Adult Vaccines
The eight vaccines recommended for adults in the US:
recommended by Advisory Committee on Immunization Practices (ACIP)
ACIP approved the Adult Immunization Schedule for 2009 in 10/08
ACIP is almost entirely composed of pharma industry people
*with congressional waivers of their conflict of interest
no new vaccines added
added indications to pneumococcal polysaccharide vaccine
clarifications made to human papillomavirus, varicella, and meningococcal vaccines
schedule information added to hepatitis A and B
BELOW ARE VACCINES RECOMMENDED BY CDC AND THEIR TIMING
1.
PNEUMOCOCCAL POLYSACCHARIDE
1-2 vaccines up to age 65 recommended if risk factors are present
1 more dose after age 65 recommended
indications: smoking, asthma
indications: Chronic liver dz (incl alc-ism, cirr), renal,
indications: chronic CV or lung dz (asthma), asplenia (incl sickle)
indications: residents of nursing home/care facility, smokers
no live vaccine for immumocompromised
http://www.cdc.gov/vaccines/pubs/acip-list.htm.
vaccinate as close to HIV dz as possible
Routine use not recommended for Alaska Native or American Indian persons under 65 years
(unless medical indication)
public health authorities may recommend for this pop age 50-64 in danger areas
one-time revaccination after 5 years recommended w/ chronic renal fail, nephrotic synd, asplenia, immunocomrpomised, and over age 65
PROS
stop elders from dying of this pneumo
CONS
additives
2.
HUMAN PAPILLOMAVIRUS
130 types of virus
30-40 are sexually transmitted
by age 50 80% of women have at least 1 type
infx may not be detectable
infx often cleared by immune system
40 types mucosal or genital, worst: 16, 18, 31, 45-->cervical dysplasia
low risk 6, 11 cause low grade cervical abn, genital warts, laryngeal
60 plus nonmucosal types
cause skin warts on hand and feet
reservoir: human
trans: contact
pattern: none
communicability: high but not well known
non-biased 2004 study, 26.8% of women are HPV positive
15.2% of the 26.8 are infx with strain that causes CA
3.4% of those are vaccine preventable
Merck studies disagree, say that 16 and 18 cuase 70% of cervical CA
gardasil is supposed to prevent warts as well
RESEARCH
26,000 young women were tested with vaccine
deaths and neuro disorders didn't happen in that population
some women did develop PCOS and DM, thought to be coincidental
anti-vaccine movement is very upset about high number of adverse events
younger cohort studies have been done but not published
no studies on older folks yet, no public health recommendation yet
website does recommend for just about everybody
don't know if people will stop getting paps after they get the vaccine
insurance companies thinking about covering this vaccine in Oregon
will they stop covering paps? not likely
3 doses, females only, age 11-26 but may begin as early as age 9
ideally administer before sexual activity
if already infected offers no protection
no increased risk for healthcare personnel
hx of genital warts, abn Papanicolaou test or + HPV not evidence of infx w/ all strains
SCHEDULE
2nd dose 2 mo after 1st, 3rd dose 6 mo after 1st (CDC)
three shots with 4, 12 weeks between, 24 weeks between dose 1 and 3 (Zwickey)
do not restart series if schedule is interrupted
administer at same visit as other age-appropriate vaccines: DTaP, MCV
TIMING
no attention is given to when in menstrual cycle vaccine is given
stronger responses during luteal phase***
expect worst result at start of luteal phase: hormone switch-->increased Th1 response
not a live-virus
VACCINE
Gardasil is first HPV vaccine
not a bad idea
prophylactic for HPV 6, 11, 16, 18
40 million doses distributed worldwide as of Feb 09
2006 was still experimental
doesn't tx dysplasia
recommended for girls 9-26
website says girls 10-12
CI: yeast hypersensitivity or vaccine sensitivity
3-4 doses
Texas tried to make it mandatory, backfired, governor corrupt
public health officials considering making it a school requirement
not mandatory in Oregon
EFFICACY according to manufacturer
100% for 16/18 cin2/3 but it takes a decade to generate these so reporting is bs
6, 11, 16, 18 95% for related CIN
genital warts 99%
ADVERSE EVENTS ASSOC W/ HPV VACCINE
join and muscle pain, fatigue, physical weakness, malaise
9,749 VAERS reports
they say only 10% of adverse effects actually get reported (est)
20+ women have died
authorities say "no evidence" that deaths relate to vaccine
deaths 7 days - 2 months after vaccine
Guillain Barre
diabetes
PCOS
neurological disorders
heart wrenching youtube videos out there right now
HPV VACCINE NUMBER 2
cervarix
covers 16 & 18, maybe 31 and 45
made by GlaxoSmithKline
used in UK
cheaper than Gardasil
adjuvant: AS04 supposed to drive stronger Th1
no adverse effects reported yet
PROS
?% chance of avoiding infx with HPV strains 16, 18, others?
these HPV strains known to cause cervical CA
it doesn't contain thimerosal
CONS
vaccines administered to girls between ages of 5 and early 20's more likely to cause AI dz
doesn't cover all HPV strains
doesn't help if you're already infected
it is recombinant
long term effects unknown
3.
