1. Herpes Zoster Vaccine Zostavax®

2. During the clinical course of varicella (chickenpox), varicella-zoster virus (VZV) is believed to pass from the skin lesions into the sensory nerve endings and is transported along the neuronal cell axon to the dorsal root ganglia, where the virus establishes lifelong latency.1,2
In response to waning cell-mediated immunity that often accompanies increasing age or to other conditions characterized by immunosuppression (eg, human immunodeficiency virus, malignancies, and immunosuppressive therapy), VZV may reactivate and replicate within the ganglion. Spread of the virus within the ganglion causes inflammation and necrosis of the neurons, often accompanied by neuralgia.1
The virus is then transported down the sensory nerves, causing intense neuritis, and is released around the nerve endings in the skin, where it produces the characteristic zoster rash.1
1. Straus SE et al. In: Freedberg IM et al, eds. Fitzpatrick’s Dermatology in General Medicine. 5th ed. Vol 2. McGraw-Hill; 1999:2427–2450.
2. Silverstein S et al. In: Arvin AM et al, eds. Varicella-Zoster Virus: Virology and Clinical Management. Cambridge, UK: Cambridge University Press; 2000:123–141. 2

3. Classically, the rash consists of a cluster of “grape-like” vesicular lesions clustered on an erythematous base. The lesions typically erupt in 1, or occasionally 2, adjacent dermatomes and are unilateral, stopping at the midline.1,2
The rash usually occurs in the regions where the original varicella rash was most concentrated. These regions frequently involve the dermatomes supplied by the trigeminal nerve or the spinal sensory ganglia from T1 to L2.1
Thoracic involvement is most common, with about 50% of zoster cases affecting thoracic dermatomes.1,2
1. Oxman MN. In: Arvin AM et al, eds. Varicella-Zoster Virus: Virology and Clinical Management. Cambridge, UK: Cambridge University Press; 2000:246–275.
2. Lycka BAS, Williamson D, Sibbald RG. Herpes Zoster and Postherpetic Neuralgia, 2nd Revised and Enlarged Edition. Vol 11. Amsterdam, The Netherlands: Elsevier Science B.V.; 2001:97–106. . 3

5. Zoster Vaccine Indication
ACIP recommends routine vaccination of all persons aged >60 years with 1 dose of zoster vaccine.
NEW FDA LABELING: “ZOSTAVAX is a live attenuated virus vaccine indicated for prevention of herpes zoster (shingles) in individuals 50 years of age and older.”
Persons who report a previous episode of zoster and persons with chronic medical conditions can be vaccinated unless those conditions are contraindications or precautions.
Zoster vaccination is not indicated to treat acute zoster.
Zostavax® [package insert]. Whitehouse Station, NJ: Merck; April 2011.
Recommendations of the Advisory Committee on Immunization Practices (ACIP)

6. Vaccine Contraindications
Allergy to neomycin or any vaccine component
Pregnancy
Immunocompromised status
AIDS or other clinical manifestations of HIV, including persons with CD4+ T-lymphocyte values <200 per mm3
malignant neoplasms affecting the bone marrow
chemotherapy or radiation within the last 3 months
Persons on immunosuppressive therapy, including high-dose corticosteroids (>20 mg/day of prednisone or equivalent) lasting two or more weeks

7. In the Shingles Prevention Study (SPS), efficacy was evaluated in a placebo-controlled, double-blind clinical trial of ZOSTAVAX® (Zoster Vaccine Live). A total of 38,546 subjects 60 years of age or older were randomized to receive a single dose of either ZOSTAVAX or placebo and were monitored for the development of zoster for a median of 3.1 years.
ZOSTAVAX reduced the overall risk of developing zoster by 51% (95% confidence interval [CI]: 44%–58%) in subjects aged 60 years and older compared to the placebo group.
Vaccine efficacy for the prevention of herpes zoster was highest for subjects aged 60–69 years (64% [95% CI: 56%–71%]) and declined with increasing age. Vaccine efficacy was 41% (95% CI: 28%–52%) in patients 70–79 years of age and 18% (95% CI: –29%–48%) in patients 80 years of age and older.

9. ZEST & Shingles Prevention Study (SPS) Results1
(-29 to 48)
18%
41%
(28 to 52) 1
(56 to 71)
64%
(54 to 81)
70%
1. Oxman et al. New England Journal of Medicine (22): 2271
2. Zostavax® [package insert]. Whitehouse Station, NJ: Merck; April 2011.

