Kenneth McCall, BSPharm, PharmD
Associate Professor & Dept. Chair
Disclosure
 I, Kenneth McCall, do not have an interest in selling a
technology, program, product, and/or service to
CME/CE professionals.
 I am a speaker for Merck Vaccines.
Objectives
 Discuss the gap between current rates and Healthy





People 2020 goals for vaccinations.
Categorize each of the CDC recommended vaccines
based upon live/inactivated, route, prep., and storage.
Recognize vaccine-preventable pathogens by common
name, classification, and transmission.
Discuss the influenza vaccines for 2012 including the
new High-Dose and Intradermal vaccines.
Identify vaccine contraindications and recommend
vaccines based upon age and medical history.
Apply ACIP recommendations and FDA approved
indications for the CDC recommended vaccines.
Outline
 Background & Principles of Vaccination
 Influenza
 Pneumonia
 Herpes zoster
Immunization Resources
 The Pink Book
http://www.cdc.gov/vaccines/pubs/pinkbook/index.html
 Adolescent and Adult Vaccine Quiz
http://www2a.cdc.gov/nip/adultImmSched/
 Screening Questionnaire
http://www.immunize.org/catg.d/p4065.pdf
 The Yellow Book
http://wwwnc.cdc.gov/travel/
 1-800-CDC-INFO
 Apps
 ACP Immunization Advisor
 CDC Vaccine Schedule for Adults
Second Regular Session – 125th Maine Legislature
 LD 1608 “An Act to Clarify the Laws Governing Pharmacy
Interns”
 Sponsored by Speaker Bob Nutting
 “…authorized to engage in the practice of pharmacy while under the
direct supervision of a licensed pharmacist.”
 LD 1715 “An Act for Timely Access to Enhanced
Administration of All Vaccines”
 Sponsored by Representative Meredith Strang Burgess
 “‘Practice of pharmacy’ means…the administration of vaccines licensed
by the US FDA that are recommended by the US CDC ACIP for
administration to adults…”
 “A pharmacy may operate a vaccine administration clinic inside,
outside, or off the pharmacy’s premises…with one-time board approval”
Pharmacist Administered Vaccines
Types of Vaccines Authorized to Administer
Based upon APhA / NASPA Survey of State IZ Laws/ Rules (updated March 2012)
Any vaccine
AL*, AK*, AZ*,
AR*, CA, CO,
DC*, DE*, GA*,
HI*, ID,IL, IN*,
IA*, KS, KY, LA*,
ME, MI*, MN,
MS, MT, NE, NV
,NJ*, NM, NC,
ND, OK, OR, PA,
RI, SC*, TN, TX,
VT, VA*, WA, WI
Influenza Only
FL, MA, PR
Influenza and
Pneumo
NY
Number of states / territories
9
Other combos
1
Influenza &
Pneumo
Influenza Only
3
Any vaccine
40
35
30
25
20
15
10
5
0
39
Number of
states /
territories
Other combos
OH, CT, MD,MO,
NH, SD, UT, WV,
WY
* Via Rx for some; ** broad list of vaccines
Pharmacist Administered Vaccines
May student interns administer vaccines?
Based upon APhA / NASPA Survey of State IZ Laws/ Rules (updated March 2012)
Number of states / territories
allowing
34
States / territories not authorized
19 (AK, CO, CT, DE, FL,IN, MA,
MN, ND, NH, NJ, NY, PA, PR, SC,
SD, WV)
Criteria common among states
•Student must be trained (complete
Certificate Training Program)
• Operating under supervision of
trained pharmacist
Principles of Vaccination*
 Passive immunity
 Transplacental
 Breast milk
 Blood products
 Active immunity
 Infection
 Vaccination
*Epidemiology and Prevention of Vaccine-Preventable Diseases, 12th Edition
Classification of Vaccines
 Live attenuated
 Weakened form of the “wild” virus or bacteria
 Inactivated
 Whole viruses or bacteria
 Fractions of viruses or bacteria
*Epidemiology and Prevention of Vaccine-Preventable Diseases, 12th Edition
Classification of Vaccines
 Live attenuated:
 Measles, mumps, rubella, varicella, zoster, intranasal
influenza
 Inactivated:
 hepatitis A, hepatitis B, influenza, pneumonia,
diphtheria, tetanus, pertussis, HPV, meningicoccal
*Epidemiology and Prevention of Vaccine-Preventable Diseases, 12th Edition
Timing & Spacing of Vaccines
 All vaccines can be administered at the same visit as all other
vaccines.
