Immunization week one

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Goal of immunization

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Goal of immunization

to protect against disease upon subsequent exposure to the infection

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Passive immunity

  • transfer of immunity produced by one human or animal to another

  • implications for immunization - drug interaction with live vaccines

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Transplacental transfer

mode of passive immunity

  • active transport of IgG during last 1-2 months of gestation (weeks 32-40)

    • go across concentration gradient

    • baby will get antibodies

  • good protection from some diseases - measles, rubella, tetanus

  • poor protection from some diseases - polio

  • interferes with response to live vaccines as maternal antibodies neutralize vaccine before infant mounts an immune response

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active immunity

  • stimulate the host to produce a protective response to an antigen

    • natural infection

    • immunizations

  • relies on immunologic memory

    • makes its own memory

    • makes their own response

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vaccine formulations

  • live attenuated

  • whole inactivated

  • polysaccharide

  • conjugate

  • recombinant DNA

  • toxoid

  • mRNA

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general recommendations for vaccines

  • timing of immunization

  • childhood and adult immunization schedules updated frequently and published each year

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vaccine timing

  • any commonly used vaccines can be administered during the same encounter

  • inactivated vaccines and inactivated and live vaccines can be administered at intervals without regard to each other

    • live vaccines must be separated by 4 weeks if not administered simultaneously

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live vaccine timing

  • on or after the first birthday

  • delay following administration of antibody-containing product

  • separated by at least 4 weeks

    • live vaccine administered second should not be counted

    • repeat that vaccine at least four weeks after it was administered as an invalid dose

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vaccine dosing intervals

  • increasing the interval between doses does NOT diminish the effectiveness

    • no need to restart ANY vaccine series

  • decreasing the interval between doses may interfere with vaccine response

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immunization of immune individuals

  • no evidence of harm

    • MMR, varicella, HiB hepB, polio

  • increased incidence and severity of local reactions

    • PPSV23 administered <4 years

    • Td too frequently

    • pain, swelling, redness

    • hence, can’t find on records, REIMMUNIZE

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vaccine contraindications (general)

  • severe allergy to vaccine component

  • for future pertussis containing vaccines: encephalopathy without known cause within seven days of pertussis vaccine

    • very uncommon

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temporary contraindications

  • pregnancy

  • immunosuppression

    • decreased response to immunization

    • live attenuated vaccines contraindicated

  • severe illness (not terrible but worse things to worry about)

  • recent receipt of blood and immune globulin products

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herd immunity

  • community immunity, community protection, indirect protection

  • protection conferred to susceptible individuals when sufficient proportion of the population is immune

  • depends on reproduction number, Ro

    • on how transmissible it is

    • number of people to which an infected person transmits the infection

    • assumes equal mixing of an entirely susceptible population

    • for sars-cov2 estimated Ro=2-3

    • measles was Ro=18

  • Threshold = 1-1/Ro

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approach to herd immunity

  • herd immunity describes immunization strategies

  • no infection has ever achieved herd immunity

  • likely unable to protect the vulnerable

    • NEED IMMUNIZATIONS TO GET TO HERD IMMUNITY

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immunization to herd immunity

  • need community immunity at 60%

  • assume

    • estimate that 10% has been infected

    • vaccine confers 70% protection

    • to achieve herd immunity, need vaccine uptake at least 70%

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measles

  • highly infective viral disease

    • most contagious disease known

  • transmitted primarily by larger respiratory droplets

  • fever, cough, coryza (runny nose), conjunctivitis

  • complications include otitis media, pneumonia, encephalitis

    • estimated that 10% of cases involve complications

    • death rate 1-3/1,000

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measles elimination

  • goal of healthy people 2010

  • WHO, Pan American Health Organization formulated plans for elimination and eradication

  • measles eliminated from US

    • importations frequent

    • threats from vaccine hesitancy and delay

    • must keep immunizing

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measles outbreaks

  • immunization rates sufficient to prevent widespread

  • transmission within unimmunized communities

  • 85% of cases in unimmunized due to philosophical or religious belief (from 2014 outbreak)

    • other 15% were too young

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measles vaccine

  • live attenuated viral vaccine

    • usually administered in combination with mumps and rubella

    • combination of measles, mumps, rubella, and varicella available

  • vaccine administered at 12-15 months of age with a second dose prior to entering school

  • evaluate travelers for immune status

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vaccination strategies for measles

  • two dose strategy implemented in early 1990s

  • second dose is not a “booster”

