UWorld - Immunizations & Travelers

FDA

Approves vaccine indications, safety, and efficacy

ACIP

Make recommendations for vaccine administrations

CDC

Publishes recommendations in MMWR and Pink Book

Prepares/Publishes VIS for patient info

Thimerosal

• Mercury (Hg) containing preservative in multi-dose flu vaccines

• Studies proved no relationship btw Thimerosal or ANY vaccine w/ Autism

• but parents can request for single-dose flu vaccine or multidose vaccines w/o thimerosal

Common Live Vaccines

MICRO-VY

M- MMR

I - Influenza (live, Flumist)

C - Cholera

R - Rotavirus

O - Oral typhoid

V - Varicella (Chickenpox)

Y - Yellow Fever

Live Vaccine Timing

1. live & live

2. live → live

3. live → Ab

4. Ab → live

5. live & TB test

6. live → TB test

(technically, TST → live는 전에 하는거니까 상관없음)

In weeks:

1. 0 (동시가능)

2. 2+2 = 4

3. 2+0 = 2

4. 3-11 months

   • 그래서 보통 애기들 live vaccine 은 1살 (12mo) 부터 받기 시작.

   • Inactivated는 상관없음. Anytime but >2mo *except HepB vaccine @ birth

   • **Exception for simultaneous IVIG/Ab + Vaccine for PEP: Rabies, Tetanus, Hep A/B

5. 0 (동시가능)

6. 4

   • 사실 live-live 랑 live-TST랑 똑같음

Invalid contraindications to vaccine:

(그냥 받아도 괜찮을때)

1. mild acute illness (slight fever, mild diarrhea)

2. current Abx/ARV tx

   • *Except Varicella (valacyclovir, acyclovir, famciclovir), live influenza (Tamiflu, etc.), typhoid vaccines

3. previous mild-moderate local skin reaction

4. allergy to PCN or any other products not in the vacine

5. pregnancy (LIVE 는 CI맞지만 inactivated is fine), breastfeeding, premature birth

6. recent TB test (TST)

7. immunosuppressed person in the house (본인아님)

8. FH of ADE to vaccine (본인아님)

*CI and Precautions - All Vaccines*

CI - severe allergic reaction (anaphylaxis)

Precaution - moderate-severe illness → just delay and wait until fully recovered

(mild illness 는 그냥 cold 같은건 그냥 받아도 ok)

*CI and Precautions - Live Vaccines*

CI - pregnancy, immunosuppressed

Precaution - recent IVIG/Ab

*CI and Precautions - DTaP, Tdap 등 Pertussis-containing Vaccines*

CI - previously having encephalopathy w/in 7 days after receiving pertussis vaccine

Precaution - GBS w/in 6 weeks of previous pertussis vx, infantile spasms, uncontrolled seizures

*CI and Precautions - HBV, HPV*

CI - Yeast allergy

*CI and Precautions - LAIV4*

CI - live 니까 pregnant, immunosuppressed + LAIV4는:

• ASA-containing products (in kids)

• recent use of oseltamivir, zanamivir w/in 48h / peramivir w/in 5 days / baloxavir w/in 17 days

• Children 2-4 yo w/ asthma or wheezing in last 12 mo

• close contact w/ immunosuppressed person

*CI and Precautions - RZV (recombinant Zoster)*

Precaution - pregnancy, breastfeeding → delay vx

*CI and Precautions - Varicella*

CI - Gelatin, Neomycin allergy (anaphylaxis)

Precaution - use of Valacyclovir, Acyclovir, Famciclovir 24h before & 14 days after

*CI and Precautions - Rotavirus Vaccines*

뭔가 GI issues

*CI and Precautions - Yellow Fever*

CI - Egg (Yolk), Gelatin (노른자라 비슷한 탱탱한 텍스쳐) allergy

Vaccines for Infants & Children

• 3 doses (0-1-6) HepB @ birth

• RSV mab if mother didn’t get it during this pregnancy (nirsevimab, Beyfortus)

• Pediarix (IPV, DTaP, HepB) 같이 다른거 본격적으로 Inactivated @ 2 mo: DTaP, polio, Hib, rotavirus, PCV15/PCV20

  • No PPSV23 (polysaccharide vx) until @ 2 yo

• Live vx generally start @ 1 yo: MMR, Varicella

Vaccines for Adolescents & Young Adults

• MenACWY (Menveo, MenQuadfi)

  • (2) 11-12살 → 16살

  • (1) College student (freshmen) if not vx’ed before

• HPV (Gardasil 9)

  • 11-12살 ~ < 26 yo

  • 어릴때 하면 2 dose / 나중에 하면 3 doses

• Tdap routinely Q 10 yrs

Vaccines for Pregnancy

• NO LIVE Vx

• Inactivated Flu shot (each pregnancy 마다)

  • any trimester 노 상관

• Tdap x 1 (each pregnancy 마다)

  • Week 27-36

  • + Husband, grandparents, baby sitter등 close contact도 x1 if not up to date

• RSV (Abrysvo*) 인생에 딱 한번만. 예: 첫째 임신때.

