Immunizations & Travelers

Common Live Vaccines

[MICRO VY]

MMR

Intranasal influenza

Cholera

Rotavirus

Oral Typhoid

Varicella

Yellow Fever

Starting Vaccines for Infants & Child

Most Live Vaccines

• Help until 12 months of age

Live Rotavirus Vaccine

• Give at 2 months of age

Most Inactivated Vaccines

• Give at 2 months of age

Hepatitis B Vaccine

• Give at birth

Live Vaccines & TB Skin Test (TST)

1. Live + TST the SAME day

2. Live, wait 4 weeks, TST

3. TST, wait >/= 24 hours, Live

Vaccine Timing & Spacing

General Rules

• Vaccines can be given at the same time (same visit or same day)

• Multiple live vaccines can be given same day or (if not same day) spaced 4 weeks apart

  • Oral rotavirus or typhoid doesn’t need separation

• If vaccine needs> 1 dose, intervals can be extended without restarting, BUT should not be shortened intervals

Live Vaccines & Antibodies

• MMR & Varicella vaccines separate from antibody-containing product (blood transfusion, IVIG)

  • Vaccine → wait 2 weeks → antibody-containing product

  • Antibody-containing product → wait >/= 3 months → vaccine

• Simultaneous administration of vaccine & antibody recommended for post-exposure prophylaxis of certain diseases

  • Hep A & B

  • Rabies

  • Tetanus

DTaP [Diphtheria, Tetanus, Pertussis]

Td or Tdap [Tetanus, Diphtheria, Pertussis]

DTaP (Daptacel, Infanrix)

DTaP-HepB-IPV (Pediarix)

• IPV = inactivated polio virus

DTaP (Daptacel, Infanrix) DTaP-HepB-IPV (Pediarix) IPV = inactivated polio virus	5 doses @ 2,4,6,15-18 months & 4-6 YO Only for < 7 YO
Tdap (Adacel, Boostrix)	Give @ age 11-12 YO Give every 10 years Give EACH pregnancy Give close contacts of infants (e.g., obstetrician) Give Would Prophylaxis (deep/dirty wounds & has been > 5 yrs since last Td/Tdap)

Haemophilus Influenzae Type B (Hib)- Containing Vaccines

Hib (ActHIB, Hibeerix, PedvaxHIB) DTaP-IPV/Hib (Pentacel) DTap-IPV-Hib-HepB (Vaxelis)

Give @ 2-15 months Give to adults with Asplenia

Hepatitis-Containing Vaccines

Hepatitis A (Havrix, Vaqta)	Children: 2 doses @ 12-23 months (6 months apart) Adults: men-men sex, illicit drug use, chronic liver disease, homelessness, HIV, travelers to endemic area
Hepatitis B (Engerix-B, Heplisav-B, Recombivax HB) DTaP-HepB-IPV (Pediarix)	Children: within 24 hours after birth; 3 doses @ 0, 1-2, & 6-18 months Adults (not vaccinated before): 19-59 YO, > 60 YO with risk factors (chronic liver disease, HIV, blood exposure)

Human Papillomavirus Vaccine

• Prevent cervical cancers & genital warts

HPV9 (9-Valent) Gardasil 9

Give 9-26 YO (Recommend 11-12 YO) AVOID in severe yeast allergy < 15 YO → 2 dose (0, 6-12 months) >/= 15 YO → 3 doses (0, 1-2, 6 months)

Influenza Vaccines

**Give annually to >/= 6 months of age

***6 months - 8 YO (1st time vaccinating) → 2 doses (4 weeks apart)

Quadrivalent Live Attenuated Influenza Vaccine (LAIV4)

FluMist

For 2-49 YO AVOID pregnancy & immunocompromised Divide into 2 nostrils

Quadrivalent Inactivated Influenza Vaccine (IIV4)

Afluria, Fluarix, FluLaval, Fluzone	>/= 6 months of age
Flucelvax (>/= 6 months) Flublok (>/= 18 YO)	For egg allergy PT
Fluzone High-Dose, Fluad, Flublok	>/= 65 YO