    • second chance to get immune

  • two doses recommended for healthcare workers and college students

  • can consider those before 1957 immune

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mumps

  • acute self-limited parotitis

  • transmitted by large respiratory droplets

  • complications include gastritis, meningoencephalitis, orchitis, mastitis, and oophoritis

  • death 1-3.4/10,000 (much smaller)

<ul><li><p>acute self-limited parotitis</p></li><li><p>transmitted by large respiratory droplets</p></li><li><p>complications include gastritis, meningoencephalitis, orchitis, mastitis, and oophoritis</p></li><li><p>death 1-3.4/10,000 (much smaller)</p></li></ul>
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mumps immunization

  • live attenuated viral vaccine

  • administered with measles and rubella (MMR)

    • combination of measles, mumps, rubella, and varicella available

  • recommended for 12-15 months olds, susceptible adolescents and adults

    • can consider immune if born before 1957

  • two doses for school aged children and high risk adults

    • healthcare workers

    • international travelers

    • students at post-high school educational institutions

  • third dose recommended for outbreak response

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rubella

  • mild exanthematous (rash) viral infection

  • transmitted via respiratory route

  • congenital rubella syndrome if infection during pregnancy

    • deafness, cataracts, heart defects, intellectual disabilities, liver and spleen damage, low birth weight

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rubella elimination

  • rubella and congenital rubella syndrome eliminated from Western Hemisphere

  • immunization continues to be required because threat of transportation

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rubella immunization

  • live attenuated viral vaccine

  • administered with measles and mumps (MMR) or varicella (MMRV)

    • recommended for 12-15 months, susceptible adolescents and adults

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rubella vaccine cautions

  • do not immunize pregnant individuals

    • no evidence for congenital rubella syndrome from vaccine

    • avoid pregnancy for 28 days

    • routine pregnancy screening not recommended

      • don’t need a pregnancy test

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vaccinations of adults who may become pregnant for rubella

  • vaccination of susceptible people of childbearing age

    • routine general medical and gynecologic outpatient care

    • all family planning settings

    • before discharge from hospital, birthing center, or other medical facility

  • prenatal assessment and post partum immunization

  • will be screened for rubella immunity

  • pregnant people should not get live vaccines

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Viral hepatitis - overview

knowt flashcard image
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Hepatitis A infection

  • viral disease caused by hepA virus

  • transmitted by fecal-oral route

  • immune mediated liver injury

  • relatively mild illness in children

  • more serious illness in adults

    • elevated LFT (live function test)

    • jaundice

  • rare fulminant hepatitis (makes you so sick you end up in ICU)

  • no chronic carrier state

  • no specific treatment; supportive care

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Hepatitis A outbreak

as of 2023 61% of people had hospitilizations

  • this is really high

    • if you get it as a child you may be asymptomatic and won’t be as sick

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Hepatitis A Vaccine Indications

  • travelers to countries with high or intermediate endemicity

  • men who have sex with men

  • people who use drugs

  • persons with occupational risk

  • perons with chronic liver disease

    • if they do get it, their liver may fail

  • experiencing unstable housing or homelessness aged 1 and older

  • currently or recently incarcerated

  • all children 12 months of age and catch up for unimmunized 18 years and younger

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Haemophilus influenzae type b

  • small gram negative organism causing infections ranging from colonization to meningitis

  • meningitis has 10% mortality rate and 40% have neurological deficits

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Haemophilus influenzae type b vaccine

  • conjugate vaccines

  • recommended at 2,4, (6), and 12-15 months of age

  • recommended for those >5 years if immunocompromised

    • sickle cell, splenectomy, HSCT (hematopoietic stem cell transplantation)

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hepatitis b virus

  • affects liver

  • viral disease caused by hepb virus

  • transmitted by parenteral routes (injected/not oral)

    • blood transfusion

    • sharing of needels

    • sexual contact

    • mother to neonate

      • must have chronic infection at the time of pregnancy

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hepatitis b infection in US

the groups from 0-19 and 20-29 are very low numbers for infections since they were immunized as babies

similarly, ages 60+ have a low rise

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reported risks for hepatitis B infections

  • injection drug use most commonly reported rise

  • note that no risk identified/reported in about 2/3 of cases

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hepatitis b immunization of adults