 Individual vaccines should not be mixed in the same syringe.
 When live vaccines (MMR, Varicella, Zoster, and Flumist) are
not administered at the same visit, they should be separated by
at least 4 weeks.
 All other combinations of two inactivated vaccines, or live and
inactivated vaccines may be given at any time before or after
each other.
 Increasing the interval between doses of a multidose vaccine
does not diminish the effectiveness of the vaccine.
 Decreasing the interval between doses of a multidose vaccine
may interfere with antibody response and protection.
*Epidemiology and Prevention of Vaccine-Preventable Diseases, 12th Edition
A healthcare provider requests a flu shot, MMR, and
varicella vaccine. Which of the following statement about
the timing of the vaccines is true?
25%
1. All three , separate syringes, same day
25%
2. All three, mix in 1 syringe, same day
25%
3. Must separate MMR and varicella by 4 wk
25%
4. Must separate MMR and varicella by 7 day
An 12-year-old girl received the first dose of the HPV vaccine six months ago.
The recommend HPV series is a second dose 1-2 mos after first and third dose
at least 3 mos after second. What would you recommend to the parent?
25%
1. The vaccine is no longer indicated
25%
2. Start the series over and repeat first dose
25%
3. Give 2nd dose today; 3rd dose in 1 month
25%
4. Give 2nd dose today; 3rd dose in 3 mos.
Low Adult Vaccination Rates Are in
Contrast to the High Rates Among US Children
 Vaccination is one of the 10 greatest public health achievements of
the 20th century1
 Childhood vaccination rates remain at or near highest levels in the
United States, but many adults are not vaccinated as
recommended2,3
“Although >90% of young children have received the individual
vaccines recommended for them, coverage for adult vaccines can
range from 26% to 65%, depending on the vaccine and the target
population.”2
—Infectious Diseases Society of America
1. Centers for Disease Control and Prevention (CDC). MMWR Weekly Rep. 1999;48(12):241–243. 2. Infectious Diseases Society of America. Clin Infect Dis.
2007;44:e104–e108. 3. Centers for Disease Control and Prevention (CDC). MMWR Weekly Rep. 2009;58(33):921–926.
4
17
18
Perceived Challenges to Adult
Vaccination: Survey1,a
Patient Reasons
Health Care Provider Perceptions
 “Doctor hasn’t told me I need it”
 Not knowing when to get it
 The belief that a healthy person
doesn’t need it
 Financial concerns were not a
deterrent for most




Side effects
Dislike of needles
Lack of insurance coverage
Lack of knowledge about disease
prevention
Most patients indicated that they were likely to receive a vaccination
if their health care provider recommended it.
aA
recent survey was conducted to identify the reasons adult patients may decide to NOT receive vaccinations and health care providers’ perceptions regarding
patients NOT being vaccinated. Consumers (N = 2,002) and health care providers (N = 200) completed structured telephone interviews, e-mails, or faxes
emphasizing tetanus, influenza, and pneumococcal vaccines.
