Immune system modulation and Vaccines

What is Cell-mediated immunity?

• immune response that activates specialized cells to destroy infected, abnormal, or foreign cells instead of producing antibodies

• Based on T cells

• This system is being manipulated to create drugs that both stimulate and suppress the immune system

What are the 2 types of T cells?

• Helper cells

• Cytotoxic T cells

What are helper cells?

• they activate all other immune cells including B cells (humoral immunity→ targets invaders outside cells, ex: viruses, bacteria, fungi, etc.)

What are cytotoxic T cells?

• killers of bacteria, viruses, parasites and cancer cells

• produce cytokines

What are cytokines?

• hormone like proteins that regulate the duration and intensity of immune response

• can kill foreign organsisms

• can also trigger INFLAMMATION and enhance the killing power of macrophages (ex’s: interleukin, interferon, tumor necrosis factor)

What are immunostimulants?

• increase the ability of the immune system to fight disease

• include: BRM’s, interferons, and interleukins

What are Biologic response modifiers (BRM’S)?

• made through recombinant DNA technology and boost specific functions of immune system (ex: filgrastim-Neupogen)

• specific to detailed target point

What are interferons?

• secreted by lymphoctyes that have been infected by virus- they warn the surrounding cells that infection has occurred. these have antiviral, anticancer, and anti-inflammatory properties.

• only respond to virus infecting cell

What are interleukins?

• secreted by lymphocytes and macrophages in response to an antigen. widespread effect on immune system- regulate cytotoxic T cell activity against tumor cells, increase B-cell and plasma cell production.

• respond when an antigen is involved

What is an immunosuppressant?

• a type of medicine that lowers or slows down the activity of the body's immune system

What is immunosuppression used for?

• Used in disease management

  • Transplantation

  • Acute inflammatory disease

  • Body is creating antibodies against its own cells (RA, lupus, myeasthenia gravis, psoriasis, UC, Crohn’s disease)

What is the pathophysiology regarding immunosuppression?

• Non-selectively effects T cell function. Newer drugs may be more targeted

• Toxic to bone marrow- can cause serious AE’s

• During treatment, pt’s highly susceptible to all pathogens. Infections are common. May take prophylactic anti-infectives

What are some ex’s of immunosuppressants?

• corticosteroids

• antimetabolites

• calcinerium inhibitors and anitbodies

• chemo as a result of the death of white cells and stem cells within the bone marrow

Why do those getting transplants need immunosuppression?

• Given to dampen immune response and retain the organ- body’s defenses want to kill it and remove it

• “Transplant rejection” is often acute and can turn into chronic rejection

• Long-term survivors of transplants are at high risk of developing cancers, especially lymphoma, skin cancer, and Kaposi’s sarcoma

What are Monoclonal Antibodies (MABs)?

• newest drugs for treatment of cancer and other immune-related disease. not cure-all, lots of SE’s, don’t always work

• made by injecting human T cells (antigens) into an animal which recognizes the cells as foreign and creates antibodies. then these are purified, replicated, and injected back into humans so that they will attack these T cells (autoimmune disease) or the tumor

What letters will a virus directed MAB have?

• vi-xx-mab

What letters will a cardiovascular directed MAB have?

• ci-xx-mab

What letters will a immune directed MAB have?

• li-xx-mab

What letters will a tumor directed MAB have?

• tu-xx-mab

What are the different types of immunity?

• Non-specific, innate (skin, epithelial linings, complement, fever, inflammation)

• Cell-mediated

• Humoral (anitbody development)

What are the different types of humoral immunity?

• Active: vaccination or having the disease and the body creates antibodies as a result of the exposure

• Passive: “borrowed” immunity, can come from mom to baby, or via immune globulins (often given following exposure to disease). examples: antivenins for snakebites, botulsim, tetanus, and rabies

With passive immunity, how does it come from mom to baby?

• IgG antibodies transferred- cover baby while their own humoral immunity is being developed, usually 6-12 months

• Recommend pregnant mom’s get a vaccine of Tdap between 27-30 weeks

Why are immunoglobulins given?

