Vaccinations
Thi Mai, Julia Lee, Kim Truoung,
Melvie Kim, Maylyn Martinez, Cory
Taylor
Influenza Vaccine
• INDICATIONS
– Everyone older than 6 months
– Prior to 2010, used to be only at risk individuals and their close contacts
• WHY DO I NEED IT, DOC?
– Influenza vaccination not only reduces the risk of influenza infection but also
reduces the severity of illness in those who are infected -- PMID 23532475,
Clin Infect Dis 2012
– Vaccination results in fewer influenza infections and fewer missed days from
work in such individuals -- PMID 10411194, JAMA 1999
• HOW DO THEY PICK THE ANTIGENS?
– Global surveillance of influenza viruses circulating at the end of the prior
influenza season
– Quadrivalent means two influenza A virus es and two influenza viruses
– Translates in a large committee, a large dart board, and a lot of darts
Influenza Vaccine -- Preparations
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STANDARD DOSE TRIVALENT OR QUADRIVALENT INACTIVATED
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HIGH DOSE TRIVALENT INACTIVATED
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1/5 the dose = more vaccine to go around
higher incidence of site reactions: erythema, swelling, pruritis, but not pain or sore shoulder
STANDARD DOSE QUADRIVALENT LAIV
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intramuscular
greater than 65 years old
may be more effective in individuals on statin
may be displaced in future by forthcoming adjuvinated standard dose
INTRADERMAL TRIVALENT OR QUADRIVALENT INACTIVATED
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intramuscular vs jet-injected
any age
intranasal
non-pregnant adults younger than 50
contraindicated for immunocompromised or close contacts
FOR EGG ALLERGIES: TRIVALENT CELL-CULTURED vs TRIVALENT RECOMBINANT
Influenza Vaccine – Schedule
• Northern Hemisphere – October - March
• Southern Hemisphere – May - August
• Tropics and Cruise ships: year-round
Influenza Vaccine -- Shortages
• Limited supply of vaccine may necessitate
rationing
• Higher risk individuals and contacts:
– Extremes of Age: younger than 2, older than 65
– Lung, heart, liver, kidney failure; diabetes; severely
debilitated
– Healthcare workers
– Pregnant and postpartum
– Health and custodial care facility residents
– Immunocompromised
Tetanus, Diptheria, Pertussis
• DTaP series in children until 4-6 years old
– Start at 6 weeks; 4-5 doses depending on timing
• Tdap booster 10 years later
• Td booster every 10 years for life
– Tdap booster again if older than 19 replacing routine Td
• If unsure or less than 3 Td prior, start series of 3 similar
to DTaP schedule; at least one should be Tdap
• Pregnant – you get Tdapped each pregnancy
PNEUMOCOCCAL
VACCINES
Pneumococcal Disease
• Second most common cause of vaccine preventable
death in the US
• Major clinical syndromes include
• Pneumonia
• Bacteremia
• Meningitis
It is better to prevent than to try and fight pneumococcal disease
with antibiotics that might not work.
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Available Vaccines
• >90 different capsular serotypes identified, however not
possible to include all in a vaccine
• Available vaccines contain capsular serotypes found to
cause invasive disease:
1) Pneumococcal polysaccharide vaccine (Pneumovax,
PPSV23)
2) Pneumococcal conjugated vaccine (was Prevnar 7,
PCV7, now replaced by Prevnar 13, PCV13)
Pneumovax (PPSV23)
• Consists of capsular material from 23 serotypes
• These serotypes cause about 50-60% of pneumococcal
disease in adults
• Has been used in adults for decades, but not in infants
since polysaccharide antigens are poorly immunogenic in
such individuals
Updates on Prevnar (PCV7  13)
• Consists of capsular material from 13 serotypes,
covalently linked to a protein almost identical to diphtheria
toxin
• This link renders vaccine immunogenic to infants and toddlers
• Timeline:
• 2000 - Prevnar 7 was adopted was adopted for universal use in
toddlers/infants
• 2010 – Prevnar 13 recommended in its place
• 2012 – Prevnar 13 also recommended for use in selected high risk
adults
• 2014 – Prevnar 13 also recommended for use in adults > 65
Adult 65 and Older
• CDC recommends all adult ≥ 65 receive 2 types of
pneumococcal vaccines
• One dose of PCV13 (first)
• One dose of PPSV23 ( 6 to 12 months after PCV vaccine)
• This age group requires both vaccines for the best protection
against pneumococcal disease
Adult 19 to 64 Years Who Only Need
PPSV23
• Those with chronic conditions
• Asthma
• Diabetes
• Heart disease
• Alcoholism
• Liver disease
• Cigarette smokers
• Residents of nursing homes or other long-term care
facilities
• When they turn 65 this group should receive a dose of
PCV13
Adults 19 to 64 Who Should Receive both
PCV13 and PPSV23*
• Functional or anatomic asplenia†
• Cochlear implants
• Cerebrospinal fluid leaks†
• Lymphoma, leukemia, Hodgkin disease,†
• Solid organ transplants†
• * PCV13 and PPSV23 cannot be given at the same visit
• † A second PPSV23 vaccine is recommended for these
individuals five years after the first PPSV23 dose
Herpes Zoster (Shingles) Vaccine
Herpes Zoster (shingles)
• Caused by reactivation of a latent varicella
zoster virus infection
• Generally associated with normal aging and
with anything that causes reduced
immunocompetence
• Lifetime risk of 32% in the United States
• Estimated 1 million cases zoster diagnosed
annually in the U.S.