1. Johnson DR et al. Am J Med. 2008;121(Suppl 2):S28–S35.
47
Recommended Adult Immunization
Schedule, by vaccine and age group
< -------------TIV or LAIV--------- >
TIV or TIV HD
< -----------------------------TIV or TIV ID-------------------------------- >
FDA approved
age 50+ yrs
Vaccines that might be indicated for adults
based on medical and other indications
Smoker
College Dorm / Military Recruit
23
Influenza Virus Strains
 Influenza A virus
 Moderate to severe illness
 All age groups
 Humans and other animals
 Influenza B virus
 Milder disease
 Primarily affects children
 Humans only
 Influenza C virus
 Rarely reported in humans
 No epidemics
Seasonal influenza
vaccine contains
2 type-A and 1 type-B
24
Estimated Influenza Vaccination
Coverage: 2010-11.
100
90
80
70
60
50
40
30
20
10
0
HP 2020
US
New England
Maine
Children Adults 18- Adults 50- Adults >65 Adults 1864 yrs at
49 yrs
65 yrs
yrs
high risk†
†Persons with asthma, diabetes, or heart disease
MMWR / June 10, 2011 / Vol. 60 / No. 22
2012-13 ACIP/CDC Recommendations
 Routine influenza vaccination continues to be recommended
for all persons aged ≥6 months.
 While the H1N1 virus is the same as the 2011-2012
recommendation, the recommended influenza H3N2 and B
vaccine viruses are different from those recommended for the
Northern Hemisphere for the 2011-2012 influenza vaccine.
 Persons aged ≥65 years can be administered any of the
standard-dose inactivated vaccine or Fluzone High-Dose.
 A new intradermally administered TIV preparation, Fluzone
Intradermal, was licensed in May 2011 for adults 18 to 65.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6132a3.htm?s_cid=mm6132a3_e
26
US Influenza Vaccines: 2012-13
Vaccine
Inactivated, Standard
Dose
Inactivated, High Dose
Inactivated, Intradermal
Live, Intranasal
Age Group Dosage
Schedule
Route
6-35 mos
0.25 ml
1 or 2 shots
IM
3-8 years
0.5 ml
1 or 2 shots
IM
>9 years
0.5 ml
1 shot
IM
>65 years
0.5 ml
1 shot
IM
18-64 years
0.1 ml
1 shot
ID
2-8 years
0.2 ml
1 or 2
doses
Nasal
9-49 years
0.2 ml
1 dose
Nasal
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6132a3.htm?s_cid=mm6132a3_e#tab
Recommendations regarding influenza vaccination for
persons who report allergy to eggs
29
Live Attenuated Influenza Vaccine
 Indication
 Healthy people 2 through 49 years of age
 Contraindications
I pick my nose!
 Pregnant women
 People who have long-term health problems with:






heart disease
kidney or liver disease
lung disease
metabolic disease, such as diabetes
asthma
anemia, and other blood disorders
 Anyone with a weakened immune system
 Severe egg allergy
30
Live Attenuated Influenza Vaccine
Adverse Reactions
 Runny nose or nasal congestion
 Fever > 100°F in children 2-6 years of age
 Sore throat in adults
 Wheezing and hospitalization in children < 2 years old
Administration
 Flumist®: 0.1-mL dose in each nostril
 Intranasal
32
Flumist Quadrivalent ®
 In February 2012, FDA approved a new seasonal
quadrivalent LAIV, FluMist Quadrivalent
(MedImmune). This vaccine currently is not
anticipated to be available until the 2013–14 influenza
season.
 All currently available influenza vaccines are trivalent
and contain A(H1N1), A(H3N2), and B viral antigens.
There are two antigenically distinct lineages of
influenza B viruses referred to as Victoria and
Yamagata lineages.
34
 Methods:
 Multicenter, randomized, double-blind controlled study
 HD vaccine (60 mcg of hemagglutinin per strain): N=2,575
 SD vaccine (15 mcg of hemagglutinin per strain): N=1,262
 in adults 65 years of age and older.
