWY

• travelers to African meningitis belt

• age ≥2 months: asplenia, sickle cell disease, HIV infection

• lab workers with N. meningitidis exposure

• first-year college students

which brand MenAWCY has both vials containing the vaccine? (powder and liquid)

Menveo

MenB brand names

Bexsero

Trumenba

MenABCWY: Penbraya

who should receive MenB vaccine

age ≥10 yrs at high risk

• asplenia/sickle cell disease

• lab workers

• outbreak!!!

not at high risk (ages 16-23) optional

what pneumo vaccines should children <5 yrs receive as part of routine childhood vaccinations?

PCV15 or PCV20

what pneumo vaccines can adults receive?

PCV20 × 1

PCV21 × 1

PCV15 followed by PPSV23 1 yr later

brand names of conjugate pneumo vaccines

Prevnar 20 (PCV20)

Capvaxive (PCV21)

Vaxneuvance (PCV15)

which pneumo vaccine can be given IM or SC?

Pneumovax 23 (PPSV23)

how should rotavirus vaccine (live) be given?

orally

RV1 brand name

Rotarix

RV5 brand name

RotaTeq

RSV vaccine brand names (2)

Abrysvo

Arexvy

RSV monoclonal antibodies (2)

nirsevimab (Beyfortus)

Palivizumab (Synagis)

how many doses of Abrysvo should be given in pregnant people 32-26 weeks?

1 dose to prevent RSV in infants <6 months

when are RSV monoclonal antibodies indicated?

neonates and infants <8 months born during or entering first RSV season

what RSV monocloncal antibody is indicated if mother was not previously vaccinated during pgrenancy?

nirsevimab (Beyfortus)

brand names for varicella containing (3)

Varicella Virus Vaccine (chickenpox): Varivax (live)

MMRV: ProQuad

Zoster Virus Vaccine (herpes zoster/shingles): Shingrix

how many doses is Varivax for adolescents/adults without immunity?

2 doses

what class of medications interfere with Varivax?

antivirals (acyclovir, famciclovir)

stop 24 hrs before admin and do NOT take for 14 days after

T/F: patients should still be vaccinated with Shingrix if previously received Varivax or Zostavax or has hx of zoster infection

TRUE

How should Varivax be stored?

freezer

Varivax important notes

reconstitute immediately upon freezer removal and administer within 30 minutes

do NOT given if hypersentivitiy to gelatin or neomycin

give SC or IM

how should Shingrix be stored and admin

admin IM

store NOT in the freezer

what is given with RabAvert (rabies) vaccine 1st dose for post-exposure?

1 dose rabies immune globulin (RIG)

typhoid oral capsules vaccine (live) should be stored where?

refrigerator

prevents Salmonella typhi

what vaccine can cause a positive reaction to TB skin test?

BCG vaccine (TB vaccine)

what is contraindicated with Yellow Fever Vaccine (YF-VAX)?

severe (life-threatening) allergy to eggs or gelatin

what is given with the Yellow Fever Vaccine?

International Certificate of Vaccination (yellow card)

• valid for 10 years, starting 10 days after vaccination

how is yellow fever vaccine admin?

SC

reconstitute with provided diluent