Herpes Zoster Vaccine
(Zostavax)
• Contains live attenuated varicella virus in an amount
that is approximately 14 times greater than that in
regular varicella vaccine
• Approved for persons 60 years of age and older
• Administered by the subcutaneous route
Zostavax Clinical Trial
• Compared to the placebo group the vaccine group had:
• 51% fewer episodes of zoster
• less severe disease
• 66% less postherpetic neuralgia
• No significant safety issues were identified
NEJM 2005;352(22):2271-84.
Recommendations
for Zoster Vaccine
• Single dose of zoster vaccine for adults 60 years of age
and older whether or not they report a prior episode of
shingles
• Persons with a chronic medical condition may be
vaccinated unless a contraindication or precaution
exists for their condition
MMWR 2008;57(RR-5)
Zoster Vaccine Contraindications
• Severe allergic reaction to a vaccine component or
following a prior dose
• Pregnancy or planned pregnancy within 4 weeks
• Immunosuppression
MMWR 2008;57(RR-5)
Zoster Vaccine Contraindications
Immunosuppression
• Leukemia, lymphoma or other malignant
neoplasm affecting the bone marrow or
lymphatic system
• persons whose leukemia or lymphoma is in
remission and who have not received
chemotherapy or radiation for at least 3
months can be vaccinated
• AIDS or other clinical manifestation of HIV
infection
• includes persons with CD4+ T-lymphocyte
values less than 200 per mm3 or less than
15% of total lymphocytes
MMWR 2008;57(RR-5)
Zoster Vaccine Contraindications
Immunosuppression
• High-dose corticosteroid therapy
• 20 milligrams or more per day of prednisone or equivalent lasting
2 or more weeks
• vaccination should be deferred for at least 1 month after
discontinuation of therapy
MMWR 2008;57(RR-5)
HEPATITIS A
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Hepatitis A is a form of acute viral hepatitis
Symptoms include acute onset jaundice, scleral icterus, abdominal pain, flu-like symptoms,
anorexia, nausea, diarrhea
Transmission: fecal-oral route often via contaminated food or water
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Vaccine recommendations:
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Everyone, but especially those at higher risk
Can start as early as 1 years old
Higher risk groups:
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Living or traveling to endemic areas with hepatitis A
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Central or South America, Mexico, Asia (except Japan), Africa, and eastern Europe
At least 1 month before traveling
Men who have sex with men
Chronic liver disease
Those who have close contact with international adoptees from endemic region
Postexposure prophylaxis in those with sick contacts
Patients who are treated with clotting factor concentrates (ie for hemophilia)
Schedule: at month 0 and 6-12
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Inactivated virus, and usually combined with Hepatitis B (TWINRIX), although there are single antigen Hep
A vaccines (HAVRIX, VAQTA)
HEPATITIS B
• Hepatitis B virus can cause acute and chronic
liver disease
– Acute: manifestations range among subclinical,
icteric, and fulminant hepatitis
– Chronic: can progress from asymptomatic carrier
to chronic hepatitis to cirrhosis with increased risk
for hepatocellular carcinoma
• Worldwide, 240 million are chronic carriers
and over 780,000 hepatitis B related deaths
occur annually
Hepatitis B
Recommendations for vaccine
• All infants, beginning at birth and then all unvaccinated children <19 years
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High risk individuals
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Sexual partners of HBsAg-positive persons
Sexually promiscuous individuals at risk for STDs in general
Injection drug users
Other individuals to think about
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Susceptible household contacts of HBsAg-positive persons
Healthcare and public safety workers with occupational exposure to blood
Screen women at their first prenatal visit
Chronic liver disease or HIV
Persons with ESRD regardless of dialysis status
Travelers to endemic HBV regions
Unvaccinated adults with diabetes mellitus age 19-59 years
Age >60 is at discretion of clinician
Patients who request it
Hepatitis B
• Schedule = 3 shots
