2
3
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
5
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
6
ZEST & Shingles Prevention Study (SPS) Results
1 (-29 to 48)
(28 to 52)
1
18%
41%
(56 to 71)
64%
(54 to 81)
1. Oxman et al. New England Journal of Medicine. 2005. 352 (22): 2271
2. Zostavax® [package insert]. Whitehouse Station, NJ: Merck; April 2011.
70%
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.
10
Administration
 Zostavax: 0.65-mL dose (reconstituted)
 SQ – upper, outer tricep
 5/8 inch, 25 gauge needle
11
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
18
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
23
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
30
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
39
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
45
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
50
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 IIV
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