  • routine immunizations for all adults aged <60 years

    • doesn’t work great for people older than 60 since they don’t respond well

  • routine immunization of infants since 1991

  • routing immunization of adolescents since 1997

  • not a huge ordeal since many people are immunized

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hepB vaccines

  • recombinant hepatitis b surface angtigen with aluminum adjuvant

    • energix (pediatric or adult)

    • recombivax (pediatric or adult)

    • both require 3 doses for immunity: 0, 1, and 6 months

  • recombinant hepatitis b surface antigen with CpG 1018 adjuvant

    • cool new adjuvant

    • heplisav-b (ages 18 and older)

      • two doses separated by one month

  • recombinant vaccine with multiple surface antigens with aluminum adjuvant

    • prehevbrio (ages 18 and older)

      • three dose series: 0, 1, and 6 months

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post vaccination testing for hepb

  • post vaccine antibody testing in healthcare workers at risk for sharp injury

    • measure antiHBs (antibody to hepatitis B surface antigen)

    • antiHBS > 10 mlUml protective

  • 100% effective in those who develop an antibody response

  • older individuals (age >40 years), chronic conditions, immunosuppression at risk for nonresponse

    • repeat series

    • choose hepB with CPG

      • heplisav b or prehevbrio

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polio

  • acute viral illness which in its serious form affects the central nervous system

  • fecal-oral transmission

  • complications include flaccid paralysis

  • death rate as high as 10%

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polio vaccines

  • live attenuated vaccine - no longer used (hasn’t been for 23 years)

    • OPV (stockpile with CDC for public health emergency)

  • enhanced-potency inactivated vaccine

    • IPV

  • No wild type polio cases in the western hemisphere since 1991

  • Vaccine associated poliomyelitis occurs in approximately 1 in 2.4 million doses

    • become infectious after receiving the vaccine

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polio case in NY

  • unvaccinated young adult developed symptoms in June 2022

  • caused by VDPV2

    • vaccine deprived

  • wastewater monitoring shows vaccine virus present in April 2022

  • low immunization rates in Rockland County

  • high vaccine coverage rates absolutely needed

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polio vaccine scheduling

  • polio vaccine recommended at 2, 4, 6-18 months and again at 4-6 years

  • any immunized adult; however if person received any childhood vaccines, almost certainly vaccinated for polio

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varicella

  • highly contagious disease due to varicella zoster virus

  • spread by directed contact or the respiratory route

  • characteristic pruritic vesicular rash with fever

  • complications include bacterial infection of lesion, pneumonia, encephalitis, and cellulitis

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varicella epidemiology

  • children

    • 3.5 to 4 million cases each year

    • generally mild disease with rare complications

  • adults

    • 5% of all cases occur in those >15 years

    • complications much more common

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varicella vaccine

  • varivax licensed april 1995

  • a live attenuated viral vaccine

  • contraindicated in these situations:

    • immunosuppression

    • pregnancy

    • receipt of blood products - dose dependent

    • active and untreated TB

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evidence of varicella immunity

  • born in US before 1980

  • physician documented clinical history of chicken pox or zoster

  • laboratory evidence of immunity

    • two doses of varicella vaccine after first birthday separated by at least 4 weeks

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evidence of varicella immunity for healthcare worker

  • physician documented clinical history of chicken pox or zoster

  • laboratory evidence of immunity

  • two doses of varicella vaccine after first birthday separated by at least 4 weeks

*birth before 1980 doesn’t count*

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varicella vaccine indications

  • all infants at age 12 months with second dose prior to entering school

    • minimum 3 month interval between doses

  • second dose recommended for anyone who has received only one dose

    • when first licensed, it was only one dose

  • children entering child care facilities or schools (or evidence of immunity)

  • assume immune in US before 1980 unless healthcare worker, pregnant woman, or immunocompromised

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varicella vaccine indications

  • routine immunization of all adolescents and adults without evidence of immunity

  • prenatal assessment + postpartum immunization

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varicella vaccine adverse effects

  • fever

  • rash

    • at injection site: median number of lesions = 2

    • generalized: median number of lesions = 5

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rotavirus infection

  • half million childhood deaths worldwide

    • serious infection

  • one third of hospitalizations for diarrhea

    • w/o immunization

  • incidence similar in developing AND developed countries

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rotavirus vaccines

  • live oral vaccine stores refrigerated

  • two preparations

    • rotateq (merck)

      • pentavalent bovine reassortment viruses

      • must be reconstituted with supplied diluent

      • three oral doses

    • rotarix (GSK)