– Children: at birth, then 1-2 months, then 6-18 months old
– Adults:
• At months 0, 1, and 4-6 months for single antigen vaccine ENGERIX and RECOMBIVAX HB
• At month 0, 1, and 6 for combined HepAHepB vaccine TWINRIX
• Incomplete vaccinations: not necessary to restart entire series
– If stopped after first dose, second dose should be given asap, then third dose
after 8 weeks
– If stopped after 2nd dose, third dose should be give as soon as possible
• Contraindications and Adverse reactions
– Contraindications: serious allergic reaction to a prior dose of hepatitis B
vaccine, a component of the hepatitis B vaccine, or yeast
– Common adverse reactions: soreness at site, low grade fever, malaise,
headache, joint pain and myalgia
Hepatitis B
• Post-vaccination testing
– current hepatitis B vaccines have a response rate of 95 percent
and immune response can last over 20 years
– No indication to test for seroconversion (Hep B surface
antibody), except:
• health-care workers
• patients on chronic hemodialysis
• individuals (such as spouses or sexual partners of carriers and infants
of carrier mothers) who are at risk for recurrent exposure to hepatitis
B
– Draw HBsAb 1-2 months after completion of vaccination series
– Nonresponders should complete a second three-dose vaccine
series, then repeat testing
• Non-responders to the second course of vaccine should be tested for
HBsAg.
HUMAN PAPILLOMA VIRUS
• HPV can cause several types of cancer
– cervical, anal, oropharyngeal
– Type 16, 18 cause 70% of cervical cancers
• HPV vaccines: GARDASIL, CERVARIX
– Both protect against HPV type 16 and 18
– Gardasil also prevents against HPV type 6 and 11
• Gardasil 9 protects against additional 5 high risk strains
– Cervarix is approved for females 9-25 years old
– Evidence of cross-protection against a few additional
HPV types that can cause cancer
HPV VACCINE
Recommendations: 3 shots
• Boys and girls starting at age 11 or 12
• Male until 21
• Female until age 26
• High risk males until age 26:
– MSM
– immunocompromised
Schedule: vaccinate at months 0, 1-2, and 6
Question 1
• A 63-year-old man is in clinic for routine
follow up. His recently diagnosed COPD is
controlled with tiotropium and albuterol as
needed. He receives yearly influenza
vaccinations. Although he has never received
the pneumococcal vaccination, all other
immunizations are up-to-date.
• On physical examination, vital signs are
normal and lungs are clear to auscultation.
• Which of the following is the best influenza and
pneumococcal immunization regimen for this
patient?
A: Influenza vaccine now
B: Influenza and pneumococcal vaccines now
C: Influenza vaccine now and pneumococcal vaccine
at the next routine visit
D: Influenza vaccine now and pneumococcal
vaccine at age 65 years
• Which of the following is the best influenza and
pneumococcal immunization regimen for this
patient?
A: Influenza vaccine now
B: Influenza and pneumococcal vaccines now
C: Influenza vaccine now and pneumococcal vaccine
at the next routine visit
D: Influenza vaccine now and pneumococcal
vaccine at age 65 years
• The most appropriate immunization regimen for this patient is
influenza and pneumococcal vaccines now.
• Pneumococcal vaccine may be administered concurrently with
other vaccines, such as the influenza vaccine, but at a
separate site. Waiting for the next scheduled routine visit to
administer the pneumococcal vaccine carries a risk of not
administering the vaccine in a timely fashion and the
possibility of failing to administer the vaccine at all.
• Influenza and pneumococcal vaccines are recommended for
patients with COPD.
• Influenza vaccine is recommended annually for all adults.
High-dose influenza vaccine is an option for patients 65 years
and older.
• Pneumococcal vaccine is recommended for adults 65 years and older.
Pneumococcal vaccine is recommended for all adults regardless of age if
they have the following chronic conditions: chronic lung disease (including
asthma), chronic liver disease, diabetes mellitus, cirrhosis, chronic
alcoholism, functional or anatomic asplenia, immunocompromising
conditions (including chronic kidney failure or the nephrotic syndrome),
cochlear implants, or cerebrospinal fluid leaks. Other indications are
smokers and residents of nursing homes or long-term care facilities.