• passive immunity

• almost always given (usually IV or IM) to someone who has been exposed to a virulent pathogen or is very at risk of exposure and doesn’t have time to develop immunity

• almost always given as a borrowed immunity and the protective effects disappear within several weeks to months

What are ex’s of borrowed immunity?

• RhoGAM: immunoglobulin w/Rh+ antibodies, given to Rh neg. moms who may have Rh pos. babies. usually given at 28 weeks, can save babies life

• Varicella Zoster Immune Globulin: within 10 days of exposure to varicella zoster (chicken pox)

• IVIG: induces anti-inflammatory cytokines (masively down reglautes the immune system)- given to people w/acute auto-inflammatory problems (ITP, Kawasaki’s disease)

What are vaccines give to do?

• GIVEN TO PREVENT ILLNESS!

What are the different types of vaccines?

• Attenuated (live) vaccines

• Inactivated (killed) vaccines

• Toxoid vaccines

• Recombinant vaccines

What are attenuated (live) vaccines?

• the microbes are alive but weakend so unable to produce disease unless immune system is already weakened or you have had prior exposure

• ex: MMR vaccine

What are inactivated (killed) vaccines?

• the microbes have been inactivated by heat or chemicals and are unable to replicate or cause disease

• ex: Hep A and influenza

What are toxoid vaccines?

• contain bacterial toxins that have been chemically modifed to be incapable of causing disease

• ex: Diptheria and tetanus

What are recombinant vaccines?

• contain partial viral subunits or bacterial proteins - contain NO viral genetic material - viruses cannot become infectious

• ex: Hepatitis B or Human Papilloma Virus (HPV)

What are contraindications for vaccination?

• Hx of severe allergic reaction, anaphylaxis

• Week immune system

• Currrently experiencing symptoms of vomiting, fever, diarrhea

• Pregnancy (except influenza vaccine and COVID vaccine)

What is a “catch up schedule” for vaccines?

• a customized timeline used by healthcare providers to safely complete a series of missed or delayed immunizations

What leads to vaccine hesitancy?

• Culture/Religion

• Misinformation/myths

• Distrust and Politicization, not sure if they can trust the information (lack of transparency)

• Safety/Efficacy concerns

What is the nurse’s role with vaccine hesitancy?

• neither to ignroe or to convince people to take them

• provide information and education

What vaccines cause side effects?

• ANY vaccine can sause side effects

• vaccines are continually monitored for safety and every person should receive a vaccine information sheet for each vaccine given

What are some common SE’s of vaccines?

• Redness, swelling, tenderness, rash at injection site

• Fever, headache, body aches, loss of appetite

• In infants/young children- fussiness, feeling tired, loss of appetite, vomiting

What is VAERS?

• Vaccine Adverse Event Reporting System

  • Provider can report (healthcare providers required to report some AE’s)

  • Pt can report

  • Vaccine manufacturer is required to report all AE’s that come to their attention

  • Nurses should be familiar with VAERS and how to report an AE

Who deals with vaccine development?

• Advisory committe on Immunization Practices (ACIP): group of medical and public health experts who develop recommendations for use of a vaccine in the US

• There is a vaccine development outline that is gone through and at the end safety continues with CDC and FDA safety monitioring

What are antibodies?

• a specialized protein produced by your immune system's B cells to identify, bind to, and neutralize harmful foreign substances

What are antigens?

• any substance, like a protein or sugar, that enters the body and triggers an immune system response

What is immunization?

• the process of making a person resistant to an infectious disease, typically through the administration of a vaccine

What is autoimmune?

• your body's immune system mistakenly attacks its own healthy cells and tissues instead of fighting off outside germs

What is the immune response?

• How your body recognizes and defends itself against germs, viruses, bacteria, and other harmful foreign substances

• Recogniztion, attack, memory

What are innate body defenses?