J Infect Dis. 2009;200(2):172-80
35
antibody titer level
Comparison of responses to high-dose (HD)
and standard-dose (SD) influenza vaccine
140
700
120
600
100
500
80
400
60
300
40
200
20
100
0
0
SD
A/H1N1
B
J Infect Dis. 2009;200(2):172-80
HD
A/H3N2
36
Comparison of systemic side effects to
HD and SD influenza vaccine
25
Percent
20
15
SD
HD
10
5
0
Fever
Headache
Malaise
J Infect Dis. 2009;200(2):172-80
Myalgia
37
Administration
 Fluzone HD®: 0.5-mL dose
 IM - deltoid
 1 inch, 25 gauge needle
38
A 30-year-old healthy male requests an annual flu shot.
He has no allergies. His wife is currently pregnant.
Which flu vaccine(s) is/are appropriate?
0%
1. Influenza intradermal vaccine 0.1 ml
0%
2. Influenza SD shot 0.5 ml IM
0%
3. Influenza HD shot 0.5 ml IM
0%
4. Flumist nasal spray 0.1 ml in each nostril
0%
5. Either 1 or 2
0%
6. Either 3 or 4
0%
7. Either 1, 2 or 4
Intradermal Influenza Vaccine
 Indication
 Persons 18 through 64 years of age
 Contraindications
 Severe egg allergy
41
Intradermal vs Traditional IM needle Length
30 Gauge Needle and Less Volume
 Methods:
 Multicenter, randomized, double-blind controlled study
 ID vaccine (9 mcg of hemagglutinin per strain) N=1,803
 IM vaccine (15 mcg of hemagglutinin per strain): N=452
 in adults 18 to 60 years of age.
Human Vaccines. 2010;6:346-54.
Seroprotection Rate
Comparison of responses to Intradermal (ID)
and Intramuscular (IM) influenza vaccine
100
100
90
90
80
80
70
70
60
60
50
50
IM 15 mcg
40
40
ID 9 mcg
30
30
20
20
10
10
0
0
A/H1N1
B
A/H3N2
Human Vaccines. 2010;6:346-54.
45
Comparison of systemic side effects to
ID and IM influenza vaccine
35
30
Percent
25
20
IM 15 mcg
15
ID 9 mcg
10
5
0
Fever
Headache
Malaise
Myalgia
Human Vaccines. 2010;6:346-54.
46
Comparison of local side effects to ID
and IM influenza vaccine
90
80
70
Percent
60
50
IM 15 mcg
40
ID 9 mcg
30
20
10
0
Erythema
Swelling
Induration
Pain
Human Vaccines. 2010;6:346-54.
47
Which side effect is more common with the intradermal
influenza vaccine than the IM influenza vaccine?
0%
1. Injection site pain
0%
2. Headache
0%
3. Fever
0%
4. Injection site swelling
0%
5. Malaise
A 35-year-old woman requests an annual flu shot. She
has ulcerative colitis and is taking Prednisone 40 mg QD.
Which flu vaccine(s) is/are appropriate?
0%
1. Influenza intradermal shot 0.1 ml
0%
2. Influenza SD shot 0.5 ml IM
0%
3. Influenza HD shot 0.5 ml IM
0%
4. Flumist nasal spray 0.2 ml nasal
0%
5. Either 1 or 2
0%
6. Either 2 or 3
0%
7. Either 2 or 4
Cases per 100,000 Persons
Incidence of IPD in Healthy Adults vs
Adults With Certain Chronic Conditions,
United States (1999–2000)1
Patients 65 years of age aren’t the only ones
who are susceptible to IPD.
Chronic heart disease
Chronic lung disease
Diabetes
HEALTHY ADULTS
18–34
35–49
50–64
Age (years)
IPD = invasive pneumococcal disease.
1. Adapted with permission from Kyaw MH et al. J Infect Dis. 2005;192:377–386.
65–79
80
12
http://www.cdc.gov/flu/weekly/
US Vaccination Rates Are Low
Current pneumococcal vaccination rates are far below Healthy People 2020 goals1,2
Estimated % of US Adults Who Have Received Pneumococcal Vaccine
90% goal*
100
US Adults (%)
80
60
Diabetes
40
40%
20
0
*Healthy
60% goal*
65.6%
Lung
disease
Heart
disease
27%
28%
18–64 years of age at high risk
(2006)
 65 years of age
(2007)
People 2020 goal.