10. Storage and Handling zoster vaccine must be stored frozen
The vaccine must be discarded if not used within 30 minutes after reconstitution.
New labeling: Zostavax may be stored and/or transported at fridge temp for up to 72 hours prior to reconstitution. Any unused vaccine at fridge temp should be discarded.
Zostavax® [package insert]. Whitehouse Station, NJ: Merck; April 2011.

11. Administration Zostavax: 0.65-mL dose (reconstituted)
SQ – upper, outer tricep
5/8 inch, 25 gauge needle

12. Same day, opposite arm, separate syringe.
Which of the following statements about the administration of influenza and zoster vaccines is true?
Same day, opposite arm, separate syringe.
Same day, same arm, mixed in 1 syringe.
Must be separated by at least 7 days.
Must be separated by at least 4 weeks.

13. Flumist nasal spray 0.1 ml in each nostril Zostavax 0.65 ml SQ
RR is a 70-year-old woman with COPD. She has no allergies. Her meds include albuterol, Pulmicort and Spiriva. She has an 80-pack-year history of smoking. She quit smoking 5 years ago. Her last pneumonia shot was 8 years ago. Which vaccine(s) is/are appropriate for her?
Pneumovax 0.5 ml IM
Influenza SD shot 0.25 ml IM
Influenza HD shot 0.5 ml IM
Flumist nasal spray 0.1 ml in each nostril
Zostavax 0.65 ml SQ
Both 1 and 2
1, 2 and 5
1, 3 and 5
1, 4 and 5

14. Varicella Vaccine Varivax®

15. Pathogen (Common name) Table
Classification
Transmission
Complication
Influenza
(flu)
Virus
Respiratory
Pneumonia
Pneumococcus
Gram + Bacteria
Meningitis/
Bacteremia
Varicella
(chicken pox)
Bacterial skin
infection
Zoster
(shingles)
Latent varicella
Neuralgia

16. Varicella Vaccination
All adults without evidence of immunity to varicella should receive 2 doses of single-antigen varicella vaccine or a second dose if they have received only 1 dose.
Special consideration for vaccination should be given to those who
have close contact with persons at high risk for severe disease (e.g., health-care personnel and family contacts of persons with immunocompromising conditions) or
are at high risk for exposure or transmission (e.g., teachers; child care employees; residents and staff members of institutional settings, including correctional institutions; college students; military personnel; adolescents and adults living in households with children; nonpregnant women of childbearing age; and international travelers).

17. Varicella Vaccination
Immunocompromised status is a contraindication.
Pregnancy is a contraindication.
Pregnant women should be assessed for evidence of varicella immunity. Women who do not have evidence of immunity should receive the first dose of varicella vaccine upon completion or termination of pregnancy and before discharge from the health-care facility. The second dose should be administered 4–8 weeks after the first dose.

18. Administration Varivax: 0.65-mL dose (reconstituted)
SQ – upper, outer tricep
5/8 inch, 25 gauge needle

19. Measles, Mumps, Rubella MMR®

20. Pathogen (Common name) Table
Classification
Transmission
Complication
Measles
Virus
Respiratory
Diarrhea
pneumonia
Mumps
Meningitis
Rubella
Arthritis

21. Measles, Mumps, Rubella Vaccination
All adults born in 1957 or later should have documentation of 1 or more doses of MMR vaccine unless they have a medical contraindication to the vaccine, laboratory evidence of immunity to each of the three diseases, or documentation of provider-diagnosed measles or mumps disease.
A routine second dose of MMR vaccine, administered a minimum of 28 days after the first dose, is recommended for adults who
are students in postsecondary educational institutions;
work in a health-care facility; or
plan to travel internationally.

22. MMR Vaccine Contraindications
AIDS or other clinical manifestations of HIV, including persons with CD4+ T-lymphocyte values <200 per mm3
Malignant neoplasms affecting the bone marrow
Chemotherapy or radiation within the last 3 months
Persons on immunosuppressive therapy, including high-dose corticosteroids (>20 mg/day of prednisone or equivalent) lasting two or more weeks

23. Administration MMR: 0.65-mL dose (reconstituted)
SQ – upper, outer tricep
5/8 inch, 25 gauge needle

24. Which of the following vaccine-preventable pathogens is a bacteria?
Measles
Mumps
Rubella
Pneumococcus
Influenza
Varicella

25. Tetanus, Diphtheria, Pertussis Boostrix® Adacel®

26. Pathogen (Common name) Table
Classification
Transmission
Complication
Tetanus
(lockjaw)
Gram + Bacteria-
toxin
Wound
Respiratory failure
Diphtheria
Respiratory
Myocarditis/Neuritis
Pertussis
(whooping cough)
Gram – Bacteria
Pneumonia

