2. adult immunizations
DESCRIPTION
2. Adult ImmunizationsTRANSCRIPT
ADULT IMMUNIZATIONS
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OUTLINE
♥ Significance of immunization ♥ Principles of immunization ♥ Immune response ♥ Categories of adult immunization ♥ Special situations in which vaccination is needed
Immunization - Vaccination... A Long Story
♥ One of the most effective <weapons> in medicine • 10th century in Central Asia Smallpox -> Africa - Europe • 1798 Edward Jenner immunizes first time against
smallpox • 1885 Louis Pasteur prepares the 1st vaccine against
Rabbies • 1927 BCG (bacillus Calmette-Guerin) • 1995 Salk vaccine against poliomyelitis • 1960 MMR...
Why Vaccinate
In the Philippines
♥ Increasing trend of vaccine-preventable diseases ♥ Ignorance and apathy among MDs regarding VPDs ♥ Adult immunization is not a significant part of a doctor's training ♥ Prevention is not deeply ingrained in our culture
Definition
♥ Immunity • Self vs nonself • Provides protection fro. Infectious diseases • Usually indicated by the presence of antibody • Very specific to a single antigen
— Antigen - live or inactivated substance capable of producing an immune response
— Antibody - protein molecules (immunoglobulins) produced by B lymphocytes to help eliminate an antigen
♥ Immunization • Induction or provision of immunity by any means, active
or passive ♥ Vaccination
• Administration of a vaccine Why Vaccinate Adults
♥ Immunity wanes overtime ♥ Increase susceptibility and morbidity to serious diseases caused
by common infections • More medical complications • Increase hospitalization • Diminished quality of life • Decrease ability to earn
Mechanisms for Acquiring Immunity
♥ Active Immunity • Protection produced by the person's own immune system • Administration of vaccine that induces long-lasting
immunity ♥ Passive Immunity
• Protection transferred from another person or animal as antibody
• Temporary protection Ways to Get Immunized
Internal Medicine II
Module 6
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Active Immunization ♥ Live the attenuated vaccine
• Attenuated (weakened) form of the "wild" virus or bacteria
• Must replicate to be effective • Immune response similar to natural infection • Usually effective with one dose • Severe reactions possible • Interference from circulating antibody • Unstable
— Viral: MMRV, YF, Oral polio, Influenza nasal spray
— Bacterial: BGC, Oral typhoid ♥ Inactivated Vaccines
• NOT live and cannot replicate • Minimal interference from circulating antibody • Generally NOT as effective as live vaccines • Generally require 3-5 doses • Immune response mostly humoral • Antibody titer falls over time
— Whole cell: influenza, polio, rabies, hepa A, Jap B, pertussis, typhoid, cholera
— Fractional vaccines § Subunit: Hepa B, influenza, Acellular
pertussis, HPV, typhoi Vi § Toxoid: Diptheria, Tetanus
Sources of Passive Immunity
♥ Almost all blood or blood products ♥ Homologous pooled human antibody (immune globulin) ♥ Homologous human hyperimmune globulin ♥ Heterologous hyperimmune serum (antitoxin)
The Aim of an Ideal Vaccine
♥ To produce the same immune protection which usually follows natural infection but without cuasing disease
♥ To generalize long-lasting immunity ♥ To interrupt spread of infection
The Immune Response
♥ Primary response
♥ Secondary response
• Specific memory is the hallmark of the adaptive immune response
♥ Seroconversion • Transition from antibody negative to antibody positive • Responses to vaccine are often guaged by the
concentration of specific antibody in serum • Does not necessarily correlate with protection
♥ Herd Immunity • The indirect protection from infection of susceptible
members of the population, and the protection of the population as a whole, which is brought about by the presence of immune individuals
• No vaccine is 100% effective — E.g. Measles is 90-95% effective
• Some people unable to receive live vaccines are protected
• Most effective way of protecting people who do not respond to vaccines or cannot be given to them for medical reasons
• Not effective for disease that are mot readily transmissible
— E.g. Tetanus Philippine Adult Immunization Handbook
• Cholera • Hepatitis A • Hepatitis B • HPV • Influenza • MMR • MeningococcL • Pneumococcal • Rabies • Tdap • Typhoid fever • Yellow fever • HiB • Herpes Zoster • Japanese enchephalitis • Varicella • Chapters on vaccines for special populations • Serious adverse event form
Case Scenario
• 45-year-old JN consulted your clinic for the result of her executive check-up. Her laboratory results were normal and you declared her to be physically fit for work. She said she recently got hold of a large amount of money from unknown source and is asking you what vaccines she should have
• How would you respond? Step 1: Screen the Patient
♥ Are you sick today? ♥ Do you have any problem with the immune system? (Lung
disease, heart disease, kidney disease, diabetes, blood disorder, malignancy, HIV/AIDS)
♥ Did you receive any blood products within the last 12 months? ♥ Are you taking any steroids or anti-cancer drugs or had x-ray
treatments in the past 3 months? ♥ Are you pregnant or trying to be pregnant in the next 4 weeks? ♥ Did you receive vaccinations in the past 4 weeks?