1. Centers for Disease Control and Prevention (CDC). Healthy People 2020 Database.
www.healthypeople.gov/2020/topicsobjectives2020/pdfs/HP2020objectives.pdf Accessed July 14, 2011. 2. NCIRD. Vaccination coverage among U.S. adults.
National Immunization Survey – Adult, 2007. www.cdc.gov/vaccines/stats-surv/nis/downloads/nis-adult-summer-2007.pdf. Accessed June 25, 2009.
20
Pneumococcal-23 Vaccine
 Indication
 Routine vaccination of persons > 65 years (ACIP)
 Routine vaccination of persons > 50 years (FDA)
 Persons > 2 years of age with chronic conditions
 Chronic illness (diabetes, heart disease, lung disease)
 Asplenia
 Immunocompromised / HIV infection
 Cochlear implant
 Smokers
 Contraindications
 Hypersensitivity to any component of the vaccine
56
Revaccination: ACIP Recommendations1
Group
Recommendation
Immunocompetent persons  65 years
of age
• If patient received vaccine  5 years previously
and was < 65 years of age at time of initial
vaccination, revaccinate
Immunocompromised persons  2
years of age
Persons 2 to 64 years of age with
functional or anatomic aspleniaa
• If patient is > 10 years of age, administer single
revaccination  5 years after previous dose
• If patient is 10 years of age, consider
revaccination 3 years after previous dose
If prior vaccination status of patients in high-risk groups is unknown,
pneumococcal vaccine should be administered.
aIncluding
sickle cell disease and splenectomy.
ACIP = Advisory Committee on Immunization Practices.
1. Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep. 1997;46(RR-8):1–24.
18
ACIP Recommendations for PREVNAR 13 in Adults >50
 12/30/11-FDA expanded indication to adults 50+
 February 2012 ACIP meeting: “At this time, the
available evidence is insufficient to recommend
routine use of PCV13 among older adults”
 Critical data elements for the ACIP recommendation to
be made are not available at this time


–the indirect effects of PCV13 use in children on adult disease
incidence
–results from the CAPITA trial
 Clinical relevance of immunogenicity data unclear
without defined correlate of protection
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm285431.htm
http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb12/02-PCV13.pdf (slide 37)
Administration
 Pneumovax®: 0.5-mL dose
 IM - deltoid
 1 inch, 25 gauge needle
61
JB is a 40-year-old man with diabetes. He has no allergies. His
current meds include metformin 500 mg PO BID and lisinopril 20 mg
PO QD. Which vaccine(s) is/are appropriate for him?
0%
1. Pneumovax 0.5 ml IM
0%
2. Influenza SD vaccine 0.5 ml IM
0%
3. Influenza HD vaccine 0.5 ml IM
0%
4. Flumist nasal spray 0.2 ml nasal
0%
5. Both 1 and 2
0%
6. Both 2 and 3
0%
7. Both 2 and 4
Which of the following statements about the administration of
influenza and pneumonia vaccines is true?
0%
1. Same day, opposite arm, separate syringe
0%
2. Same day, same arm, mixed in 1 syringe
0%
3. Must be separated by at least 7 days
0%
4. Must be separated by at least 4 weeks
65
66
Zoster Incidence by Age Group1
12
Number of Cases
Rate per person-years
1,800
10
1,600
1,400
8
1,200
1,000
6
800
4
600
400
Rate per 1,000 Person-Years
Number of Cases of Zoster (n = 9,152)
2,000
2
200
0
0
0-14
15-29
30-39
40-49
50-59
60-69
70-79
80+
Age
1. Insinga RP et al. J Gen Intern Med. 2005;20:748–753.
55
The Age Group at Greatest Risk for
Zoster Is Growing Each Year

As the population ages, we can expect to see more cases of zoster
– Age is the biggest risk factor for zoster1,2
•
•
Epidemiological studies indicate a sharp increase in zoster at 50 to 60 years of age that increases further
as individuals age3
More than half of the estimated 1 million annual cases of zoster are in persons 60 years of age and older3
– US Census Bureau projections show a substantial, steady increase in the US population 50 years
of age and older4
131,381,657
Projected US Population 50 Years of Age and Older
33% INCREASE
98,601,888
2010–2030
1. Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep. 2008;57(RR–5):1–30. 2. Gnann JW et al. N Engl J Med. 2002;347:340–346.
