VACCINES PART 2

FEBRUARY 5, 2008
STORAGE AND HANDLING

reduce their potency

reconstitution of the vaccine should be
followed carefully
cold chain
STORAGE TEMPERATURE

35°F--46°F (2°C--8°C)
Avoid freezing temperatures
aluminum adjuvant precipitates at <32°F (<0°C)

anthrax, DTP, Hib ,HepA, HepB, PCV,

rabies, and HPV
MMR, varicella, MMRV, LAIV, and yellow fever
lose potency when exposed to increased
temperature
 EXPIRATION DATES AND
WINDOWS

live-attenuated influenza
vaccine:discarded after 60 hours at ref.
temp.
MMR vaccine: give within 8 hours after
reconstitution; ref.temp.
Doses of expired vaccines are invalid,
repeat.
 Multidose Vials
DT, Td, Typhoid Vi, meningococcal
polysaccharide vaccine [MPSV], TIV, JE,
MMR, IPV, and yellow fever
Multidose vials that do not require
reconstitution: until the expiration date ;the
vaccine is not visibly contaminated
Vaccines for immunocompromised
patients
Live vaccines generally should be
deferred until immune function has
improved
Vaccines for immunocompromised
patients
Inactivated vaccines might need to be
repeated after immune function has
improved
Vaccines for immunocompromised
patients
increased risk for an adverse reaction
after administration of live-attenuated
vaccines
reduced ability to mount an effective
immune response.
 TEST FIRST FOR IMMUNE
STATUS
immunoglobulin (and immunoglobulin subset)
levels
specific antibody levels (tetanus, diphtheria, and
response to pneumococcal vaccine).
lymphocyte numbers (i.e., a complete blood
count with differential
B and T-lymphocytes
CD4+ versus CD8+ lymphocytes
lymphocyte proliferation assays
 VACCINES REQUIRED FOR
IMMUNOCOMPROMISED PATIENTS
TIV (INFLUENZA VACCINE)
PCV(PNEUMOCOCCAL VACCINE,
<2Y/O)
PPV(PNEUMOCOCCAL VACCINE, >2
Y/O)
MCV4(MENINGOCOCCAL VACCINE)
PSV (MENINGOCOCCAL VACCINE)
Hib (H.influenzae vaccine)
 VACCINATION OF CONTACTS OF
PERSONS WITH ALTERED
IMMUNOCOMPETENCE
Household and other close contacts must
receive all age-appropriate vaccines
EXCEMPTION: live OPV and smallpox
vaccine
varicella vaccine recipient: Avoid contact if
with rash after vaccination
rotavirus-vaccinated infant: frequent
handwashing for at least 1 week
LAIV required
 Vaccination with Inactivated
Vaccines
for Immunocompromised
patients
All inactivated vaccines safe
Suboptimal effectiveness
Avoid during chemotherapy or radiation therapy,
but not contraindicated
vaccinated within 2 weeks before starting
immunosuppressive therapy or while receiving
immunosuppressive therapy: invalid
revaccinated at least 3 months after therapy is
discontinued if immune competence has been
restored.
Vaccination with Live-Attenuated
Vaccines for IC patients