27. Comparison of 20th Century and current US Morbidity of VPDs
Diseases
20th Century Annual Morbidity
2010 Reported Cases
Percent Decrease
Smallpox
29,005
100%
Polio (paralytic)
16,316
Measles
530,217 61
>99%
Mumps
162,344
2,528
98%
Pertussis
200,752
21,291
89%
Diphtheria
21,053
Rubella
47,745 6
Congenital Rubella Syndrome
152
Tetanus
580 8
99%
Haemophilus influenzae
20,000
270
Most significant medical achievement in the last century:
Cost-effectiveness
One of top contributions to prolong life expectancy
Successfully eradicated smallpox worldwide

28. New FDA Approval – July 8, 2011
US FDA has approved Boostrix® vaccine to prevent tetanus, diphtheria, and pertussis (whooping cough) in people ages 65 and older.
Boostrix® is the first vaccine approved to prevent all three diseases in older people.
Adacel® is approved for persons 11 through 64 years.
Boostrix® [package insert]. Rixensart, Belgium: GlaxoSmithKline; July 2011.
Adacel® [package insert]. Swiftwater, PA: Sanofi Pasteur Inc.; February 2012.

29. Tetanus, diphtheria, and pertussis (Td/Tdap) Vaccination
Administer a one-time dose of Tdap to adults younger than age 65 years who have not received Tdap previously or for whom vaccine status is unknown to replace one of the 10-year Td boosters.
Tdap is specifically recommended for the following persons:
pregnant women more than 20 weeks’ gestation,
adults, regardless of age, who are close contacts of infants younger than age 12 months (e.g., parents, grandparents, or child care providers), and
health-care personnel.
Tdap can be administered regardless of interval since the most recent tetanus or diphtheria containing vaccine.
Pregnant women not vaccinated during pregnancy should receive Tdap immediately postpartum.
Adults 65 years and older may receive Tdap.

30. Administration Boostrix®/Adacel®: 0.5-mL dose IM - deltoid
1 inch, 25 gauge needle

31. Flumist nasal spray 0.1 ml in each nostril Zostavax 0.65 ml SQ
AB is a 52-year-old woman with hypertension. She has no allergies. Her meds include amlodipine 10 mg PO QD. She smokes 1 PPD. Her newborn grandson lives with her. Which vaccine(s) is/are appropriate for her?
Pneumovax 0.5 ml IM
Influenza SD shot 0.5 ml IM
Influenza HD shot 0.5 ml IM
Flumist nasal spray 0.1 ml in each nostril
Zostavax 0.65 ml SQ
Tdap 0.5 ml IM
1, 2 and 5
1, 3 and 5
1, 2, 5 and 6

32. Human Papilloma Virus Gardasil® (HPV4) Cervarix® (HPV2)

37. Human papillomavirus (HPV) vaccination
Two vaccines are licensed for use in females, bivalent HPV vaccine (HPV2) and quadrivalent HPV vaccine (HPV4), and one HPV vaccine for use in males (HPV4).
For females, either HPV4 or HPV2 is recommended in a 3-dose series for routine vaccination at 11 or 12 years of age, and for those 13 through 26 years of age, if not previously vaccinated.
For males, HPV4 is recommended in a 3-dose series for routine vaccination at 11 or 12 years f age, and for those 13 through 21 years of age, if not previously vaccinated. Males 22 through 26 years of age may be vaccinated.

38. Human papillomavirus (HPV) vaccination
HPV vaccines are not live vaccines and can be administered to persons who are immuno-compromised as a result of infection (including HIV infection), disease, or medications.
HPV vaccine can be administered to persons with a history of genital warts, abnormal Papanicolaou test, or positive HPV DNA test.

39. Administration Gardasil®/Cervarix® IM - deltoid
1 inch, 25 gauge needle

40. Gardasil®: 3 dose series Cervarix®: 3 dose series
The mother of a 12-year-old boy requests the HPV vaccination. Select the correct vaccine and series.
Gardasil®: 3 dose series
Cervarix®: 3 dose series
Gardasil®: 2 dose series
Cervarix®: 2 dose series

41. Meningococcus Vaccine Menactra®, Menveo® Menomune® (MPSV4)

42. Meningocococcal Disease
Gram – Bacteria
Respiratory
Invasive disease

43. Meningococcal Vaccination
Administer 2 doses of meningococcal conjugate vaccine quadrivalent (MCV4) at least 2 months apart to adults with functional asplenia or persistent complement component deficiencies.
HIV-infected persons who are vaccinated should also receive 2 doses.
Administer a single dose of meningococcal vaccine to microbiologists routinely exposed to isolates of Neisseria meningitidis, military recruits, and persons who travel to or live in countries in which meningococcal disease is hyperendemic or epidemic.
First-year college students up through age 21 years who are living in residence halls should be vaccinated if they have not received a dose on or after their 16th birthday.