3. Schmader K et al. J Infect Dis. 2008;197:S207–S215. 4. Centers for Disease Control and Prevention (CDC) Web site. Population projections, United
States, 2010–2030. http://wonder.cdc.gov/population-projections.html. Accessed May 19, 2011.
56
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)
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1.htm?s_cid=rr5705a1_e
69
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 highdose corticosteroids (>20 mg/day of prednisone or
equivalent) lasting two or more weeks
70
ZEST & Shingles Prevention Study (SPS) Results
Vaccine Efficacy (%)
95% CI
1
>80 yrs (n=1,263) (-29 to 48)
70-79 yrs (n=7,621) 1
60-69 yrs (n=10,370)
18%
41%
(28 to 52)
1
(56 to 71)
2
50-59 yrs (n=11,211)
0
64%
(54 to 81)
10
70%
20
30
40
50
60
70
1. Oxman et al. New England Journal of Medicine. 2005. 352 (22): 2271
2. Zostavax® [package insert]. Whitehouse Station, NJ: Merck; April 2011.
80
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.
74
Administration
 Zostavax: 0.65-mL dose (reconstituted)
 SQ – upper, outer tricep
 5/8 inch, 25 gauge needle
75
Which of the following statements about the
administration of influenza and zoster vaccines is true?
0%
1. Same day, opposite arm, separate syringe.
0%
2. Same day, same arm, mixed in 1 syringe.
0%
3. Must be separated by at least 7 days.
0%
4. Must be separated by at least 4 weeks.
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?
11%
1. Pneumovax 0.5 ml IM
11%
2. Influenza SD shot 0.25 ml IM
11%
3. Influenza HD shot 0.5 ml IM
11%
4. Flumist nasal spray 0.1 ml in each nostril
11%
5. Zostavax 0.65 ml SQ
11%
6. Both 1 and 2
11%
7. 1, 2 and 5
11%
8. 1, 3 and 5
11%
9. 1, 4 and 5
Pathogen (Common name) Table
Pathogen
Classification
Transmission
Complication
Influenza
(flu)
Pneumococcus
Virus
Respiratory
Pneumonia
Gram + Bacteria
Respiratory
Varicella
(chicken pox)
Zoster
(shingles)
Virus
Respiratory
Virus
Latent varicella
Meningitis/
Bacteremia
Bacterial skin
infection
Neuralgia
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).
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.
Administration
 Varivax: 0.65-mL dose (reconstituted)
 SQ – upper, outer tricep
 5/8 inch, 25 gauge needle
82
Pathogen (Common name) Table
Pathogen
Measles
Classification
Virus
Transmission
Respiratory
Mumps
Virus
Respiratory
Complication
Diarrhea
pneumonia
Meningitis
Rubella
Virus
Respiratory
Arthritis
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.
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
Administration
 MMR: 0.65-mL dose (reconstituted)
 SQ – upper, outer tricep
 5/8 inch, 25 gauge needle
87
Which of the following vaccinepreventable pathogens is a bacteria?