should not receive live vaccines

MMR
varicella vaccine
LAIV
yellow fever vaccine
oral typhoid
BCG
rotavirus
 IC PATIENTS
THE FOLLOWING CAN RECEIVE LIVE
VACCINES:
Leukemia
Lymphoma
in remission
chemotherapy has been terminated for at
least 3 months
 CGD
May give live-attenuated viral vaccines in
addition to inactivated vaccines
live-attenuated bacterial vaccines ( BCG
and Ty21a oral typhoid vaccine
 HIV AND LIVE VACCINES
Persons with severe cell-mediated
immune deficiency should not receive live
attenuated vaccines
children with HIV infection:increased risk
for complications of primary varicella and
herpes zoster
Varicella vaccine : 2 doses of varicella
vaccine with a 3-month interval between
doses
HIV AND MEASLES VACCINE
severe complications with measles
No severe or unusual adverse events
have been reported
age-specific CD4+ lymphocyte
percentages of >15%
 VCCINES IN HIV PATIENTS
RECEIVING IG
might not respond to varicella vaccine or
MMR
give 2 weeks before the next scheduled
dose of IGIV
(+) exposed to measles or varicella: give
additional IVIG 3 or more weeks after
administering a standard dose
IMPAIRED HUMORAL IMMUNITY
AND VARICELLA VACCINE
hypogammaglobulinemia or
dysgammaglobulinemia
Appropriate spacing should be maintained
between administration of IGIV and
varicella vaccine
prevent an inadequate response to
vaccination due to neutralizing antibodies
Household and other close contacts: NO
live OPV and smallpox vaccine.
BONE MARROW TRANSPLANT
PATIENTS AND VACCINES
Hematopoietic stem cell transplantation
(HSCT) results in immunosuppression:
ablative therapy preceding transplant
drugs used to prevent,treat graft-versus-
host
underlying disease process
Antibody titers to vaccine-preventable
diseases decline 1--4 years after HSCT if
the recipient is not revaccinated
BONE MARROW PATIENTS AND
VACCINES
Revaccination with inactivated vaccines
should begin 12 months after HSCT
EXCEMPTION: inactivated influenza
vaccine; 6 months after HSCT and
annually thereafter
PPV:2 and 24 months after HSCT.
BONE MARROW TRANSPLANT
AND VACCINES
Hib vaccine: 12, 14, and 24 months after
transplantation for all age groups
MMR vaccine: 24 months after
transplantation
varicella vaccine:minimum of 24 months
after transplantation
STEROID USE AND VACCINES
IMMUNOSUPPRESSIVE DOSE:
>2 mg/kg of body weight
or 20 mg/day of prednisone
for >2 weeks
STEROIDS AND VACCINES
GIVE LIVE VACCINES AFTER 1 MONTH
FROM DISCONTINUING HIGH DOSE
STEROIDS ( >/= 2 WEEKS TREATMENT)
OTHER FORMS OF STEROID USE IS
NOT CONTRAINDICATED
CHEMOTHERAPY, RADIATION
AND VACCINES
GIVE ALL LIVE VACCINES BEFORE
STARTING CHEMO/RADIOTHERAPY
POST THERAPY: >/= 3 MONTHS REST
PRIOR TO VACCINATION
INACTIVATED VACCINES GIVEN
DURING CHEMO/RADIO:
READMINISTER
ANTIBIOTICS AND VACCINES

TY21a VACCINE SHOULD NOT BE

GIVEN UNTIL > 24 HOURS AFTER LAST
DOSE OF ANTIBIOTICS
All other vaccines can be given with
antibiotics
 ANTIVIRAL DRUGS AND
VACCINES
IF ON ANTIVIRALS: WAIT 48 HOURS
BEFORE GIVING LAIV
IF GIVEN LAIV:WAIT 2 WEEKS BEFORE
USING ANTIVIRALS
ACYCLOVIR USE: WAIT 24 HOURS
PRIOR TO GIVING VARICELLA
VACCINE
ALLERGY TO EGG PROTEIN IN
VACCINES
Found in influenza and yellow fever
vaccines
Embryonated chicken eggs
persons with histories of anaphylactic or
anaphylactic-like allergy to eggs or egg
proteins should generally not receive
these vaccines.
Measles and mumps vaccine: chick embryo
fibroblast tissue culture
Rubella and varicella vaccines:human diploid
cell cultures
MMR, MMRV, and their component vaccines :
hydrolyzed gelatin as a stabilizer
Caution:anaphylactic reaction to gelatin or
gelatin-containing products
skin testing for gelatin sensitivity
 OTHER ALLERGENS
neomycin
thimerosal (in Td)
contact dermatitis :not a contraindication
for administration of these vaccines.
LATEX ALLERGY AND VACCINES
ANAPHYLACTIC REACTION: VACCINES
WITH LATEX/RUBBER CAPS ARE
CONTRAINDICTATED
CONTACT DERMATITIS NOT A
CONTRAINDICATION
 PRETERM INFANTS AND
VACCINES
In the majority of cases, infants born
prematurely, regardless of birthweight,
should be vaccinated at the same
chronological age and according to the
same schedule and precautions as full-
term infants and children.
 PRETERM INFANTS AND
VACCINES
Birthweight and size are not factors in
deciding whether to postpone routine
vaccination of a clinically stable preterm
infant
full recommended dose
Divided or reduced doses are not
recommended
 PRETERM INFANTS AND
VACCINES
EXCEMPTION
HEP B VACCINE