• One-time revaccination is indicated after 5 years for persons aged 19 to 64
years with the nephrotic syndrome or chronic kidney failure, functional or
anatomic asplenia, and immunocompromising conditions. One-time
revaccination is recommended for patients who were vaccinated 5 or
more years ago and were less than 65 years of age at the time of primary
vaccination. The 7-valent pneumococcal polysaccharide vaccine seems to
induce a superior immune response than the 23-valent-pneumococcal
polysaccharide vaccine. Data suggest that influenza vaccination, but not
pneumococcal vaccination, is associated with reduced all-cause mortality.
Key Point
• Influenza and pneumococcal vaccines are
recommended for patients with COPD and can
be administered at the same time but at
different sites.
Uptodate.com
Question 2
• A 30-year-old woman is evaluated during a
routine examination. She was born in the United
States and reports getting “routine shots” in
childhood. She received a routine tetanus,
diphtheria, and acellular pertussis (Tdap) booster
5 years ago. She is sexually active with a single
lifetime sexual partner. She has had no history of
sexually transmitted infection. She has had
regular Pap smears without any abnormal results;
her most recent was 3 years ago. She does not
smoke cigarettes. She works as a 3rd-grade school
teacher. Physical exam is normal.
• Which of the following vaccinations should be
administered?
A: Hepatitis B vaccine series
B: Human papillomavirus vaccine series
C: Influenza vaccine
D: Tetanus and diphtheria (Td) vaccine
• Which of the following vaccinations should be
administered?
A: Hepatitis B vaccine series
B: Human papillomavirus vaccine series
C: Influenza vaccine
D: Tetanus and diphtheria (Td) vaccine
• This healthy 30-year-old woman should receive a seasonal
influenza vaccination. The Centers for Disease Control and
Prevention currently recommends that all adults be
vaccinated annually against influenza, regardless of risk
factors. Vaccination usually takes place between September
and March in the Northern hemisphere. Healthy adults can be
vaccinated with either an inactivated vaccine injected
intramuscularly or a live attenuated intranasal vaccine.
• The hepatitis B vaccine is indicated for all children and adolescents
through age 18 years, persons with HIV or other recent sexually
transmitted infections, persons who are sexually active but not
monogamous, workers with occupational exposure to blood, clients and
staff of institutions for the developmentally disabled, correctional facility
inmates, illicit drug users, persons with diabetes mellitus who are younger
than 60 years, and persons with advanced chronic kidney disease who are
approaching hemodialysis. Hepatitis B vaccination is also indicated for
those planning travel to an endemic area and those with an increased risk
for morbidity related to the disease, as well as for persons who request
vaccination. This patient has no indication for hepatitis B vaccination.
• The human papillomavirus vaccine is licensed for males and females aged
9 through 26 years and is recommended for females between the ages of
11 and 26 years and males between the ages of 11 and 21 years. The
vaccine is not indicated for this 30-year-old woman
• Current recommendations are that a tetanus and diphtheria (Td) vaccine
be routinely administered every 10 years.
• Owing to an increased incidence of pertussis, thought in part to be related
to waning immunity from childhood vaccination, all adults are
recommended to receive a single tetanus, diphtheria, and acellular
pertussis (Tdap) vaccination regardless of the interval since their last Td
booster (although it may be given in place of a decennial Td booster if
scheduled); this is a particularly important recommendation for persons
aged 65 years or older because of the high burden of associated disease in
this patient population.
• In addition, all postpartum women, health care workers, and adults who
have close contact with infants younger than 12 months should receive a
one-time Tdap booster if not already given. This patient is not due for a
routine repeat Td booster for another 5 years and has no indications to
receive either a Td or Tdap vaccination at this time.
Key Point
• Annual seasonal influenza vaccination is
recommended for all adults, regardless of risk
factors.
Question 3
• A 58-year-old man is in clinic to establish care. A
review of his previous records shows he received
a pneumococcal vaccination 6 years ago when he
was admitted to the hospital with communityacquired pneumonia. He has no complaints and
feels well. Medical history includes type 2
diabetes mellitus, hypertension, and
hyperlipidemia. Medications include insulin
glargine, metformin, lisinopril, and simvastatin.
His physical exam is unremarkable.
• When should this patient receive an
additional pneumococcal vaccination?
A: Today
B: Today and repeat every 5 years
C: Today and at age 65 years
D: At age 65 years
E: No further pneumococcal vaccinations are
required
• When should this patient receive an
additional pneumococcal vaccination?
