1. Vaccinations Lauren Sisco 9/22/14 fluvaccineingredients.com

7. Influenza WHO – Everyone >6 months TYPES – Inactivated (IM, ID) Anyone, including hives-only allergy to eggs – Live, attenuated Healthy, non-pregnant, age 2-49 Not recommended for those who work in a HC environment or with immunocompromised patients. – Recombinant Ages 18-49 Contains no egg protein

10. Tetanus, diptheria, acellular pertussis WHO – Pregnant women with each pregnancy – DTaP x5 in childhood schedule – Tdap x1 (typically age 11-12)-> Td every 10 yrs after – Unknown: complete 3 dose series (2 doses at least 4 weeks apart, then third dose 6-12 mos later) TYPES – Tdap – Td – DTaP (higher concentration of diptheria and pertussis)

11. Tetanus

12. Thomas Sydenham (1624–1689) “Whilst I lived in Dr Sydenham’s house, I had myself the Small Pox, and fell ill on the Twelfth Day. In the beginning I lost twenty two Ounces of Blood [from bloodletting]. He gave me a Vomit, but I find by Experience Purging much better. I went abroad, by his Direction, till I was blind, and then took to my Bed. I had no Fire allowed in my Room, my Windows were constantly open, my Bed-Clothes were ordered to be laid no higher than my Waste. He made me take twelve Bottles of Small Beer, acidulated with Spirit of Vitriol, every twenty Four hours. I had of this Anomalous Kind [of smallpox] to a very great Degree, yet never lost my Senses one Moment.” — Thomas Dover, The Ancient Physician’s Legacy to His Country

13. From variolation to vaccination varius, meaning “stained” varus, meaning “mark on the skin” Inoculation of healthy people with material from infected individuals was then termed “variolation” Called small pockes in England in the 15 th century to distinguish disease from syphilis, the great pockes

14. Edward Jenner Latin word for cow is vacca, and cowpox is vaccinia; Jenner decided to call this new procedure vaccination. May 14, 1796 vaccinated 8 yo James Phipps with coxpox July 1796, inoculated with smallpox and developed no symptoms In science credit goes to the man who convinces the world, not the man to whom the idea first occurs. —Francis Galton

15. Eradication of Smallpox 1967: WHO begins global health campaign to eradicate smallpox 1977: Last known natural case of smallpox reported in Somalia 1978: limited outbreak in England due to lab accident May 8, 1980: World Health Assembly proclaims the work is free of smallpox and vaccinations are ceased. Courtesy Bennett Lorber, MD www.historyofvaccines.org

18. Varicella All non-immune adults LIVE vaccine, contraindicated in: – Pregnancy – HIV/AIDS with CD4<200 – Immunocompromised 2 doses if no evidence of immunity

19. Varicella Evidence of immunity – 2 doses of vaccine at least 4 weeks apart – US born before 1980 – History of zoster or varicella – Lab evidence of immunity

22. HPV WHO – Females: 3-dose series age 11-12 (up to age 26) – Males: 3-dose series age 11-12 (up to age 21) Up to age 26 for MSM and immunocompromised TYPES – HPV4, HPV2 (only licensed for use in females)

25. Zoster WHO – Adults >60 yo – Regardless of prior episode of zoster LIVE vaccine – Contraindicated in immunocompromised

28. MMR WHO – Measles repeat dose for healthcare workers, international travelers 2 doses if received inactivated measles vaccine (1963-67) – Mumps repeat dose for healthcare workers, international travelers 2 doses if received inactivated mumps vaccine (before 1979) and are at high risk – Rubella Determine immunity in women of childbearing age Repeat MMR if non-immune and NOT pregnant

29. MMR LIVE vaccine – Contraindicated in immunocompromised

30. RECAP LIVE vaccines contraindicated in immunocompromised: – Varicella – Zoster – MMR – Yellow fever

33. Pneumonia PCV13 (Prevnar) – Conjugate vaccine PPSV23 (Pneumovax) – Polysaccharide vaccine

34. Pneumonia PCV13 – GIVE FIRST (better immune response) WHO – >19 yo with immunocompromising conditions – Functional or anatomic asplenia – CSF leaks – Cochlear implant – > followed by PPSV23 >8 weeks later