Measles, Mumps, & Rubella Vaccines (MMR)

MMR (M-M-R II, Priorix)	2 doses @ 12-15 months, 4-6 YO 1-2 doses (4 weeks apart) for Healthcare workers who have no evidence of immunity Refrigerator or Freezer SC or IM
MMRV (MMR + Varicella) [ProQuad]	For 12 months - 12 YO 1-2 doses (4 weeks apart) for Healthcare workers who have no evidence of immunity In the Freezer SC or IM

Meningococcal Vaccines

MenACWY (MenQuadfi) (Menveo)	MenQuadfi → >/= 2 YO Menveo → 2 months - 55 YO (> 56 YO if needed) Routine 2 doses @ 11-12 YO & 16 YO Special Populations at High Risk Travelers in the African meningitis belt >/= 2 months of age with asplenia/sickle cell disease, HIV infection Lab workers, First-Year college students
MenB (Bexsero, Trumenba) MenABCWY (Penbraya)	>/= 10 YO at High Risk Asplenia/sickle cell disease Lab workers During an Outbreak Penbraya Prefilled syringe → MenB Vial → MenACWY Must use both components

Pneumococcal Vaccines

Conjugated Vaccines Prevnar 20 (PCV20) Vaxneuvance (PCV15)	Children 4 doses of PCV20 or PCV15 @ 2,4,6,& 12-15 months Adult (never received) 19-64 YO with specific medical condition or >/= 65 YO PCV20 × 1  PCV15 × 1 followed by PPSV23 × 1 12 months later (can be 8 weeks later if immunocompromised) Specific medical condition: alcohol disorder, cigarette, DM, chronic heart, lung, liver disease, immunocompromised
Polysaccharide Vaccine Pneumovax 23 (PPSV23)	Children 2-18 YO who have done PCV20 or PCV15 series Adults Done after PCV15 **Give SC or IM

Poliovirus Vaccines

IPV [SC or IM] DTap-HepB-IPV (Pediarix) → [IM]

4 dose give @ 2, 4, 6-18 months & 4-6 YO

Rotavirus Vaccines

RV1 (Rotarix) RV5 (RotaTeq)

Give @ 2 months after birth Oral

RSV Vaccines

• Prevent lower respiratory tract disease during RSV season

RSV Vaccines (Abrysvo)	Pregnant @ 32-36 weeks gestation during RSV season (Sep-Jan) → Abrysvo × 1 to prevent RSV in infants < 6 months old >/= 60 YO at increased risk
RSV Monoclonal Antibodies Nirsevimab (Beyfortus) Palivizumab (Synagis)	Neonates & Infants < 8 months that born during or entering their 1st RSV season → Nirsevimab ×1 (if mother not vaccinated during pregnancy) Palivizumab → Premature infants

Varicella Vaccines (for Chicken pox)

Varivax MMRV (ProQuad)

Varivax 2 doses @ 12-15 months & 4-6 YO Adolescent/Adult without evidence of immunity → 2 doses Acyclovir, Valacyclovir, Famciclovir → D/C 24hrs before vaccine & held for 14 days after vaccines Freezer; Reconstitute immediately & administer within 30 mins AVOID if hypersensitive to Gelatin or Neomycin SC or IM

Zoster Virus Vaccine (for Herpes zoster/Shingles)

Shingrix

>/= 50 YO or >/= 19 YO who are or will be immunocompromised → 2 doses Vaccinate EVEN if they received Varivax or Zostavax or have a history of zoster infection DO NOT FREEZE

Rabies Vaccine

RabAvert

Post-exposure (no previous vaccination) 4 doses + 1 dose of rabies immune globulin with the 1st vaccine dose

Typhoid Vaccine

Vivotif (Live) → Oral

• >/= 1 week prior travel

Typhim Vi (inactivated) → IM

• >/= 2 weeks before expected exposure

Tuberculosis Bacille Calmette-Guerin (BCG) Vaccine

A live vaccine that can cause a positive reaction to the TB skin test

Yellow Fever Vaccine

YF-VAX (Live Vaccine)

