Immunizations_2009

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Immunizations 2009: Pediatric & Adult by Johns & Anderson
1. Become familiar w/ basic concepts of immunization
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Highly effective, cost-effective, universally recommended & measurable
1796-Dr. Jenner smallpox vaccine
1941-Influenza
1955-Polio injection
Total disease pre-vaccine is 566,706; total disease in 2000 is 8,624, & total adverse events are 13,497.
In MN, most disease is seen from pertussis & influenza.
Old Types of Vaccines:
o Live attenuated- live microbes are weakened by growing them for many generations in animals or
tissue cultures. Ie. Oral polio, MMR, zoster. Px: in immunosuppressed patients.
o Inactivated- whole organism that have been killed. Stimulate the immune syst, but do not cause dx.
Ie. Polio, influenza, Hepatitis A.
o Inactivated toxins- used to prevent dx from toxins of bacteria. Ie. Tetanus & diphtheria.
Immune- protected against a specific dx-active & passive
Herd immunity- protection given to an unimmunized indl when community levels of immunity are high.
Endemic- an outbreak of dx that localizes w/in a small population area.
Epidemic- an outbreak of dx that spreads widely w/in a specific rgn.
Pandemic- an outbreak of dx that spreads throughout the world.
Minnesota in 2006-2007 was above the national average, and mostly better than Wisconsin in immunizations of
kindergarten children.
2. Become familiar w/ current adult & pediatric immunization issues
Pediatric:
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Pre-teen vaccines include HPV, Meningococcal (MCV), & Whooping cough.
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CDC recommends routine vaccine of all girls 11-12 yrs for HPV & MCV.
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Cases of pertussis have increased since 1980; older children, adolescents, & adults appear to be a source of
pertussis for young children & infants.
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35 immunizations by kindergarten, 26 by the age of 2 (14 as combinations) for a cost of $1465 + cost of visits.
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Vaccines show direct relationship with dx prevention. Great Britain stopped vaccinating for pertussis and an
epidemic arose (100,000 cases).
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11% of the vaccinated can get the dx, while 100% of unvaccinated will.
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Few adverse affects considering the number of vaccinations. Only 1 death reported to FDA may be vaccine
related. No medical intervention is as effective as immunization.
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Imported epidemics are prevented by high vaccination rates.
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Combined vaccines reduce pain of injections/office visits.
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No link btwn vaccines & harm to immune system, autism, or diabetes.
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Since Mercury has been decreased autism has continued to rise.
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Invalid contraindications:
o Minor illness
o Mild/moderate local rxn or fever following a prior dose
o Antimicrobial th.
o Dx exposure or convalescence
o Pregnancy or immune-suppression in the household
o Premature birth
o Breastfeeding
o Allergies to products not in vaccine
o Family history (unrelated to immune-suppression)
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Valid contraindications:
o Anaphylactic rxn
o Prior high fever
o Immunodeficiency
o Pregnancy
o Significant acute illness
Adult:
Influenza:
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Yearly influenza responsible for on average 20,000 deaths.
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For nursing home residents, the influenza vaccine is 50-60% effective in preventing pneumonia & hospitalization.
60-70% effective in preventing death, yet not effective in reducing ambulatory care visits for respiratory
problems. Pxs: of antigenic drift or shift.
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Influenza vaccines are indicated for everyonefewer episodes of URI, fewer sick days, fewer visits to physicians’
offices. Saves $46.85 per person.
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Contraindications for Influenza vaccine:
o Anaphylactic hypersensitivity to eggs
o Allergy to THIMEROSOL
o History of Guillain-Barre Syndrome
o Acute febrile conditions (delay until sxs abate)
Pneumococcal vaccine:
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Pneumococcal pneumonia causes 10-20% of bacterial pneumonias, causing 40,000 deaths/yr.
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After the pneumococcal vaccine- up to 50% have local erythema & soreness. Revaccination is recommended
every 5 years for patients w/ chronic renal failure, nephritic syndrome, transplanted organs, or asplenia. Also
after 5 yrs if the initial immunization was before age 65.