35. Pneumonia PPSV23 WHO – All adults >65 yo – <65 yo with Chronic lung disease Heart disease Diabetes Renal failure Chronic liver disease Alcoholism Other indications for PCV13

36. Pneumonia Revaccination with PPSV23 – 5 years after first dose (ages 19-64) – If 1-2 doses given before age 65, give additional dose at age 65 (or around 5 years after last dose) – No additional dose needed if given after age 65

39. Meningococcal WHO – 2 doses 2 months apart Functional asplenia Complement component deficiencies – Single dose to at-risk populations Microbiologists, first-year college students, military, at risk during outbreak, travel to endemic or hyperendemic country – Revaccinate every 5 yrs for asplenia, complement def, microbiologists – HIV alone is not an indication

40. Meningitis belt http://www.meningvax.org/epidemics-africa.php

41. cdc.gov/travel

44. Hepatitis A WHO – MSM – IVDU, drug use in general – Chronic liver disease – Those receiving clotting factor concentrates – Travelers to countries with high or intermediate incidence 2 doses

45. Hepatitis B WHO – Sexually active, not in monogamous relationship (>1 partner in last 6 mo), evaluation or treatment of STD – MSM – IVDU – Healthcare workers, public safety workers – Diabetes – ESRD on HD – HIV – Chronic liver disease – Contacts and partners of hep B + persons 3 dose series

46. “…and any person seeking protection from heptitis A/B virus.” Twinrix – combo hep A and B vaccine

50. Answer & Critique(Correct Answer: E) Key Point In patients who are HIV-positive, CD4 cell counts should be obtained before administering live attenuated vaccines. Educational Objective Select an appropriate vaccination strategy for an HIV-positive patient. A CD4 cell count should be obtained in this patient before any vaccines are administered. This woman is entering school to become a certified nursing assistant; all health care workers should be vaccinated against or have serologic evidence of immunity to hepatitis B, varicella, measles, mumps, and rubella. In addition, health care workers should receive a one-time tetanus, diphtheria, and acellular pertussis (Tdap) vaccine as well as annual influenza vaccination. In general, vaccines can either be inactivated viral proteins or live attenuated viruses. Inactivated viral proteins are safe to administer in all patients, including those with HIV infection, except those with a documented allergy to the vaccine or its growth media (such as eggs). Live attenuated vaccines, on the other hand, should be withheld in patients with immune deficiency, including HIV-positive patients with a CD4 cell count below 200/microliter. Therefore, before administering any vaccines, however, it is important to determine whether or not she is functionally immunodeficient. The measles, mumps, and rubella vaccine contains live, attenuated virus, and for this patient, it would be inappropriate to administer it before verifying that she is immunocompetent and also that she needs revaccination (based on negative serologic studies). Live, attenuated influenza vaccine should be avoided in patients with immunodeficiency. Regardless of her CD4 cell count, the inactivated influenza vaccine would likely be preferred for this patient. Hepatitis B vaccination is indicated in health care workers and in HIV-positive patients, as well as in patients with unknown hepatitis B status for whom hepatitis B vaccination is needed. As for other vaccines, it would be best to determine this patient's immune status before providing the vaccine. Persons born after 1980, health care workers, and those born before 1980 who have a high risk for disseminated varicella should receive a two-dose varicella vaccination series unless they have serologic evidence of varicella immunity or physician-documented evidence of either varicella or varicella vaccination. Patient or parent self-report is not considered reliable

52. References http://www.chop.edu/service/vaccine-education- center/vaccine-schedule/history-of-vaccine- schedule.html http://www.cdc.gov/vaccines/adults/index.html Riedel. Edward Jenner and the history of smallpox and vaccination. Proc (Bayl Univ Med Cent). Jan 2005; 18(1): 21–25. http://www.historyofvaccines.org MKSAP 16