  • Week 32-36, during RSV season

Vaccines for Elders

• >= 75 yo

  • RSV

  • 60-74 yo + RF (living in LT care facility**)

• >= 50 yo

  • Shingrix

  • Pneumococcal

    • PCV 20 or 21 × 1, or

    • PCV 15 → 12mo 후 → PPSV23

      • 8 weeks interval if Immunocompromised

      • 19-49 yo + RF (AUD**, Smoking**, 온갖comorbidities, Immcomp, Immsupp meds)

Vaccines for Pts w/ DM

(약간 immunocompromised라고 보기도 하고, needle 자주쓰고)

• Pneumococcal

  • PCV 20 or 21 × 1, or

  • PCV 15 → 12mo 후 → PPSV23

    • 8 weeks interval if Immunocompromised

    • 19-49 yo + RF (AUD**, Smoking**, 온갖comorbidities, Immcomp, Immsupp meds)

• HBV: >60 yo if not previously vx’ed

  • DM glucometer, insulin injection 등 needle 많이 쓰니까 HBV = Blood, Bodily fluid transmission.

Vaccines for HCPs

• annual influenza usually required

• HBV

• Varicella

• MMR

if no immunity demonstrated in vx record

Vaccines for Pts w/ Sickle Cell, Asplenia

(immunocompromised)

• Hib (H. influenzae)

• Pneumococcal

  • PCV 20 or 21 × 1, or

  • PCV 15 → 8 weeks b/c immcomp → PPSV23

    • 19-49 yo + RF (AUD**, Smoking**, 온갖comorbidities, Immcomp, Immsupp meds)

• MenACWY & MenB (Bexsero, Trumenba)

Vaccines for Immunocompromised pts

• Cancer

• HIV

• Transplant

• CKD

• Immsupp meds: TNFai, CNI, mabs, systemic steroids > 14 days > 20mg prednisone daily (이거 물어보더라;)

• NO LIVE Vx

• Pneumococcal

  • PCV 20 or 21 × 1, or

  • PCV 15 → 8 weeks b/c immcomp → PPSV23

    • 19-49 yo + RF (AUD**, Smoking**, 온갖comorbidities, Immcomp, Immsupp meds)

• MenACWY

• Shingrix (Herpes Zoster) @ > 19 yo

  • (2) 0 — 2-6

• HAV, HBV (Twinrix는 꼭 둘다 필요할때만)

  • Hep A RF: homelessness, MSM, illicit drug use

  • Hep B RF: tattoo, piercing, IVDU, MSM/multiple sex partners, jail, dialysis

COVID-19

• routine, need most up-to-date

• 2 doses if > 65 yo

• mRNA, so all pts > 6 mo

DTaP, Tdap, Td

• DTaP < 7 yo

  • 5 dose series for kids

  • 2→4→6→15-18mo→4-6yo

• Tdap or Td > 7 yo

  • Q 10 yr routine vx

  • 보통 11-12살에.

  • Wound ppx after deep/dirty wound & has been > 5 yrs since last Td/Tdap dose (tetanus, 파상풍 때문)

Hib

• routine childhood vx

• H influenzae bacteria

• Adults w/ asplenia

Hep A (Havrix, Vaqta)

Hep B (Engerix-B, Recombivax HB, Heplisav-B)

Twinrix

Pediarix

Hep A

• (2) 1-2살부터, 6 mo interval

• RF: MSM, illicit drug use, homelessness, HIV, travelers, cirrhosis

Hep B

• @ Birth. w/in 24h. 태어나자마자.

• > 60 yo if not previously. 어렸을때 안했다면?