Decreased seroconversion rates:<2,000

gms, vaccinated at birth
chronological age 1 month, all preterm
infants, regardless of initial birth weight or
gestational age, are likely to respond as
adequately as older and larger infants
Preterm infants born to HBsAg-positive mothers
and mothers with unknown HBsAg status :
HepB and HBIG within 12 hours after birth.
BW<2,000 gms, the initial vaccine dose should
not be counted towards completion of the HepB
series
3 additional doses of HepB STARTING age 1
month
BW<2,000 gms and born to HBsAg-
negative mothers: first dose of the HepB
series at age 1 month or at hospital
discharge
 BREASTFEEDING AND
VACCINES
inactivated nor live vaccines ARE SAFE
in breastfeeding
Exception:smallpox vaccine
Inactivated, recombinant, subunit,
polysaccharide, conjugate vaccines and
toxoids: no risk for mothers who are breast
feeding or for their infants.
PREGNANCY AND VACCINES
No evidence exists of risk from vaccinating
pregnant women with inactivated virus or
bacterial vaccines or toxoids
Live vaccines pose a theoretical risk to the
fetus.
PREGNANCY AND VACCINES
Benefits of vaccinating pregnant women
usually outweigh potential risks when the
likelihood of disease exposure is high
infection would pose a risk to the mother
or fetus
vaccine is unlikely to cause harm.
 PREGNANCY AND TETANUS
VACCINE
Pregnant women should receive Td vaccine if
indicated
LAST DOSE >10 years: booster dose
COMPLETE SERIES: Pregnant women who are
not vaccinated or only partially immunized
At risk, but doses not completed during
pregnancy: give after delivery to ensure the
series is completed.
Pregnant adolescents and adults who received
the last tetanus vaccine <10 years:Tdap after
delivery.
 PREGNANCY AND TETANUS
VACCINES
pregnant adolescents who received the
last dose of tetanus-toxoid containing
vaccine >10 years: Td
PREGNANCY AND VACCINES
IPV
HepB
HepA
pneumococcal polysaccharide
meningococcal conjugate
meningococcal polysaccharide vaccines
yellow fever vaccine
PREGNANCY AND VACCINES
contraindication
smallpox (vaccinia)
measles
mumps
rubella
varicella-containing vaccines
Smallpox (vaccinia) vaccine is the only vaccine known to
cause harm to a fetus when administered to a pregnant
woman
smallpox (vaccinia) vaccine should not be administered
to a household contact of a pregnant woman
PREGNANCY AND VACCINES
Although of theoretical concern, no cases
of congenital rubella or varicella syndrome
or abnormalities attributable to fetal
infection have been observed among
infants born to susceptible women who
received rubella or varicella vaccines
during pregnancy
ask women if they are pregnant or might
become pregnant in the next 4 weeks
PREGNANCY AND VACCINES
Do not vaccinate women who state that
they are or plan to be pregnant
explain the theoretical risk for the fetus if
MMR, varicella, or MMRV vaccine were
administered during pregnancy
counseling women who are vaccinated not
to become pregnant during the 4 weeks
after MMR, varicella, or MMRV
vaccination
PREGNANCY AND VACCINES
Routine pregnancy testing of women of
childbearing age before administering a
live-virus vaccine is not recommended
If vaccination of an unknowingly pregnant
woman occurs or if she becomes pregnant
within 4 weeks after MMR or varicella
vaccination: COUNSELLING
PREGNANCY AND VACCINES
MMR or varicella vaccination
during pregnancy should not be
regarded as a reason to terminate
pregnancy
 VACCINE-PREVENTABLE
DISEASE
Anthrax
Cervical Cancer
Diphtheria
Hepatitis A
Hepatitis B
Haemophilus influenzae type b (Hib)
 VPD
Human Papillomavirus (HPV)
Influenza (Flu)
Japanese Encephalitis (JE)
Lyme Disease
Measles
Meningococcal
Monkeypox
 VPD
Mumps
Pertussis (Whooping Cough)
Pneumococcal
Poliomyelitis (Polio)
Rabies
Rotavirus
 VPD
Rubella (German Measles)
Shingles (Herpes Zoster)
Smallpox
Tetanus (Lockjaw)
Tuberculosis
Typhoid Fever
Varicella (Chickenpox)
Yellow Fever
 HEPATITIS B VACCINE
1ST ANTI-CANCER VACCINE
HEPATOCELLULAR CA
 HEP B VACCINE
0-19 YRS OLD
3 DOSES :birth,
: 1–4, 6–18 mos
intervals for older children: 0, 1–2, 4
mos
20 YRS OLD
3 DOSES
Dose interval: 0, 1, 6 mos
 HEP B VACCINE AND
HEALTHCARE WORKERS (HCP)
should receive a 3-dose series of hepatitis
B vaccine
DOSE INTERVALS: 0-, 1-, and 6-month
Test for anti-HBs 1–2 months after dose
#3.
 HEP B AND HCP
>/=10 mIU/Ml: positive immunity .
No further serologic testing
No vaccination is recommended
</=10 mIU/mL: negative immunity
revaccinate with a 3-dose series
Retest anti-HBs 1–2 months after dose #3.
If anti-HBs is still negative: nonresponder
 NONRESPONDERS
Considered susceptible to HBV
counseled regarding precautions to
prevent HBV infection
HBIG prophylaxis
also possible that non-responders are
HBsAg positive
 HEP B VACCINE
Post-vaccination testing IS recommended for
persons whose medical management will
depend on knowledge of their immune status.