VARICELLA
two doses in lifetime if no evidence of immunity
recommends additional dose for adults who have had one dose
unless medical contraindication
special consideration: healthcare workers and contacts of immunocompromised, teachers, households w/ kids, nonpreg women of childbearing age, international travel
Evidence of immunity incl any of these: 1) documentated 2 doses varicella vacc min 4 wks apart; 2) U.S.-born before 1980 (except for healthcare workers and preg); 3) confirmed hx of varicella infx; 4) conf hx of zoster; 5) lab evidence of immunity or lab confirmation of dz
if preg with no evidence of immunity, 1st dose postpartum or after termination
2nd dose 4-8 wks later
PROS
avoid a common childhood infection which can be more severe later in life
CONS
dz severity low enough that vaccine need debatable, maybe better just to get dz and have
lifelong immunity
4.
HERPES ZOSTER
1 dose for adults over 60, .65mLs
this vaccine studied in conjunction with trivalent inactivated flu vaccine (TIV)
prevents future shingles regardless of prior episodes of zoster???
includes vaccinations for those with chronic conditions unless specifically CI
http://www.zostavax.com/ from Merck
vaccine is live attenuated
evaluated for safety in more than 20,000 adults
SEs: redness, pain, itching, swelling, warmth, bruising at injx, headache
contains weakened chickenpox virus
CI: close contact with newborns, preg, or non-immune to chickpox, immunocompromise or suppression, hx of anaphylactic rxn to gelatin, neomycin or other component, leukemia, lymphoma, malignant neoplasm of marrow or lymph, AIDS, women of childbearing age, preg
"Over the course of the entire study, in the overall study population, investigator-determined, vaccine-related serious adverse experiences were reported for 2 subjects vaccinated with ZOSTAVAX (asthma exacerbation and polymyalgia rheumatica) and 3 subjects who received placebo (Goodpasture's syndrome, anaphylactic reaction, and polymyalgia rheumatica)."
see also: http://www.cdc.gov/vaccines/vpd-vac/shingles/default.htm (get notes from this page)
PROS
stops shingles
single dose, subcu
CONS
doesn't help with shingles or post-zoster neuralgias
contains gelatin and neomycin
5.
MEASLES, MUMPS, RUBELLA (MMR)
1-2 doses up to age 50
1 more dose after age 50 recommended if indications present
adults born before 1957 considered immune to measles, mumps
adults born during or after 1957 should receive 1 or more doses of MMR
unless: medical CI, documentation of 1+ doses, confirmed hx of measles dx, lab confirmation
second dose recommended w/ recent exposure, outbreak, previous vaccines were killed, vaccinated with unknown vaccine type in '63-67, grad students, healthcare workers, int. travel
consider vaccinating health care worker born before '57 w/ no evidence of mumps immunity
also recommended for women whose rubella vaccination hx unreliable or show no lab immunity
fertile women must be counseled re: congenital rubella syndrome
preg women w/o immunity get vaccine postpartum or upon termination
PROS
prevent dz which can be quite severe (measles)
prevent birth defects (rubella)
prevent male sterility (mumps)
CONS
additives
6.
MENINGOCOCCUS
revaccination interval 5 yrs
1 or more doses
indications: asplenia, terminal complement component deficiencies
indications: dorm or military living, microbe research on Neisseria meningitidis,
indications: travel to hyperendemic or epidemic regions (“meningitis belt” of sub-Saharan Africa during the dry season [December-June])
vacc required by Saudi Arabia for travellers to Mecca during the annual Hajj
Meningococcal conjugate vaccine (MCV) preferred for adults w/ any indic and are 55 or less
meningococcal polysaccharide vaccin.e (MPSV) is an acceptable alternative
Revaccination w/ MCV after 5 years mb indic for those who w/ risk who got MPSV the 1st time
PROS
protects vs deadly meningitis
indications are logical
CONS
additives
cumulative impact of multiple vaccines on young military/college pop
7.
