Immunization APhA Content

Examples of active immunity

Infection with a disease

Vaccination

Examples of passive immunity

Antibodies in breast milk

Antivenom injection

Immune globulin infusion

Live Vaccines include:

MMR

Varicella

Rotavirus

Live attenuated influenza

Oral typhoid capsules

Yellow fever

Chikungunya

Why are adjuvants added to vaccines?

To help build immunity

Why are pure polysaccharide vaccines NOT recommended in children < 2 years?

Pure polysaccharide vaccines only produce a B cell response

• Ineffective in children < 2 years

Minimum interval between an inactivated vaccine and a live vaccine, another inactivated vaccine, or antibodies

No minimum

Minimum interval between two live vaccines

28 days if not administered simultaneously

Minimum interval between a live vaccine and blood products

Blood products before vaccine → minimum interval varies

Blood products after vaccine → 2 weeks

Minimum interval between a live vaccine and PPD skin test

PPD skin test before vaccine → administer vaccine after PPD skin test has been read

PPD skin test after vaccine → 28 days

When PPD follows a live vaccine, it leads to a _____

False negative

PPD test

Purified protein derivative

• Skin test for tuberculosis

Vaccine grace period

Refers to the period inside of the stated “minimum interval”

• ACIP counts “on time” as within 4 days of the minimum interval

• There is no grace period for live vaccines

What happens if the interval between vaccine doses in a series is decreased?

Interferes with antibody response

What happens if the interval between vaccine doses in a series is increased?

May delay protection

False Contraindications for Vaccines

Minor illness

• Vaccine should not be given if patient is ill enough to refer to physician or hospital

Allergies that are not immediate and life-threatening

Pregnancy in the household

Breastfeeding

Premature birth

General guidelines for vaccination during pregnancy

Tdap is recommended for every pregnancy, ideally weeks 27-36

Inactivated influenza vaccine is recommended

Bivalent RSVPreF is recommended during weeks 32-36 in RSV season

Generally defer live vaccines and any inactivated vaccines not mentioned as recommended → administer after pregnancy

How does immunosuppression affect live and inactivated vaccines?

Live vaccines pose an increased risk for an adverse effect

Inactivated vaccines may have decreased effectiveness

Types of immunosuppression

Congenital immunodeficiency

Cancer

Hematopoietic stem cell transplant patients

Solid organ transplant recipients

Asplenia or sickle cell diseases

HIV infection

Radiation therapy or chemotherapy

Immunosuppressive medications

How long should vaccines be given before immunosuppression?

Live vaccines → 4 weeks prior

Inactivated vaccines → preferably 4 weeks prior, at least 2 weeks prior

Precautions for immunosuppressed patients if someone in the household received a vaccine

Caution handling diapers following oral rotavirus vaccine

Avoid contact with skin lesions if they occur following varicella or zoster vaccine

Vaccine schedules key - yellow

Recommended

Vaccine schedules key - yellow with spots

Recommended vaccination can begin in this age group

Vaccine schedules key - green

Recommended for catch-up

Vaccine schedules key - blue

Shared clinical decision making

Vaccine schedules key - purple

Recommended if high risk

Vaccine schedules key - gray

No guidance/not applicable

Vaccine schedules key - brown

Recommended, additional doses may be necessary based on medical condition or other indications

Vaccine schedules key - orange

Precaution, vaccine might be indicated if benefit of protection outweighs risk of adverse reaction

Vaccine schedules key - red

Not recommended/contraindicated

What is the typical onset of influenza symptoms after exposure?

2 days (range of 1-4 days) after exposure

How long is a patient with influenza considered contagious?