17%
1. Measles
17%
2. Mumps
17%
3. Rubella
17%
4. Pneumococcus
17%
5. Influenza
17%
6. Varicella
Pathogen (Common name) Table
Pathogen
Tetanus
(lockjaw)
Diphtheria
Pertussis
(whooping cough)
Classification
Gram + Bacteriatoxin
Gram + Bacteriatoxin
Gram – Bacteria
Transmission
Wound
Complication
Respiratory failure
Respiratory
Myocarditis/Neuritis
Respiratory
Pneumonia
Comparison of 20th Century and current
US Morbidity of VPDs
Diseases
20th Century
2010 Reported
Annual Morbidity Cases
Percent Decrease
Smallpox
29,005
0
100%
Polio (paralytic)
16,316
0
100%
Measles
530,217
61
>99%
Mumps
162,344
2,528
98%
Pertussis
200,752
21,291
89%
Diphtheria
21,053
0
100%
Rubella
47,745
6
>99%
Congenital Rubella
Syndrome
152
0
100%
Tetanus
580
8
99%
20,000
270
99%
Haemophilus
influenzae
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.
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.
Administration
 Boostrix®/Adacel®: 0.5-mL dose
 IM - deltoid
 1 inch, 25 gauge needle
94
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?
11%
1. Pneumovax 0.5 ml IM
11%
2. Influenza SD shot 0.5 ml IM
11%
3. Influenza HD shot 0.5 ml IM
11%
4. Flumist nasal spray 0.1 ml in each nostril
11%
5. Zostavax 0.65 ml SQ
11%
6. Tdap 0.5 ml IM
11%
7. 1, 2 and 5
11%
8. 1, 3 and 5
11%
9. 1, 2, 5 and 6
HPV Overview
 Nonenveloped, double-stranded DNA virus1; necessary cause
of cervical cancer.2
 More than 100 types of HPV viruses identified; 30 to 40 infect the
anogenital tract.3,4
– HPV 16 and 18 account for ~70% of cervical cancers worldwide.5
– HPV 16 and 18 are also associated with precancerous lesions.6
1. Howley PM. In: Fields BN et al, eds. Fundamental Virology. Lippincott-Raven;1996:2045–2076. 2. Walboomers JM et al. J Pathol. 1999;189:12–19.
3. Schiffman M et al. Arch Pathol Lab Med. 2003;127:930–934. 4. Wiley DJ et al. Clin Infect Dis. 2002;35(Suppl 2):S210–S224. 5. Dunne EF et al. JAMA.
2007;297:813–819. 6. Clifford GM et al. Br J Cancer. 2003;89:101–105.
41
HPV Infects Females1
Cervical HPV Prevalence Rates in Femalesa
b
Prevalence (%)
b
Age (years)
aPrevalence
of cervical HPV infection among 2,356 study participants who completed at least 1 clinical visit.
HPV types included 16, 18, 26, 31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59, 66, 68, 70, 73, 82. Low-risk/non-oncogenic HPV
types included 6, 11, 40, 42, 54, 61, 72, 81, 89.
1. Goodman MT et al. Cancer Res. 2008;68:8813–8824.
bHigh-risk/oncogenic
37
HPV Infects Males1
Genital HPV Prevalence Rates in Malesa
b
Period prevalence (%)
b
Age (years)
aMales
aged 18–44 years in Tucson, Arizona (N = 290).
HPV types included 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66. Low-risk/non-oncogenic HPV types included 6, 11, 26, 40, 42, 53,
54, 55,62, 64, 67–73, 81–84, IS39, CP6108.
1. Giuliano AR et al. J Infect Dis. 2008;198:827–835.
bHigh-risk/oncogenic
38
Natural History of High-Risk HPV
Infection and Potential Progression
to Cervical Cancer1
~1 Year
Transient
Infection
HPV Infection
2–5 Years
Persistent
Infection
Low-Grade
Dysplasia
CIN 1
4–5
Years
High-Grade
Dysplasia
CIN 2/3
9–15
Years
>2 Years
Invasive
Cancer
CIN = cervical intraepithelial neoplasia.
1. Reprinted from Pagliusi SR, Aguado MT. Vaccine. 2004;23:569–578. Copyright© 2004, with permission from Elsevier.
43
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.
Human papillomavirus (HPV) vaccination
 HPV vaccines are not live vaccines and can be
administered to persons who are immunocompromised 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.