Hepatitis A:
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Hepatitis A 100 deaths per year. Fecal-oral route leads to spread, many cases are asymptomatic, and outbreaks
are usu in day care sites & food related.
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Hepatitis A is an inactivated vaccine (1995) costing the adult $45, has 94% efficacy.
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Hepatitis A is indicated for travelers to high-risk areas (Mexico, SA, Africa, SE Asia), high risk populations such as
injecting drug users, indls w/ chronic liver dx, military, & health care providers.
Hepatitis B:
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Hepatitis B is 0.5% in US, spread by serum and most body fluids. Chronic Hepatitis B can lead to hepatobiliary
cancer.
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Hepatitis B vaccine (1981 & modfd 1987) is given to at risk adults, for travel to HBV common parts of the world,
and health care providers. Three doses give 95% efficacy. Very minimal side effects.
3. Learn about potential new vaccines
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Subunit vaccines- use only a part of the bacterium. Ie. Typhoid, hepatitis B, pertussis, & meningitis.
Conjugate Vaccines- link proteins from a second organism to the outer coat of bacteria. Allows a baby’s immune
system to recognize the bacteria. Ie. Haemophilus influenza-b (Hib) & pneumococcus.
Edible Vaccines- genetically engineered potatoes, banana, & tomatoes that when eaten, will initiate an immune
response against harmful intestinal bacteria & viruses. Ie. E.coli enterotoxin, rabies.
Plantibodies- specific abs made in plants. Ie. Strep mutans (tooth decay)
Tdap (tetanus, diphtheria, acellular pertussis)
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Pertussis has increased 1-3 million cases per year. Immunity wanes after 5-10 yrs.
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Health care workers and persons 11-65 should receive a single booster. Cost is $48.
Varicella-zoster vaccine
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> 1 million cases of shingles
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Adults 60 & older may receive one dose
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Cost $150
Human Papillomavirus vaccine (HPV)
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Cervical HPV infections w/ 50% risk w/in 5-7 yrs of first sexual contact & > 80% lifetime risk.
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2006- 11,000 new cases of cervical cancer & 3,700 deaths in US
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100% effective in preventing HPV genital lesions & CIN.
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Girls 11-12 should be vaccinated- women 13-26 even if not sexually active. Costs $360.
Avian flu (H5N1)- vaccines devpd & under study, trials however show suboptimal immunogenicity in adults, plus
H5N1 viruses show genetic differences from years 2003-2006.
HIV Vaccine- inactivated vaccine causes AIDS in monkeys, tried arecombinant vaccine too, still no vaccine due to
HIV hyper-variability, immune correlates of protection are still unknown, relevant animal models are lacking, &
clinical trials are long & costly.
Malaria Vaccine- Malaria causes 3 million deaths/year, vaccines have been studied for 50 yrs, also trying
arecombinant technology. The P. falciparum chromosome has been mapped and phase I/II trials are underway.
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Tuberculosis Vaccine- TB NUMBER ONE FOR INFECTIOUS DX DEATHS, two billion infected, 3 million die per year
WW. Also have complete genetic blueprint of M. tuberculosis and the BCG vaccine has been available & used
WW for many yrs, but has variable efficacy. So a new vaccine is being devpd.
Maybe vaccines for autoimmune dxs:
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Mucosal administration for
Myelin in MS
Type II collagen in RA
Retinal Ag in uveitis
Insulin in Type I diabetes
Maybe txg cancer w/ vaccines:
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Tried in melanoma, renal carcinoma, & measles vaccine-myeloma.
Alzheimer Dx- due to formation of amyloid B peptide plaques in brain, successful in mice.
4. Learn resources for vaccine schedules
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CDC: Morbidity & Mortality Weekly Report Recommendations of the Advisory Committee on
Immunization Practices (ACIP) & AAFP
Minnesota’s School Immunization Law
Vaccine Information Statements (VISs) are federal law! From IAC.
Health Resources & Services Administration: Vaccine Injury Compensation Program (VICP) - established by
National Childhood Vaccine Injury Act.
National Vaccine Injury Compensation Program: $0.75 per vaccine agent
Use immunization registry (MIIC)
Red Book & Pink Book
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