Generally, 1 day before symptoms and 5-7 days after onset

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

_____ should not self-administer FluMist At Home

Children < 18 years

ACIP Recommendation for Influenza Vaccine

Routine annual vaccination is recommended for all persons ≥ 6 months with no contraindications

Adults ≥ 65 years should preferntially receive IIV3-HD, RIV3, or aIIV3

• If not available, should use any other age appropriate influenza vaccine

Solid organ transplant recipients aged 18-64 years should receive IIV3-HD or aIIV3

Children who have not previously received the influenza vaccine should receive _____

2 doses at least 4 weeks apart

Timing for influenza vaccine

Generally recommended during September or October

Vaccination should continue throughout the inflenza season while influenza virus is still circulating and unexpired vaccine is still available

Influenza vaccination during July and August is not recommended for most groups, except:

Pregnant patients in the third trimester

Children < 9 years who need 2 doses in one season

Concern that vaccination later in the season might not be possible

DTaP is FDA approved for _____

Ages < 7 years

Tdap is FDA approved for _____

Boostrix → ≥ 10 years

Adacel → 10-64 years

DTaP/Tdap recommendations for ages 6 weeks-6 years

Use DTaP to complete the primary series

Tdap recommendations for age 7-10 years who are not fully vaccinated against pertussis

Give a single dose of Tdap

Tdap recommendation for 11 years and older

1 dose of Tdap every 10 years

Tdap recommendation for 65 years and older

Use Boostrix

• Use Adacel to not miss an opportunity if Boostrix is not available

Tdap recommendation in pregnancy

1 dose of Tdap, preferably during weeks 27-36

Tdap recommendation for wound management

If no record of Tdap → 1 dose of Tdap

If previously vaccinated with Tdap → 1 dose of Tdap or Td

Normal MMR series for children

Dose 1 at age 12-15 months

Dose 2 at age 4-6 years

Adults born _____ are considered immune to MMR

Before 1957

MMR recommendation for students entering post-high school training

All students with no evidence of immunity should receive 2 doses, 4 weeks apart

MMR recommendation for health care personnel

Born during or after 1957 with no evidence of immunity → receive 2 doses at least 4 weeks apart

Born before 1957 with no evidence of immunity → consider 2 doses at least 4 weeks apart

• If an outbreak occurs → receive 2 doses at least 4 weeks apart

MMR recommendations for measles outbreaks

Can be given to children as young as 6 months who are at high risk of exposure such as during international travel or during a community outbreak

• Doses before 12 months cannot be counted toward the 2 dose series

MMR vaccines given within 72 hours of initial measles exposure can reduce the risk of getting sick or reduce the severity of symptoms

MMR recommendations for mumps outbreaks

Those previously vaccinated with 2 doses who are at increased risk because of an outbreak should receive a third dose

• Third dose provides a short-term boost in antibodies to enhance protection against mumps disease and related complications

How is chicken pox transmitted?

Via respiratory droplets or contact with lesionsW

When is a patient with chicken pox considered contagious?

1-2 days before the rash and 4-5 days after onset of rash

Where does the rash appear in a patient with chicken pox?

Head first

Concentration on trunk

Duration of 5-10 days

ACIP Varicella Recommendations

Children

• First dose → 12-15 months

• Second dose → 4-6 years

Age 7-12 years without evidence of immunity → 2 doses, 3 months apart

Age ≥ 13 years without evidence of immunity → 2 doses, 4-8 weeks apart

Shingrix is a _____ zoster vaccine

Recombinant, adjuvanted

Shingrix is FDA approved for _____

Prevention of herpes zoster in:

• Adults 50 years and older

• Adults 18 years and older at increased risk due to immunodeficiency or immunosuppression

Shingrix ACIP recommendation

Immunocompetent adults 50 years and older

• Includes those who previously received zoster vaccine live (Zostavax)

Immunocompromised adults ≥ 19 years of age

Gardasil-9 protects against 90% of _____

Cervical cancers and genital warts

ACIP recommendation for HPV

Immunocompetent age 9-14 years

• 2 dose series at 0 and 6-12 months

Age 15-26 years

• 3 dose series at 0, 1-2, and 6 months

Age 27-45 years

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

Immunocompromised patients need 3 doses regardless of age

ACIP recommendation for PPSV23

Children 2-18 years with certain underlying conditions after completion of a full PCV13 or PCV15 series and an additional PCV15