A: Today
B: Today and repeat every 5 years
C: Today and at age 65 years
D: At age 65 years
E: No further pneumococcal vaccinations are
required
• This man should receive a single pneumococcal polysaccharide vaccination
at age 65 years.
• Adults 65 years and older should be immunized against pneumococcal
pneumonia.
• The vaccine contains 23 antigen types of Streptococcus pneumoniae and
protects against 60% of bacteremic disease.
• Currently, immunocompetent persons vaccinated after age 65 years are
not recommended to receive a booster.
• Immunocompetent persons vaccinated before age 65 years, such as this
patient, should receive a single booster vaccination at age 65 years, or 5
years after their first vaccination if they were vaccinated between the ages
of 60 and 64 years.
• The vaccine is also recommended in some populations of younger
patients, including:
– Alaskan natives and certain American Indian populations;
– residents of long-term care facilities;
– patients who are undergoing radiation therapy or are on immunosuppressive
medication;
– patients who smoke; and patients with chronic pulmonary disorders (including asthma),
diabetes mellitus, cardiovascular disease, chronic liver or kidney disease, cochlear
implants, asplenia, immune disorders, or malignancies.
• There is no information on vaccine safety during pregnancy. The vaccine is
reasonably effective, with high levels of antibody typically found for at
least 5 years.
• Immunocompromised patients (including those with
HIV infection and kidney disease) as well as patients
with asplenia should receive a single pneumococcal
vaccine booster 5 years after their first vaccine. This
strategy would be inappropriate for this patient.
• Current recommendations do not support more than a
single booster after initial pneumococcal vaccination
for any persons. Hence, a strategy of vaccination every
5 years would be inappropriate.
• All patients vaccinated before age 65 years need a
booster at some point. Hence, withholding further
pneumococcal vaccination is inappropriate.
Key Point
• Immunocompetent persons who received the
pneumococcal polysaccharide vaccine before
age 65 years should receive a single booster
vaccination at age 65 years, or 5 years after
their first vaccination if they were vaccinated
between the ages of 60 and 64 years.
Question 4
• A 24-year-old woman is evaluated during a
routine examination in November. She has
ulcerative colitis, which was diagnosed 10 years
ago. Her last menstrual period was 5 weeks ago.
She currently takes 6-mercaptopurine.
• On physical examination, vital signs are normal.
Abdominal examination is normal.
• Laboratory studies, including a complete blood
count, liver chemistry studies, and C-reactive
protein, are normal. Pregnancy test is negative.
• Which of the following vaccinations is
contraindicated for this patient?
A: Hepatitis B
B: Human papillomavirus
C: Pneumococcal polysaccharide vaccine
D: Trivalent inactivated influenza
E: Varicella (chickenpox)
• Which of the following vaccinations is
contraindicated for this patient?
A: Hepatitis B
B: Human papillomavirus
C: Pneumococcal polysaccharide vaccine
D: Trivalent inactivated influenza
E: Varicella (chickenpox)
• Varicella vaccination is contraindicated in this patient. Varicella
vaccine is a live-virus vaccine; live-virus vaccines are generally
contraindicated for immunocompromised patients.
• Other live vaccines include yellow fever, intranasal influenza,
measles-mumps-rubella, bacillus Calmette-Guérin, and oral
typhoid.
• Patients with inflammatory bowel disease (IBD) are considered
immunosuppressed if they have significant protein-calorie
malnutrition or are receiving corticosteroids (equivalent of
prednisone 20 mg/d or higher); effective doses of 6mercaptopurine, azathioprine, or methotrexate; anti-tumor
necrosis factor (anti-TNF) therapy; or natalizumab.
• If patients have not had varicella infection or vaccination, they
should ideally be vaccinated before initiating immunosuppression.
• Reactivation of hepatitis B has been reported during treatment with
anti-TNF therapy, so patients should be offered hepatitis B
vaccination if they are not already immune.
• Women with IBD between the ages of 9 and 26 years should be
offered vaccination for human papillomavirus (HPV), because
immunosuppressed patients appear to be at higher risk for HPV
infection and abnormal Pap smears.
• Pneumococcal vaccination is recommended for all
immunosuppressed patients with a single revaccination if 5 or more
years have passed since the first dose.
• Trivalent inactivated influenza vaccination is recommended
annually.
• Pneumococcal, inactivated influenza, HPV, and hepatitis B
vaccinations have been shown to be safe and effective in
immunosuppressed patients with IBD.
Key Point
• Live-virus vaccines such as varicella are
generally contraindicated for
immunocompromised patients with
inflammatory bowel disease.