      • attenuated human rotavirus

      • liquid preparation

      • two oral doses

  • recommended at 2, 4, and (6 if merck used) months

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vaccine schedule for rotavirus

  • first dose between 6 and 14 weeks of age

    • if inadvertently started, complete series

  • second and third doses spaced by 4 to 10 weeks

  • series must be completed by 8 months of age

    • DON’T FINISH IF IT’S PAST EIGHT MONTHS

  • initiate or complete series for infant who have had rotavirus infection

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RV and intussusception

with the old vaccine there was an increase in intussusception (bowel obstruction)

pain, inflammation, sometime surgery needed

no evidence that risk is different between vaccines

about 45-213 cases per birth cohort

prevents 53,000 hospitalizations and 170,000 ED visits per birth cohort

risk is worth the benefit

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RV vaccine impact

  • dramatic reductions in disease

  • decreased hospitalization by 42-63%

  • decreased lost workdays by 87%

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tetanus diptheria pertussis abbreviation

upper case means higher doses

bigger dose for smaller people

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pertussis

  • whooping cough

  • bacterial respiratory infection caused by bordetella pertussis

  • direct transmission from close contact

  • major manifestation is severe paroxysms of cough

  • severe complications include pneumonia, encephalopathy, malnutrition

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pertussis vaccine

  • administered in combination with diptheria and tetanus

  • recommended at 2, 4, 6, and 15-18 months with boosters at 4-6 years

  • routine Tdap for 11-12 years

    • use for 7-10 year olds with incomplete childhood series

  • Tdap for next dose of adults

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pertussis vaccine scheduling

  • adacel license for booster after 8 years

  • Td or Tdap can be administered every 10 years

  • late 2nd or 3rd trimester of each pregnancy

  • transfer immunity to baby

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vaccine products for TDAP

DTaP for children <7 years

  • several brands and combinations

  • pertussis antigens and doses included in the vaccine vary among manufacturers

Tdap

  • Adacel (sanofi-pasteur)

  • Boostrix (GSK)

  • ACIP recommended use in under-immunized 7-10 year olds and no upper age limit

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cocooning

  • strategy from protecting very young infants from pertussis

  • Tdap recommended for pregnant females in late 2nd or 3rd trimester

  • immunization of parents, siblings, grandparents, out of state home care providers

    • Tdap immunization at hospital discharge for mother

    • Key role for pharmacy based immunization services

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diptheria

  • Bacterial infection caused by Corynebacterium diphtheriae

  • Person to person transmission through direct contact

    • Must be pretty close

  • Major manifestation is membranous inflammation of respiratory tract

  • May damage myocardium, nervous system, and kidney

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diptheria vaccine

  • Toxoid, adsorbed inducing immunity to the bacterial exotoxin

  • Administered in combination with tetanus and pertussis

  • Recommended at 2, 4, 6, 16-18 months and at 4-6 years

  • Routine boosters (Td or Tdap) every 10 years

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tetanus

  • All muscles are in contracted state

  • Acquired through environmental exposure

  • Mediated via bacterial toxin

  • Not contagious

  • Get from environment

  • Worse for diabetics since they can get bad wounds

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Clinical presentation / clinical syndroms tetanus

  • Clinical syndromes

    • Localized: painful contractions, generally mild

    • Generalized: spasm of facial muscles, hyperreflexia, opisthotonos, tonic tetanic seizure-like activity

    • Cephalic: atonic cranial nerve palsies, may progress to generalized

    • Muscle constraints so strong you may break bones

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Tetanus vaccine

  • Toxid, adsorbed from Clostridium tetani

  • Administered in combination with diphtheria and pertussis

  • Recommended at 2, 4, 6, and 15-18 months and 4-6 years

  • Routine boosters (Td or Tdap) every 10 years

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Wound management

  • If wound and its been >5 years immunize

  • If wound and it’s been <5 years no need to immunize

<ul><li><p><span style="font-family: Arial, sans-serif; color: rgb(0, 0, 0)">If wound and its been &gt;5 years immunize</span></p></li><li><p><span style="font-family: Arial, sans-serif; color: rgb(0, 0, 0)">If wound and it’s been &lt;5 years no need to immunize</span></p></li></ul>
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pneumococcal disease

Infection caused by the bacteria Streptococcus pneumonia

  • Otitis media

    • 20 million office visits (28-55% strep)

  • Pneumonia

    • 175,000 cases annually

  • Meningitis

    • Leading cause 3,000-6,000 cases annually

  • Bacteremia

    • 50,000 cases annually

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invasive pneumococcal disease