HEPATITIS
a 4-dose combined A&B vaccine is available
combined hepatitis A and hepatitis B vaccine (Twinrix®): 3 doses at 0, 1, and 6 months
alternative 4-dose schedule: days 0, 7, and 21 to 30, booster at month 12 (for military???)
7.1
HEP A
2 doses
indications: chronic liver dz, using clotting factor concentrates
indications: MSM and illegal drug usek, working with HepA in lab animals or other research
indications: travel to high-intermediate endemicity of hepA see: http://wwwn.cdc.gov/travel/contentdiseases.aspx
available to anyone who wants it
DOSING SCHEDULES
single-antigen vaccine admin on 2-dose schedule, dosing depends on brand
0 and 6-12 months (Havrix®)
0 and 6-18 months (Vaqta®)
combined hepatitis A and hepatitis B vaccine (Twinrix®): 3 doses at 0, 1, and 6 months
alternative 4-dose schedule: days 0, 7, and 21 to 30, booster at month 12
PROS
don't get horribly sick when exposed
CONS
additives
7.2
HEP B
3 doses
indications: end-stage renal disease (incl hemodialysis), HIV infx and chronic liver dz
indications: Health-care personnel and public-safety workers, travellers
indications: sexually active and not monogamous, hx of STDs, drug users, MSM
indications: contacts and sex partners of persons with chronic hepatitis B virus
PROS
prevent the most likely chronic infx that is easily transmitted by needle stick
CONS
additives
8.
INFLUENZA
recommends annual vaccination for all adults
more strongly recommends flu vaccine annual after age 50
indications: CV & pulm dz, chronic metabolic dz incl DM2, renal & hepatic dysfx
indications: hemoglobinopathies, immunocompromised
indications: cognitive dysfunction, spinal cord injury, seizure disorder (aspiration risk)
incidations: pregnancy during the influenza season, anyone who wants to avoid flu
no data on asplenia and flu
indications: health-care personnel, incl long term care/assisted living, childcare workers
indications: residents of nursing homes, assisted living, etc, anyone living with fragile pt
Intranasal live attenuated vaccine for: healthy, nonpregnant adults under 50 w/o indications
attenuated influenza vaccine = FluMist®
not so health people get inactivated virus
INFLUENZA
fever, sore throat, ha myalgia, chills, anorexia, fatigue
unprod cought, runny/stuffy nose
usu better in a week
cough & malaise may persist
kids may have febrile seizures
illness mb more severe in kids
risk for complic on old & young incl: exacerbation of chronic pulm dz, pneumo (strep, staph)
other complic: reyes syndrome, myocarditis, pericarditis, encephalopathy, encephalitis, traverse myelitis, guillain barre syndrome
1976 swine flu outbreak: some got guillain barre without vaccine
more people got flu from vaccine than not
10-20% of pop gets it every year
up to 50% institutionalized pop gets it
problem: cost and stress
30-40,000 die/year
three genera: A, B, C
A is human, divided by hemagglutinin and neruaminidase
H1N1 and H3N2 are most common
antigenic drift
B in humans and seals
epidemics every few years
C in humans and pigs
sporadic
less severe URI's
VACCINE
purified subunit vaccine in US
grown in chick eggs
virions lysed with detergent, lysate purified, adjuvant and preservative added
aluminum used, MF59 being investigated
thimerosal in these
SAFETY
local acute inflam
pain, red, fever, myalgia, arthralgia, headage
allergy to egg is CI
guillain barre? 1 case/million vaccinees, may be coincidental
TRIVIA
healthcare workers are largest vector group
vaccine ineffective vs avian flu
pts most contagious before sx (day 2 & 3)
SWINE FLU
current flu is type A H1N1
spread by cough and sneeze
consider if pt has fever, URI
do nasal swab if suspect flu, refrigerate (don't freeze) and report to public health
swab only useful for about 7 days
pts should be considered contagious for up to 7 days
virus resistant to antiviral meds amantadine and rimantadine
but sensitive to oseltamivir and zanamivir (tamiflu and )
this year was light flu season
this year's swine flu is hype
if healthcare providers are not vaccinated
wearing face mask not a bad idea, stops resp droplets
change gloves, all that
70% alcohol is effective, 100% not effective at killing virus
because 100% evaporates too quickly
slower evap gives time to work on viral membrane
1918 FLU
pop that died were young with active immune response
died of cytokine storm
PROS
keep weaker people from dying of flu
CONS
additives
must be repeated every year
vaccines often totally miss the mark
don't get the immune response you would with getting sick
CI: egg allergy
9.
