Immunizing Drugs and Biochemical Terrorism Chapter 49 Immunizing Drugs and Biochemical Terrorism Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Immunity Immune response Antigens Antibodies Active immunization Passive immunization Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Artificial Active Immunization The body is exposed to a relatively harmless form of an antigen The immune system is stimulated and “remembers” this antigen if subsequent exposures occur Does not cause a full-blown infection Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Natural Active Immunization Person acquires immunity by surviving the disease itself and producing antibodies to the disease-causing organism Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Biological Antimicrobial Drugs Also called biologicals Antitoxins Antisera Toxoids and vaccines (immunizing biologicals) Used to prevent, treat, or cure infectious diseases Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Toxoids Antigenic (foreign) preparations of bacterial exotoxins Detoxified with chemicals or heat Weakened or “attenuated” Cannot revert back to a toxic form Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Toxoids (cont’d) Stimulate one’s immune system to produce a specific antibody Artificial active immune response These antibodies protect against future exposures Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Vaccines Suspensions of live, attenuated (weakened) or killed (inactivated) microorganisms These slight alterations in the bacteria and viruses prevent the person injected from contracting the disease Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Vaccines (cont’d) Also stimulate the production of antigens against a specific antibody Vaccinations with live bacteria or virus provide lifelong immunity Vaccinations with killed bacteria or virus provide partial immunity, and booster shots are needed periodically Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Active Immunizing Drugs: Examples BCG vaccine (tuberculosis) Diphtheria, tetanus, and pertussis toxoids, several forms Haemophilus influenzae type B conjugate vaccine Hepatitis A and B virus vaccines Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Active Immunizing Drugs: Examples (cont’d) Measles, mumps, and rubella virus vaccine, live—several forms Pneumococcal bacterial vaccines Human papilloma virus vaccine (Gardasil) Poliovirus vaccine; several forms Rabies virus vaccine Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Active Immunizing Drugs: Examples (cont’d) Smallpox virus vaccine Tetanus toxoid Varicella virus vaccine (chickenpox) Yellow fever virus vaccine Many others Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question A patient has an order for the varicella vaccine. It is most important for the nurse to assess the patient for use of high dose systemic steroids in the past month. allergy to aspirin. allergy to eggs. history of hypertension. Correct answer: A Rationale: Varicella vaccine is not to be given to immunodeficient patients or to patients who have received high doses of systemic steroids in the previous month. It is also recommended that salicylates be avoided for 6 weeks after administration of varicella vaccine because of the possibility of Reye’s syndrome. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Passive Immunization Serum or concentrated immunoglobulins from humans or animals are injected into a person The substances needed to fight off invading microorganisms are given directly to a person The immune system is bypassed Short-lived compared with active immunization, but works faster Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Artificial Passive Immunization Administration of serum or concentrated immunoglobulins Provides the inoculated person the substance needed to fight off the invading microorganism Bypasses the host’s immune system Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Natural Passive Immunization Antibodies are transferred From mother to fetus through the placenta From mother to infant through breast milk Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Passive Immunizing Drugs Antitoxins Immunoglobulins Snake and spider antivenins (antivenom) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Passive Immunizing Drugs: Examples Antivenins Pit viper, coral snake Black widow spider Hepatitis B immune globulin Immunoglobulin, various forms Rabies immunoglobulin (human) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Passive Immunizing Drugs: Examples (cont’d) Rho(D) immune globulin (RhoGAM) Tetanus immunoglobulin Varicella-zoster immunoglobulin Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question A patient with AIDS was cut by a rusty piece of metal while walking outside. He recalls that his last tetanus booster was over 20 years ago. Which immunization therapy will he receive at this time? He cannot receive any type of immunization therapy. Tetanus immunoglobulin Tetanus toxoid, adsorbed Tetanus and diphtheria toxoid (Td) booster Correct answer: B Rationale: Vaccines and toxoids rely on a person’s immune system in order to work. Patients who are immunocompromised (as in those receiving immunosuppressive therapy and those with AIDS) may not benefit from vaccines or toxoids because they are unable to mount an immune response. In these situations, passive immunizing drugs such as immunoglobulins are warranted. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Indications Active immunization Prevents infection caused by bacterial toxins or viruses Provides long-lasting or permanent immunity “Herd immunity” Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Indications (cont’d) Passive immunization Antitoxins, antivenins, immunoglobulins Minimizes effects of poisoning by the venoms of spiders and certain snakes Provides quick immunity before a person’s own immune system has a chance to make antibodies (such as in cases of exposure to hepatitis B or rabies viruses) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Indications (cont’d) CDC/Department of Health and Human Services recommendations for adult and pediatric immunizations (U.S.) Provide specific dosages and intervals for immunizations Refer to the CDC website for current recommendations Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question The zoster vaccine (Zostavax) is used in which situation? To prevent chickenpox in children To prevent chickenpox in children who have been exposed to herpes zoster To prevent postherpetic neuralgia in patients who have shingles To prevent reactivation of the zoster virus that causes shingles in patients age 60 or older Correct answer: D Rationale: Zoster vaccine (Zostavax) is a vaccine for the prevention of herpes zoster. The vaccine is recommended for patients 60 years or older to prevent reactivation of the zoster virus that causes shingles. The vaccine does not prevent postherpetic neuralgia. It can be given to patients who have already had shingles. The vaccine should not be used for the prevention of chickenpox and should not be given to children. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Adverse Effects Range from mild and transient to very serious or life threatening Minor effects Fever, minor rash, soreness at injection site, itching, adenopathy Severe effects Fever higher than 103° F, encephalitis, convulsions, anaphylactic reaction, dyspnea, others Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Adverse Effects (cont’d) Minor reactions Treated with acetaminophen and rest Serious or unusual reactions Serum sickness Report serious or unusual reactions to the Vaccine Adverse Event Reporting System (VAERS) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question After immunizations at a well-baby check-up, a mother notes that her infant has redness and swelling at the injection site, is irritable, and has a fever of 99.9° F. She calls the clinic and is worried about her baby. Which action by the nurse is appropriate? Tell the mother there’s nothing to worry about and that these symptoms are normal and will go away Tell the mother that she should bring her baby in to the office for an examination Tell the mother that acetaminophen and rest should help to alleviate these symptoms, which are not unusual after immunizations. Complete a Vaccine Adverse Event Reporting System form (VAERS). Correct answer: C Rationale: These minor reactions may be treated with acetaminophen and rest. Reactions that are more serious or unusual should be reported with the Vaccine Adverse Event Reporting System (VAERS). Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Nursing Implications Assess patient’s health history, medication history, allergies, pregnancy status Assess previous reactions and responses to immunizations Assess for contraindications, including immunosuppression Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Before giving any drug, recheck the specific protocols for administration and schedules for administration Follow manufacturer’s guidelines for drug storage, administration, routes, and site of administration Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Encourage parents of young children to keep a journal of the child’s immunization status, with dates of immunizations and reactions, if any Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) If discomfort occurs at the injection site, apply warm compresses and give acetaminophen Do not give aspirin to children Monitor for therapeutic responses and adverse reactions Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Illnesses Caused by Possible Bioterrorism Agents Anthrax Smallpox Botulism Tularemia Viral hemorrhagic fever Plague Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Possible Bioterrorism Agents Sarin (nerve gas) Mustard (blistering agent) Cyanide (blood agent) Chlorine (choking agent) Radioactive elements Ricin Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question A patient is admitted to the emergency department with cyanide toxicity. Which antidote drugs does the nurse expect to administer? atropine pralidoxime pyridostigmine sodium nitrite Correct answer: D Rationale: Specific antidote drug therapy for cyanide toxicity includes the chemicals amyl nitrite (by inhalation) and sodium nitrite and sodium thiosulfate (both by injection). Specific antidote drugs for sarin include atropine, pralidoxime, and pyridostigmine. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Classroom Response Question Which statement regarding possible bioterrorism agents does the nurse identify as being true? Gentamicin and tetracycline are useful in the treatment of botulism. Tetracycline and ciprofloxacin are indicated in the treatment of tularemia. Vaccination for plague is recommended for public defense personnel in the United States. Antibiotics are useful in the treatment of smallpox. Correct answer: B Rationale: Antibiotics are of no benefit in the treatment of botulism. No vaccine currently available in U.S. for the treatment of plague. A vaccine is available for the treatment of small pox and may be effective for up to 3 days after exposure. The antiviral drug cidofovir is possibly effective; however, antibiotics are not effective. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.