• (3) = Engerix-B, Recombivax HB

  • 0-1-6

• (2) = Heplisav-B

  • 0-1

    • 앗 > 18 yo only, X use in Pregnancy

• RF: MSM/Multiple sex partners, IVDU, Jail, Blood exposure/needle stick (HCP, DM, dialysis), HIV, travelers, cirrhosis

Gardasil 9 HPV

• 9-26 yo, 이후에는 상담 후

• Before 15 yo = 2 doses

• After 15 yo = 3 doses

• HPV, Hep B = CI in severe Yeast allergy

Influenza (IIV4, LAIV4)

IIV4

• fluzone, fluarix, flucelvax, afluria

• fluzone HD

• flublok

• fluad

LAIV4

• FluMist (nasal, good for fear of needles)

• recommended annually for all pts > 6 mo

• “-flu-“ in name

• (2) doses if < 8 yo, 1st time or only had once

  • live→live = 4주 interval

• *Egg allergy = technically CAN receive anything

  • BUT egg-free options = Flublok (>18yo), Flucelvax (all age, >6mo)

• X FluMist for pregnant pts

• >65 yo elders 더 쎈거

  • Fluzone High-Dose

  • Flublok

  • Fluad

MMR: M-M-R II

MMRV: ProQuad (MMR + Varicella)

• live attenuated = X for preg, immcomp

• 2 doses after 1yo → 4-6 yo

• + 1 dose for adults/HCPs who don’t have evidence of immunity

• Storage:

  • MMR = fridge, freezer둘다 OK

  • MMRV = Varicella 때문에 Freezer

• Admin:

  • IM, SC 둘다 가능.

MenACWY

• adolescents & young adults

• RF:

  • travelers to African meningitis belt

  • Saudi Arabia visitors (required)

  • Haji, Umrah pilgrimage

  • asplenia/sickle cell

  • HIV

  • Lab workers exposed to N. meningitidis

  • ACWY = first-year college students living in dorms if not vaccinated

MenB

• >= 10 yo + only at high risk

• asplenia/sickle cell

• lab workers exposed to N. meningitidis

• outbreak

PCV20, PCV15, PPSV23

• 보통 어릴때 4-dose series 로 받음. 2/4/6/12-15

• adults 받은적없다면 > 50 yo

• 19-49 yo + RF

  • RF: AUD, Cigarette smoking, DM, CVD/HF, Asthma, COPD, cirrohsis, immcomp, immsupp drugs, sickle cell/asplenia, HIV, transplant, CKD, cancer

• PCV20 × 1 (IM)

• PCV15 × 1 → 12mo or 8 wk* 후 → PPSV23 (IM/SC)

  • PPSV23 = polysaccharide vx = only use in > 2 yo

IPV, Pediarix

IPOL, polio

Rotarix = RV1

RotaTeq = RV5

• rotavirus

• live

• given orally**

RSV (Abrysvo, Arexvy)

RSV-mabs (Nirsevimab = Beyfortus, Palivzumab = Synagis)

• all pts > 75 yo 적극추천

• 60-74 yo + RF

  • RF = living in LT care facility, COPD, asthma, HF, CKD, cirrhosis, DM, immcomp

• (1) Pregnant 32-36 weeks 근데 인생에 1번

  • 첫째 때 받음 → 둘째 때 못받음

  • Babies w/in < 8 mo born during RSV season → give nirsevimab

  • palivizumab for premature infants 😕

Varicella (Chickenpox) = Varivax

MMRV = ProQuad

• LIVE - X preg, immcomp

• Freezer, diluent in fridge or RT

  • reconstitute immediately

  • use w/in 30min

• CI - Allergy to gelatin, neomycin!

• Valacyclovir, acyclovir, famciclovir 24h 전, 14d 후 피하기.

• SC, IM 둘다가능.

Herpes Zoster (Shingles) = Shingrix

• all > 50 yo

• immunocomp > 19 yo

• X live, recombinant (inactivated)

• Vaccinate AGAIN even if pt was previously vaccinated w/ Varivax or Zostavax, or has Hx of Zoster infection!

  • recurrence is possible

• Do NOT freeze, IM only.

RabAvert (Rabies)

• animal handlers (PrEP/ppx) = 2 doses

• PEP w/ vx = 2 doses

• PEP w/o previous vx = 2+2 = 4 doses + 1 Rabies IG (RIG) @ 1st vaccine dose (동시에 줬던 예외!)