  • Defined as S. pneumoniae in normally sterile body site

  • Incidence >65 years 24 cases/100,000 population

  • Pneumococcal pneumonia

    • <age 65 years: 126-422 per 100,000

    • > 65 years: 847-3365 per 100,000

      • Much larger

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pneumococcal vaccines

  • Pneumococcal conjugate 15 valent (vaxneuvance)

  • Pneumococcal conjugate 20 valent (prevnar 20)

  • Pneumococcal polysaccharide 23 valent (pneumovax23)

  • When we vaccinate kids we see way decrease because herd immunity

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PCV15 or PCV20 recommendations for children

  • Universal immunization for infants

    • 2, 4, 6, and 12-15 month schedule

  • Immunocompromised children aged 6-18 years

    • Single dose of PCV15 or PCV20 if no history of previous conjugate vaccine

    • If at least one PCV20, no additional doses

    • If PCV13 or PCV15 administer either PCV20 or PPSV23

    • So must have 20 at some point

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pneumococcal vaccines for immunosupressed

  • Congenital or acquired immunodeficiency

  • HIV

  • Chronic renal failure

  • Nephrotic syndrome

  • Leukemia

  • Lymphoma

  • Hodgkin disease

  • Generalized malignancy

  • Iatrogenic immunosuppression

  • Solid organ transplant

  • Multiple myeloma

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other conditions that are indications

  • Chronic heart disease (REAL not hypertension)

  • Chronic lung disease (asthma >19)

  • Diabetes

  • Cerebrospinal fluid leak

  • Cochlear implant

  • Sickle cell disease other hemoglobinopathy

  • Alcoholism

  • Cigarette smoking (>19 year)

  • All adults aged 65 years and older

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for those aged 65 and older

  • PCV20 or PCV15 + PPSV23 later (PCV20 can be substituted for PPSV23)

  • If adults received PCV13 and/or PPSV23 prior, PCV20 may be considered

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for those 19-64 years old

  • PCV15 or PCV20

  • If PCV15 used this should be followed up with PPSV23

  • Chronic conditions, immunocompromised

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patient has PCV13 history

  • Used for adults who were immunocompromised

  • Used by shared clinical decision making for those aged 65 years and older who were NOT immunocompromised

  • Followed by PPSV23

  • Additional dose of conjugate vaccine not routinely recommended

  • Healthcare professionals may recommend PCV20 for those 65+ years of age who were previous immunized (PCV13 +- PPSV23)

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Pneumococcal polysaccharide vaccine (PPSV23)

  • Vaccine composition

    • Capsular polysaccharide inducing type-specific antibodies

  • Used for those who receive PCV15

    • Immunocompromised: 8 weeks after PCV15

    • Chronic conditions: >1 year after PCV15

    • Aged 65 years and older: >1 year after PCV15

  • 65+ years who received PPSV23 only, PCV15 or PCV20 recommended >1 year later

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Using ACIP pneumococcal vaccine recommendations

  • Infants and immunocompromised children straightforward

  • Adults

    • Use the table posted on canvas

    • Do the problems posted on canvas

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Human papillomavirus infection

  • Most common sexually transmitted infection

    • Highest rates among sexually active young adults

    • Nearly everyone will get HPV at some point

  • Spread through intimate skin to skin contact

  • Infection often asymptomatic; clincial pathology diagnosed by Pap test

  • Screening tests not available for other cancers caused by HPV

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HPV infection

  • Oncogenic viruses associated with cervical, vulvar, vaginal, anal, oropharyngeal, penile cancer

  • Types 6 and 11 are associated with anogenital warts and respiratory papillomatosis  (wart like growth on vocal cords)

  • Besides cervical we don’t have screening

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Low HPV immunizations

  • Very low numbers although Tdap and meningitis are much higher

  • They should be given at the same time

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HPV vaccine

  • 9vHPV containing VLP 6, 11, 16, 18, 31, 33, 45, 52, 58

  • If age 9-14 years, two doses 0, 6-12 months

  • i f age 15-26 years, three doses 0, 1-2, 6 months

  • Recently expanded licensure for 27-45 years old

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ACIP HPV vaccine recommendations

  • Recommended for all adolescents aged 11-12 years

  • Also recommended for all aged 13-26 years

    • Immunization prior to sexual debut preferred

  • Can initiate series in individuals as young as 9 years if clinician deems appropriate

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