44. Meningococcal Vaccination
MCV4 (Menactra or Menveo) is preferred for adults 55 years old and younger; meningococcal polysaccharide vaccine (MPSV4-Menomune) is preferred for adults 56 years and older.
Revaccination with MCV4 every 5 years is recommended for adults previously vaccinated with MCV4 or MPSV4 who remain at increased risk for infection.

45. Administration
IM - deltoid
1 inch, 25 gauge needle

46. Hepatits A Vaccine Havrix®, Vaqta®
Hepatits B Vaccine Recombivax-HB® Engerix-B®
Combined Hep A & B Vaccine
Twinrix®

47. Pathogen Table Hepatitis A Virus Fecal-oral Acute/chronic hepatitis
Classification
Transmission
Complication
Hepatitis A
Virus
Fecal-oral
Acute/chronic hepatitis
Hepatitis B
Blood-
serous fluids
Acute hepatitis

48. Hepatitis A Vaccination
Vaccinate any person seeking protection from hepatitis A virus (HAV) infection and persons with any of the following indications:
men who have sex with men
persons who use injection drugs
persons with chronic liver disease
persons traveling to high risk countries
Single-antigen vaccine formulations should be administered in a 2-dose schedule

49. Hepatitis B Vaccination
Vaccinate any person seeking protection
Vaccinate any person in the following risk groups for hepatitis B virus (HBV) infection:
sexually active persons who are not in a long-term, mutually monogamous relationship (e.g., persons with more than one sex partner during the previous 6 months); persons seeking evaluation or treatment for a STD, current or recent injection-drug users; and men who have sex with men;
health-care personnel and public-safety workers who are exposed to blood or other potentially infectious body fluids;
persons with diabetes younger than 60 years as soon as feasible after diagnosis; persons with diabetes who are 60 years or older at the discretion of the treating clinician
persons with end-stage renal disease, including patients receiving hemodialysis; persons with HIV infection; and persons with chronic liver disease;
household contacts and sex partners of persons with chronic HBV infection; clients and staff members of institutions for persons with developmental disabilities; and international travelers to countries with high or intermediate prevalence of chronic HBV infection; and
all adults in the following settings: STD treatment facilities; HIV testing and treatment facilities; facilities providing drug-abuse treatment and prevention services; healthcare settings targeting services to injection-drug users or men who have sex with men; correctional facilities; end-stage renal disease programs and facilities for chronic hemodialysis patients; and institutions and nonresidential daycare facilities for persons with developmental disabilities.

50. Administration
IM - deltoid
1 inch, 25 gauge needle

51. The Pink Book The Red Book The Orange Book The Yellow Book
A patient is travelling to an international destination and requests the appropriate immunizations. What is the best reference to find the vaccines that are indicated?
The Pink Book
The Red Book
The Orange Book
The Yellow Book

52. Which of the following vaccines is a live vaccine?
Pneumovax
Zostavax
Gardasil
Havrix
Fluzone HD

53. Questions and Discussion

54. Adult Vaccine Table Vaccine Vaccine Type Route / Reconstitute Series
Storage
Influenza IIV
Inactivated
IM / No
1x annually
Fridge
Flumist
Live
Intranasal / No
Pneumovax
1-2 doses
Zostavax
SQ / Yes
1 dose
Freezer
Gardasil (HPV4)
Cervarix (HPV2)
3 doses Td
1 q 10 years
Tdap
1x, then Td
Varivax
2 doses
MMR
Menactra, Menveo
Menomune (MPSV4)
1-2+ doses
Havrix, Vaqta
Recombivax-HB
Engerix-B

55. Pathogen (Common name) Table
Classification
Transmission
Complication
Influenza (flu)
virus
Respiratory
Pneumonia
Pneumococcus
Gram + Bacteria
Meningitis/Bacteremia
Varicella (chicken pox)
Bacterial infection
Zoster (shingles)
Latent varicella
Neuralgia
HPV (genital warts)
Sexual contact
Cervical cancer
Meningococcus
Gram - Bacteria
Invasive disease
Tetanus (lockjaw)
Gram + Bacteria-toxin
wound
Respiratory failure
Diphtheria
Myocarditis/Neuritis
Pertussis (whooping cough)
Measles
Diarrhea, pneumonia
Mumps
Meningitis
Rubella
Arthritis
Hepatitis A
Fecal-oral
Acute/chronic hepatitis
Hepatitis B
Blood-serous fluids
Acute hepatitis