Oral typhoid = Vivotif

IM typhoid = Typhim Vi

for Salmonella typhi

• Vivotif (PO capsule) = live

  • store in fridge

  • take in empty stomach

• Typhim Vi (IM) = inactivated polysaccharide

Ixiara

Japanese encephalitis vx

BCG TB vaccine

Live vx. Might cause positive result to TST → so use IGRA (blood test)

YF-VAX (Yellow fever Vaccine)

• CI - do not use if severe allergy to egg (Yolks), gelatin (탱글)

• YELLOW = FAT = give SC

• yellow card (international travel Certificate of Vaccination)

Vaxchora (cholera live vx)

1 dose 10 days before travel/exposure

Vaccine storage

• never on fridge doors

• 선입선출, earliest exp date first

• check Temp twice daily, keep log for 3 years

Routes of Administration

• IM = mostly

• SC = Yellow Fever

• IM/SC 둘다가능 = PPSV23, MMR, MMRV, Varicella, IPV

• PO = Cholera, Oral Typhoid (Vivotif), Rotarix (RV1)

• Intranasal = FluMist

IM admin technique

• 90 degree angle

• 1 inch needle

  • males > 260 lb, females > 200 lb → use 1.5 inch needle (longer/deeper penetrate)

• deltoid muscle above armpit

SC admin technique

• 45 degree angle

• 5/8” needle

• fatty tissue behind the arm (삼두위에/over the triceps)

Drugs for TD

PPX:

1. BSS 524-1050mg po QID (w/ meals, QHS)

2. Rifaximin > azithro/FQ

Tx:

1. Salt water Hydration

2. Mild

   1. Loperamide (Imodium A-D) 4mg 1st → 2mg Q poop

      1. Max OTC = 8mg/day

      2. Max Rx = 16mg/day

   2. BSS

3. Moderate

   1. Loperamide + Azithromycin/FQ (if low resistance)

   2. rifaximin?

4. Severe/Dystentery

   1. Azithromycin 1000mg x 1 dose

   • X loperamide if blood

BSS CI/Precautions:

Pepto Bismol (bismuth subsalicylate)

• ASA allergy (salicylate임)

• renal insufficiency (ASA ~~ NSAID)

• ulcer, anticoag meds

• Kids < 16 yo → Reye’s syndrome

  • *esp after recent viral infection

• pregnancy

• gout

• Can cause black tongue/stools

Typhim Vi (IM typhoid)

• 2 week before

• 2 yo 이상

• 2 yr 마다 revax

Vivotif (PO typhoid)

• 1 week before

• 6 yo 이상

• 5 yr 마다 revax

Malaria mosquito (vector)

Anopheles mosquito

Malaria spp

• P. vivax = most common (50% of cases)

• P. falciparum = most deadly

Malaria 는 백신없음!! (낚였음) - can be fatal, so ppx meds are recommended!!

Malaria Tx - Quick Starts:

• 1-2 DAYS before travel

• Daily

• Avoid in pregnancy

• Causes nausea → take w/ Food, Milk, or Water

1. Doxycycline (Doryx, Vibramycin) - 귀국 후 4주

   • Pro: also covers lyme dz/tick-borne dz

   • Con: TC임!!

     • photosensitivity

     • X pregnancy

     • X children < 8 yo

2. Atovaquone/Proguanil (Malarone) - 귀국 후 1주

   • Pro: Good coverage

   • Con:

     • X preg

     • X breastfeeding

     • renal impairment

3. Primaquine - 귀국 후 1주

   • Pro: most effective against P. vivax

   • Con:

     • G6PD deficiency!

     • X preg

     • X BF

Malaria Tx - Advanced Starts:

• 1-2 WEEKS before travel

• Weekly

• Safe in pregnancy & Children

1. Chloroquine - 귀국 후 4주

   • Pro: n/a.

   • Con:

     • Resistance issues w/ P. falciparum & P. vivax제일 흔함 & 제일 deadly 둘다 안됌..?

     • Retinal toxicity/Visual changes

     • Exacerbtation of Psoriasis, skin rash

       • “Plaque”s in the eyes & skin! ~ Plaquenil (hydroxyChloroquine)

2. Mefloquine - 귀국 후 4주

   1. CI - underlying psych conditions, seizures, arrythmiasarrhythmias

3. Tafenoquine - 출국 3일전부터도 가능.

Altitude, Motion sickness

고산병, 멀미

• acetazolamide 125mg bid started day before 전날부터 = for 고산병

  • Pro: improve breathing

  • Con/ADE: polyuria, photosensitivity, CI in Sulfa allergy, rash, dehydration, etc.

• Scopolamine, AH