• Single dose

Adults ≥ 65 years or > 18 years with certain underlying conditions

• Single dose 1 year after PCV15

• Alternative option → No PPSV23, may give PCV20 alone

ACIP recommendation for PCV15

Children at age 2, 4, 6, 12-15 months

Children with high-risk medical conditions

• CDC recommends PCV15 as an alternative to PPSV23

Age ≥ 50 years and 19-49 years with certain underlying conditions

• Single dose followed by a dose of PPSV23 ≥ 1 year later

ACIP recommendation for PCV20

Children at age 2, 4, 6, 12-15 months

Children with high-risk medical conditions, if no documentation of PCV20

Age ≥ 50 years and 19-49 years with certain underlying conditions

ACIP recommendation for PCV21

Age ≥ 50 years and 19-49 years with certain underlying conditions

• Approved only for adults ≥ 18 years

ACIP pneumococcal recommendation summary for routine immunization of infants and children

PCV15 or PCV20

Doses at 2, 4, 6, 12-15 months

Healthy children 24-59 months with incomplete PCV series should receive 1 dose of PCV15 or PCV20

ACIP pneumococcal recommendation summary for 2 years to 18 years with certain medical conditions without history of PCV20

PCV20

or PPSV23 at least 8 weeks after last PCV

ACIP pneumococcal recommendation summary for ages 6 years to 18 years with certain medical conditions without a PCV dose

PCV20

or PCV15 followed by PPSV23 at least 8 weeks later

ACIP pneumococcal recommendation summary for adults ≥ 50 years and 19-64 years with certain medical conditions

Single dose of PCV15 followed by single dose of PPSV23 at least 1 year later

or Single dose of PCV20

or Single dose of PCV21

Typical dosing schedule for Hepatitis A vaccines

2 doses at least 6 months apart

Brands are interchangeable

Twinrix dosing schedules

Standard → 0, 1, and 6 months

Accelerated → 0, 1 week, 3 weeks, and 1 year

ACIP recommendation for Hepatitis A

Routine vaccination for:

• All children 1-2 years old

  • Catch up by age 18 → should complete a 2 dose series, minimum interval of 6 months

• Adults if risk factors are present or immunity is desired

ACIP recommendation for Hepatitis B

All infants

• 0, 1-2, 6-18 months

All adolescents and adults 19-59 years who have not previously been vaccinated

All adults ≥ 60 years who:

• Have risk factors

• Have diabetes (with shared clinical decision making)

• Request a Hepatitis B vaccine

Characteristics of RSV

Common respiratory virus that usually causes mild, cold-like symptoms

Spread via respiratory droplets

Mean incubation time of 4-6 days

Recovery time of spproximately 1-2 weeks

Infects 90% of children within the first 2 years of life

Most common cause of bronchiolitis and pneumonia in children younger than 1 year of age in the US

Symptom presentation of RSV

Usually mild to no symptoms

Upper respiratory symptoms can include rhinorrhea, pharyngitis, cough, headache, fatigue, fever, and wheezing

Some adults may progress to developing a severe lower respiratory infection such as pneumonia

Can exacerbate asthma, COPD, and CHF

Passive Immunization for RSV include _____

Nirsevimab and Clesrovimab

ACIP recommendation for RSV in Infants

Infants younger than 8 months bron during or entering their first RSV season (October-March) should receive one dose of nirsevimab or clesrovimab if:

• The mother did not receive the RSV vaccine during pregnancy

• The mother’s RSV vaccination status is unknown

• The infant was born less than 14 days after maternal RSV vaccination

Children age 8 months to 19 months at increased risk of severe RSV and entering their second RSV season should receive one dose of nirsevimab

ACIP Recommendation for RSVPreF

During 32-36 weeks gestation, with seasonal administration

• September through January in most of the continental US

ACIP recommendation for RSV vaccination in adults

All adults ≥ 75 years and adults 50-74 years at increased risk of severe RSV disease should receive a single dose