• SC ONLY

• Contraindicated in severe allergy to Egg or Gelatin

Cholera Vaccine

Vaxchora (Live) → Oral solution

Administration For Vaccines

Intramuscular (IM)

• 22-25 gauge; 90 degree

• Adult: deltoid

• Infants: mid-thigh muscle

• 1 inch for most adults

• Males > 260 lbs or Female > 200 lbs → 1.5 inch

Subcutaneous (SC)

• 23-25 gauge; 45 degree

• Fatty tissue over the triceps

• 5/8 inch needle

Infants & Children

• At Birth → HepB

• Mother not vaccinated during pregnancy → RSV monoclonal antibody

• At 2 months → PCV20/PCV15, DTaP, Hib, Polio, Rotavirus

• >/= 12 months → MMR, Varicella

Healthcare Professionals

• Annual Influenza

• No evidence of immunity → Hepatitis B, Varicella, MMR

Adolscents & Young Adults

• MenACWY

  • 2 dose @ 11-12 YO & 16 YO

  • First Year College → 1 dose if not previously vaccinated

• HPV

• Tdap

Sickle Cell Disease & Other Causes of Asplenia

• Hib

• 19-64 YO → PCV20 ×1 or PCV15 then PPSV23 ×1 8 weeks later

• MenACWY

• MenB

Pregnancy

• 32-36 weeks of gestation during RSV season→ Abrysvo

• Tdap ×1 each pregnancy

Immunodeficiency

• 19-64 YO → PCV20 ×1 or PCV15 then PPSV23 ×1 8 weeks later

• >/= 19 YO → Shingrix

• HIV → MenACWY, HepA, HepB

Older Adults

• >/= 50 YO → Shingrix

• >/= 65 YO → PCV20 ×1 or PCV15 then PPSV23 ×1 12 weeks later

Diabetes

• 19-64 YO → PCV20 ×1 or PCV15 then PPSV23 ×1 12 weeks later

• >/= 60 YO (not previously vaccinated) → Hep B

Travelers’ Diarrhea

Prophylaxis

• “Boil it, Cook it, Peel it or Forget it”

• Bismuth Subsalicylate (Pepto-Bismol)

  • AVOID in Aspirin allergy, Pregnancy, Renal Insufficiency, Gout, Anticoagulants

• Rifaximin

  • ONLY if there is a high risk of complications

Treatment

• Mild → Loperamide or Bismuth

• Moderate → Loperamide ± antibiotics

  • Azithromycin or a Quinolone (if low resistance)

  • Rifaximin (alternative)

• Severe (dysentery) → Antibiotics ± Loperamide

  • Azithromycin

  • Quinolone or Rifaximin (alternative)

Travel Vaccines

Hepatitis A (Havrix, VAQTA)

Hepatitis B (Engeerix-B, Heplisav-B, Recombivax HB)

Hepatitis A/B (Twinrix)

Japanese encephalitis (Ixiaro)’

Meningococcus (Menveo, MenQuadfi)

Polio (IPOL)

Typhoid-IM (Typhim Vi)

Cholera-PO (Vaxchora)

Typhoid-PO (Vivotif)

Yellow fever-SC (YF-VAX)

Avoid Insect Bites

• DEET (mosquito repellents) on exposed skin

• Permethrin → NOT applied directly on skin

Malaria Prophylaxis

Quick Starts [1-2 days before travel]

• Doxycycline (Doryx, Vibramycin), Atovaquone/Proguanil, Primaquine

  • Daily Regimens, Cause Nausea

  • AVOID pregnancy

Advance Starts [1-2 weeks before travel]

• Chloroquine

  • 1-2 weeks before & stop 4 weeks after travel; Take weekly

  • Retinal toxicity/visual changes

  • Safe for children & pregnancy

• Mefloquine

  • >/= 2 weeks before & stop 4 weeks after; Take weekly

  • AVOID in psychiatric conditions, seizures, arrhythmias

  • Safe for children & pregnancy

Altitude Sickness & Motion Sickness

Prophylaxis

• Acetazolamide → started the day before

• AVOID in sulfa allergy