Vaccines - Infectious Dis. - Medbullets Step 2/3

Snapshot

A 54-year-old man presents to her primary care physician for a worsening productive cough. His cough began approximately 2 months ago, and over the past week, he has been producing more yellow sputum. Medical history is significant for chronic obstructive pulmonary disease. He drinks occasionally and smokes 1-pack per day for the past 35 years. The patient is started on broad-spectrum antibiotics and receives 23-valent pneumococcal polysaccharide vaccine (PPSV23) due to his current cigarette use and chronic lung disease.

Introduction

Definition
- an effective preventative health measure of disease
Terminology
- live-attenuated vaccine
  - microorganism pathogenicity is lost but can still induce a cellular and humoral response
- killed or inactivated vaccine
  - pathogen is inactivated but the epitope structure is maintained, inducing a humoral response
- subunit vaccine
  - contains only that antigen that stimulates the immune system best
- toxoid vaccine
  - bacterial toxoid with an intact receptor binding site

Vaccinations in Children (0-6 Years of Age)

Vaccinations in Children
Vaccine	Age	Comments
Hepatitis B	First dose within the first 24 hours of life Second dose at 1-2 months of age Third dose at 6-18 months of age	Subunit vaccine In HBsAg-positive mothers, the infant should receive the hepatitis B vaccine and hepatitis B immune globulin
Rotavirus	First dose at 2 months Second dose at 4 months Third dose at 6 months	Live-attenuated vaccine Can increase risk for intussusception
Diphtheria, tetanus, and/or pertussis	First dose at 2 months Second dose at 4 months Third dose at 6 months Fourth dose at 15-18 months Fifth dose at 4-6 years of age Booster doses are given starting at 11 years of age	Inactivated vaccine
H. influenzae type b conjugate	First dose at 2 months Second dose at 4 months Third dose at 12-15 months	Inactivated vaccine
Pneumococcal conjugate (PCV 13)	First dose at 2 months Second dose at 4 months Third dose at 6 months Fourth dose at 12-15 months	Inactivated vaccine
Poliovirus	First dose at 2 months Second dose at 4 months Third dose at 6-18 months Fourth dose at 4-6 years	Inactivated vaccine
Influenza	Annually ≥ 6 months of age	Intramuscular vaccine is an inactivated vaccine Intranasal vaccine is a live-attenuated vaccine
Measles, mumps, and rubella	First dose at 12-15 months Second dose at 4-6 years of age	Live-attenuated vaccine
Varicella	First dose at 12-15 months Second dose at 4-6 years of age	Live-attenuated vaccine
Hepatitis A	First dose at 12-24 months Second dose given at least 6 months after the first dose	Inactivated vaccine

Vaccinations in Adolescents (7-18 Years of Age)

Vaccinations In Adolescents
Vaccine	Age	Comments
Tetanus, diphtheria, acellular pertussis (Tdap)	11-12 years of age	Inactivated vaccine
Human papillomavirus	Two doses at 9-14 years of age in patients between the ages of 9-14, the 2 dose are administered 6-12 months after the first dose Three doses at ≥ 15 years of age given at 0, 1-2, and 6 months	Subunit vaccine Three doses of this vaccine are also recommended in immunocompromised adolescent patients
Meningococcal	First dose at 11-12 years of age Second dose at 16 years of age	Inactivated vaccine
Influenza	First dose given at 7-10 years of age and then annually	Intramuscular vaccine is an inactivated vaccine Intranasal vaccine is a live-attenuated vaccine

Vaccinations in Adults (> 18 Years of Age)

Vaccinations in Adults
Vaccine	Age	Comments
Influenza	One dose annually	Inactivated vaccine In HBsAg-positive mothers, the infant should receive the hepatitis B vaccine and hepatitis B immune globulin
Tetanus, diphtheria, acellular pertussis (Tdap) or tetanus and diphtheria (Td)	One dose Tdap and then a Td booster every 10 years	In pregnant women, 1 dose of Tdap should be given during each pregnancy between 27-36 weeks gestation
Varicella	Two doses 4-8 weeks apart if the patient is without immunity to varicella	-
Zoster	Two doses given 2-6 months apart at ≥ 50 years of age	-
Pneumococcal (PPSV23)	Given at least 1 year after PCV13 administration in adults ≥ 65 years of age PPSV23 is indicated in patients 19-64 years of age with the following chronic heart disease (excluding hypertension chronic liver disease chronic lung disease diabetes mellitus cigarette smoking patients ≥ 19 with immunodeficiency disorders HIV anatomical or functional asplenia chronic renal failure or nephrotic syndrome cerebral spinal fluid leak cochlear implant	PPSV23 is given after PCV13 PPSV23 is not conjugated and does not stimulate a helper T-cell response

Special Circumstances

Splenectomy
- patients should receive vaccines to protect against encapsulated organisms
  - S. pneumoniae (pneumococcus)
  - H. influenzae
  - N. meningitidis (meningococcus)
- vaccine regimen
  - PCV13 followed by PPSV23 ≥8 weeks later
  - H. influenzae type b vaccine
  - meningococcus vaccine
- antibiotic prophylaxis
  - most children with anatomy or functional asplenia/hyposplenism
    - antibiotic prophylaxis (with penicillin V or amoxicillin) until the age of 5 for at least 1-year post splenectomy
HIV
- inactivated vaccines are generally safe in this patient population
- live-attenuated vaccines can be given in this patient population when their CD4+ T-cell count is ≥ 200 cells/μL
Patients with an egg allergy
- can receive the measles, mumps, and rubella vaccine
- cannot receive the yellow fever vaccine
Pregnancy
- live vaccines are generally avoided in pregnancy
- vaccines to be avoided
  - human papillomavirus
  - measles, mumps, and rubella
  - varicella
    - give post-exposure prophylaxis via varicella immune globulin (VZIG) within 10 days of exposure to varicella to confer passive immunity
  - zoster
Prematurity
- no need to delay vaccination schedule based on prematurity
- one exception, first dose of hepatitis B vaccine (typically given in the first 24-48 hours of life) can be delayed only if the infant is born with a birth weight of under 4 pounds 6 ounces