Post-vaccination testing should be completed 1-

2 months after the third vaccine dose for results
to be meaningful. A protective antibody
response is 10 or more milliinternational units
(>=10mIU/mL).
 HEP B VACCINE

are immunocompromised
received the vaccine in the buttock
are infants born to HBsAg (+) mothers
are healthcare workers, contact with blood
are sex partners with chronic hepatitis B
virus infection
NEED FOR BOOASTER DOSES
In the CDC Prevention Guidelines: A Guide to
Action (1997), the CDC states "The duration of
protection of hepatitis B vaccine and need for
booster doses are not yet fully defined. Between
30% and 50% of persons who develop adequate
antibody after three doses of vaccine will lose
detectable antibody within 7 years but protection
against viremic infection and clinical disease
appears to persist." If immunity only lasts 7
years, babies vaccinated with hepatitis B
vaccine may be candidates for more shots at
age seven.
NORMAL LIVER
LIVER HEPATITIS
HEPATOCELLULAR CA
 DPT
There are four combination vaccines used to
prevent diphtheria, tetanus and pertussis:
DTaP (CHILDREN < 7 YEARS OLD)
Tdap
DT (CHILDREN < 7 YEARS OLD)
Td.
DOSES: 5 doses of DTaP
2, 4, 6, and 15-18 months and 4-6 years
 DPT VACCINE
Td: booster shot every 10 years years
exposure to tetanus
Tdap is similar to Td, contains
pertussis
single dose of Tdap:
adolescents 11 or 12 y/o
booster in older adolescents, adults
19-64 YRS OLD
 DPT FOR HCP
Give all HCP a Td booster dose every 10
years, following the completion of the
primary 3-dose series.
Give a 1-time dose of Tdap to all HCP
younger than age 65 years with direct
patient contact
 INFLUENZA VACCINE
Inactivated, killed vaccine(TIV)
> 6 months of age
healthy people
chronic medical conditions
pregnant patients
LAIV vaccine
healthy people 2-49 years of age
nonpregnant
 INFLUENZA VACCINE
October or November is the best time
to get vaccinated
Flu season: October - May
INFLUENZA VACCINE AND HCP
Give 1 dose of TIV or LAIV annually
LAIV : INTRANASAL
TIV: IM
INFLUENZA VACCINE CAN BE
GIVEN YEARLY TO EVERYONE
People at high risk for complications
from the flu

Children aged 6 months until their 5th
birthday,
 Pregnant women

>50 YEARS OLD
 chronic medical conditions;
 nursing homes,long term care facilities.
People who live with or care for those
at high risk for complications from flu

Household contacts of persons at high
risk for complications from the flu
 Household contacts and out of home
caregivers of children less than 6 months
of age (these children are too young to be
vaccinated)
 Healthcare workers
 MMR VACCINE
DOSE(SQ)
12 – 15 MONTHS OF AGE
REPEAT AFTER 3-5 YEARS
About 2%-5% of persons do not
develop measles immunity after the
first dose of vaccine.
The second dose:another chance to
develop measles immunity for persons
who did not respond to the first dose.
MEASLES VACCINE AND HCP
For healthcare personnel (HCP) born in
1957 or later without serologic evidence of
immunity or prior vaccination:
2 doses of MMR
4 weeks apart.
For HCP born prior to 1957:
RECOMMEND 2 doses, but not
mandatory
 VARICELLA VACCINE
ALL HEALTHY SUSCEPTIBLE
PERSONS SHOULD BE VACCINATED
DOSE(SQ)
GIVE AT 12-15 MONTHS OF AGE
NEXT DOSE AFTER 3-5 YEARS
VARICELLA VACCINE AND HCP
GIVE 2 DOSES, 1 MONTH APART
UNLESS:
PRIOR HISTORY OF VARICELLA
LAB EVIDENCE OF IMMUNITY
LAB CONFIRMATION OF THE
DISEASE
MENNGOCOCCAL VACCINE
Give 1 dose to microbiologists who are
routinely exposed to isolates of N.
meningitidis
 HPV VACCINE
The HPV vaccine is routinely recommended
for girls 11 and 12 years of age
DOSE (IM)
FIRST DOSE:11-12 YEARS OLD
SECOND DOSE AFTER 2 MONTHS
THIRD DOSE AFTER 4 MONTHS
also recommended for girls and women 13
through 26 years of age who did not receive
it when they were younger
HPV vaccine may be given at the same time
as other vaccines.
 HPV VACCINE
Gardasil: first vaccine developed
prevent cervical cancer
precancerous genital lesions
genital warts due to HPV.
four HPV types, which together cause
70% of cervical cancers and 90% of
genital warts.
HPV 6, 11, 16, 18
NORMAL CERVIX
CERVICAL CA
CERVICAL CA
GENITAL WARTS
GENITAL WARTS