• physical barriers, chemical secretions, internal cellular responses, and inflammatory processes that act as the body's non-specific first and second lines of defense

• first line = skin (Acts as an impermeable physical shield against microbes), mucous membranes (trap pathogens in respiratory and digestive tract), chemical secretions (sweat, tears, saliva, and stomach acid that destroy or inhibit invaders)

What is the MOA for Hepatitis B (Energix, Recombivax HB)?

• Vaccine that stimulates production of antibodies- given IM

What are the actions and uses for Hepatitis B vaccine?

• provides active immunity for 99-100% of pt’s- lasts about 5-7 years

What are the indications for Hep B vaccine?

• all infants at birth

• children under 19 (if not vaccinated)

• Adults with risk factors (healthcare workers, high risk sexual practices, correctional facilites, those who share needles)

What is the admin instructions for Hep B?

• IM injection x3: 2nd does in 1 month, 3rd dose in 6 months from 1st dose

What are the adverse effects of Hep B?

• pain at injection site

• mild to moderate fever

• flu-like symptoms

What are the contraindications for Hep B?

• don’t give to pts sensitive to yeast or HepB vaccine

• ** only give to pregnant mothers if needed to protect health of mother or child

What is the class and MOA for interferon alpha-2-b?

• Class: Biologic Response Modifier (BMR)

• MOA: alert the pts immune system to the offending virus or interferes with cell reproduction (cancers)

What are the uses for interferon alpha-2-b?

• treat hairy cell leukemia, malignant melanoma, non hodgkins lymphoma, HPV infection and chronic hepatitis (B or C)

What is the admin for interferon alpha-2-b?

• IM or IV - must be given by someone experienced with drug

What are AE for interferon alpha-2-b?

• 50% of pts experience- fever, chills, dizziness, fatigue

• Headache, N/V, diarrhea, and anorexia are common (mostly GI)

• BBW: may cause or aggravate fatal or life-threatening neuropsychiatric, autoimmune, ischemic or infectious disorders

What is the nursing care for interferon alpha-2-b?

• monitor lab tests, hepatic enzymes, and triglyceride levels

What is the class and admin for cyclosporine (Sandimmune)?

• calcineurin inhibitor- very narrow therapeutic index!

• admin: Oral or IV

What are the uses for cyclosporine?

• inhibits T helper cells which suppresses immune response to foreign tissue (bone marrow, lung, kidney, heart transplant)

• often used with high doses of corticosteroid (prednisone)

• can also be used for autoimmune disease like psoriasis, ulcerative colitis, or Crohn’s disease

What are AE for cyclosporine?

• immunosuppression (inability to fight infection)

  • 75% experience reduction in kidney function with decreased urine output

  • >50% have HTN and tremor

  • Gingival hyperplasia

  • Elevated hepatic enzymes

What is the BBW for cyclosporine?

• only administered by HCP’s experiences in immunosuppressive therapy

  • serious infection

  • possibly malignancy

  • nephrotoxicity at high doses

What are the contraindications for cyclosporine?

• prior hypersensitivity to the drug, grapefruit juice can increase drug levels by 50-200%

What are drug-drug interactions for cyclosporine?

• many!

• Antiseizure meds

  • Azole antifungal drugs, ACE inhibitors, NSAIDS and macrolide antibiotics can increase drug levels

What is the nursing care for cyclosporine?

• high risk for infection

• monitor labs for infection

• drug levels

• education pt/family on SE’s and AE’s

What is the class for rituximab (Rituxin)?

• monoclonal antibody

What are the uses for rituximab?

• treat lymphoma, rheumatoid arthritis

• off label for many other autoimmune diseases

What is the MOA for rituximab?

• attaches to CD20 positive tumor cells and causes cell death

What are AE’s for rituximab?

• 80-90% of pts experience an allergic or anaphylactic reaction with infusion. these can be manages with premedication and slow titration of infusion rate

• nurses are critical to medication safety!

What is the nursing care for rituximab?

• monitoring for reactions

• treating and managing multiple bacterial/viral/fungal infections, lymphopenia (low lymphocytes), leukopenia, neutropenia, thrombocytopenia, and anemia