Administration
 Gardasil®/Cervarix®
 IM - deltoid
 1 inch, 25 gauge needle
103
The mother of a 12-year-old boy requests the HPV
vaccination. Select the correct vaccine and series.
25%
 Gardasil®: 3 dose series
25%
 Cervarix®: 3 dose series
25%
 Gardasil®: 2 dose series
25%
 Cervarix®: 2 dose series
Meningocococcal Disease
 Gram – Bacteria
 Respiratory
 Invasive disease
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.
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.
Administration
 IM - deltoid
 1 inch, 25 gauge needle
109
Pathogen Table
Pathogen
Classification
Transmission
Hepatitis A
Virus
Fecal-oral
Hepatitis B
Virus
Bloodserous fluids
Complication
Acute/chronic
hepatitis
Acute hepatitis
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
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 HIV infection; and persons with chronic liver disease;
 persons with end-stage renal disease, including patients receiving hemodialysis;
 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.
Administration
 IM - deltoid
 1 inch, 25 gauge needle
114
Which vaccines would you recommend for an 19-year-old
female college freshman who is living in the dorms. Her
prescription profile includes Yaz one tablet QD and a
prescription for Metronidazole 2 gm PO x1 two months ago.
14%
1. Hepatitis B: 3 dose series
14%
2. HPV: 3 dose series
14%
3. Meningocococcal
14%
4. Zoster
14%
5. 1 & 3 only
14%
6. 2 & 4 only
14%
7. 1, 2, and 3
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?
25%
1. The Pink Book
25%
2. The Red Book
25%
3. The Orange Book
25%
4. The Yellow Book
Which of the following vaccines is a live vaccine?
20%
1. Pneumovax
20%
2. Zostavax
20%
3. Gardasil
20%
4. Havrix
20%
5. Fluzone HD
Adult Vaccine Table
Vaccine
Vaccine
Type
Route /
Reconstitute
Series
Storage
Influenza TIV
Inactivated
IM / No
1x annually
Fridge
Flumist
Live
Intranasal / No
1x annually
Fridge
Pneumovax
Inactivated
IM / No
1-2 doses
Fridge
Zostavax
Live
SQ / Yes
1 dose
Freezer
Gardasil (HPV4)
Cervarix (HPV2)
Inactivated
IM / No
3 doses
Fridge
Td
Inactivated
IM / No
1 q 10 years
Fridge
Tdap
Inactivated
IM / No
1x, then Td
Fridge
Varivax
Live
SQ / Yes
2 doses
Freezer
MMR
Live
SQ / Yes
1-2 doses
Freezer
Menactra, Menveo
Menomune (MPSV4)
Inactivated
IM / No
1-2+ doses
Fridge
Havrix, Vaqta
Inactivated
IM / No
2 doses
Fridge
Recombivax-HB
Engerix-B
Inactivated
IM / No
3 doses
Fridge
Pathogen (Common name) Table
Pathogen
Classification
Transmission
Complication
Influenza (flu)
virus
Respiratory
Pneumonia
Pneumococcus
Gram + Bacteria
Respiratory
Meningitis/Bacteremia
Varicella (chicken pox)
virus
Respiratory
Bacterial infection
Zoster (shingles)
virus
Latent varicella
Neuralgia
HPV (genital warts)
virus
Sexual contact
Cervical cancer
Meningococcus
Gram - Bacteria
Respiratory
Invasive disease
Tetanus (lockjaw)
Gram + Bacteria-toxin
wound
Respiratory failure
Diphtheria
Gram + Bacteria-toxin
Respiratory
Myocarditis/Neuritis
Pertussis (whooping cough)
Gram - Bacteria
Respiratory
Pneumonia
Measles
virus
Respiratory
Diarrhea, pneumonia
Mumps
virus
Respiratory
Meningitis
Rubella
virus
Respiratory
Arthritis
Hepatitis A
virus
Fecal-oral
Acute/chronic hepatitis
Hepatitis B
virus
Blood-serous fluids
Acute hepatitis