ADULT IMMUNIZATIONS
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Invalid Contraindications ♥ Mild illness ♥ Disease exposure ♥ Antibiotic therapy ♥ Pregnancy in the household ♥ Breastfeeding ♥ Premature birth ♥ Family history unrelated to immunosuppression ♥ Need for TB skin testing ♥ Need for multiple vaccines
Step 2: Know what Vaccines to Give
♥ Routine Immunization for Adults • Influenza • Tdap • Hepatitis B • Varicella • MMR • HPV • Pneumococcal
Routine Adult Immunization
Administration
*Never on the buttocks Side Effects
♥ Frequent/Mild • Soreness at injection site • Redness, erythema • Swelling, itching
♥ Systemic • Fever, malaise • Headache, dizziness
♥ Rare • Severe allergic reactions
Spacing of Vaccine Combinations not Given Simultaneously
Antibody and Live Vaccines
Selective Vaccination
♥ Vaccine given specifically to those at increased risk of disease: ♥ High risk groups
• e.g. Pneumococcal vaccine ♥ Occupational risk
• e.g. Hepatitis B, influenza ♥ Travellers
• e.g. Yellow fever, rabies, meningitis ♥ Outbreak control
• e.g. Hepatitis A vaccine, measles Selective Vaccination
♥ Vaccinating an immunocompromised individual and achieve a less than optimal response is acceptable
♥ Live vaccines should not be administered to: • Severely immunosuppressed persons • Persons receiving large doses of corticosteroids • Persons with HIV/AIDS • Persons receiving immunomodulators
♥ Household and close contacts of immunocompromised individuals should receive all age-appropriate vaccines
♥ Travellers • Tdap • Hepatitis A (for departing < 2 weeks, give IG) • Hepatitis B (begin 6 mos before travel) • Influenza • Japanese B Encephalitis vaccine • MMR • Meningococcal
♥ HIV • MUST be given regardless of CD4 cell count
— Hepatitis B — Influenza — Pneumococcal
♥ Healthcare workers • Tdap, Hepa B, Influenza, Varicella, MMR, Pneumococcal • Selected HCWs: Meningococcal, Typhoid, Hepatitis A,
Rabies ♥ Outbreak control
• Measles • Hepatitis A • Meningococcal vaccine
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Vaccine and Pregnancy ♥ Live virus are contraindicated during pregnancy because of
possibility that vaccine virus replication will cause congenital infection or have other adverse effects on the fetus
♥ Brest-feeding is not a contraindication for live-virus or other vaccines
♥ Vaccines that may be given • Hepatitis B, Influenza, Rabies, Tdap
Current State of VPD
Small Pox Eradication
♥ Ali Maow Maalin, a cook in Merca, Somalia was the last person to contract smallpox naturally in 1976
Measles Eradication?
♥ Severe disease with high mortality ♥ No animal reservoir ♥ Very few cases of subclinical disease ♥ Recurrent disease did not occur ♥ Vaccine available ♥ Cases did not become infectious until rash appeared ♥ Effective methods of laboratory diagnosis
Measles Eradication Challenges
♥ Lack of political will ♥ Transmission amongst adults ♥ Increasing urbanization and population density ♥ Warning immunity and the possibility of transmission from sub-
clinical cases ♥ Highly mobile population ♥ Lack of health education
Changing Lanes in the Perception of Vaccination
♥ From an expensive prevention policy ♥ To a critical investment for the sustained improvement in the
quality of life resulting to healthier population and better economic growth
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“That in al l th ings , God may b e g lor i f i ed”