TETANUS, DIPTHERIA, AND ACELLULAR PERTUSSIS (Td/Tdap)
boost every 10 years for life with Td
Tdap to replace a single dose of Td for adults aged 19 through 64 years receiving 1st dose
if vaccination hx uncertain CDC recommends starting over with 3 doses tet/dipth toxoid
first 2 doses 4 wks apart, 3rd dose 6-12 mo later
Tdap can sub for any Td in primary sequence
booster neededd if last vaccine over 10 yrs prior
Td may be given to preg in 2nd-3rd trimester, or Tdap
if last Td in preg was less than 10 yrs prior, give Tdap postpartum
also Td for all close contacts of infants
all healthcare pros
use in wound management
DIPHTHERIA
herd immunity
aerobic gram pos bacillus
corynebacterium diptheriae
toxin is dangerous, causes extensive organ and membrane damage
peripheral nerves, UR tract, throat condition assoc with cyanosis and temp paralysis in kids
only occurs in diptherium infx by virus (phage) carrying tox gene
C. dip may not have phage
trans: resp & physical contact (skin??)
appears as membranous pharyngitis is pharyngeal exudate
gradual onset
growth behind uvula
gray in color, has odor, diagnostic
rare in US, still in developing countries esp Asia these days
anti-toxin given intramuscularly or IV combined with penicillin or erythromycin
not abx resistant
catch it before paralysis
none in US since 1970's
humans can be asx carriers
communicable up to several weeks without abx
VACCINE
toxoid developed in 1900s
tx toxin with formalin
combine in 1948 with tet and pretuss
absorb all 3 on aluminum salt
immunogenicity depends on pertussis
pertussis is adjuvant (you don't want DT vaccine)
injected IM at 2, 4, 6mos and 15-18 mos, boost at 4-6 yrs and 11-12 yrs
ADVERSE EFFECTS
red & tender at site of injx, 2-8 hours later, painful form shoulder to elbow
only in adults with sx at time of injx
urticaria, anaphylaxis, or neuro complications (rare)
PERTUSSIS
Bordatella pertussis
most common childhood dz of 20th century
bact produce toxins that paralyze resp cilia
immunity to pertussis is not permanent
even if you get infx
vaccine gives immunity about 5 years
PT pertussis toxin is primary antigen
more antigens: FHA, agglutinogens, adenylate cyclase, pertactin, more
bact attaches to cilia
antigens allow evasion of host defenses
end up with local tissue damage from immune response
trans: resp droplets, humans, adults are most common vector
80% of household will be infected if one person gets it
infectious during catarrhal stage (first 2-3 weeks)
STAGES
incub: 7-10 days
catarrhal stage looks like cold
paroxysmal stage: bact is in cell so not as communicable, burst of coughing, thick mucus, whooping inhale, vomiting and exhaustion, 1-6 weeks, very young infants may not be able to whoop but still will have coughing spasms
convalescent stage: 2-3 weeks gradual improvement
tx: erythromycin usu eliminated pertuss from secretions
vaccinations recommended for all kids under 7 years old who haven't completed 4 doses of DTaP
if child had first two doses of vaccine they may become carrier
if child has documented pertussis infx then vaccine is not required
vaccine recommended therapy for infected kids under 7 who haven't had the whole series
if first injx after 1 year no more shots needed
INCIDENCE
increasing in US since 1900, but recently declining again
Oregon 111 cases in 2007, 175 in 2008 but pop is increasing so % is decreasing
attributed to unvaccinated kids incl partial vaccination
lots of these kids out there, they don't know they can get pertussis
often because parents only get early doses with Th2 response but need Th1 response
need vaccine after 1 year
breastfeeding slightly protective, mb20%
used to be peak every 10 yrs
mort 130/100000
now less than 100 cases/year worldwide
VACCINE
purified subunit vaccine
acellular
DTaP is acellular, get more AB's
2 phenyoxinol
AB titers increase over 7 days after vaccine
vaccine response is faster than prodrome so vaccine is helpful when people have been exposed
DPT and DwPT include whole cell pertussis most effective but variable by manufacturer
but lots of adverse events so we don't have it anymore
45 million cases worldwide wtih 400,000 deaths according to WHO
we don't have a toxoid vaccine yet???
ADVERSE EFFECTS
red, swell pain, vomit
fussy, drowy, anorexia
not so much fever
not so much "unusual cry"
not so much hypotonic hyporesponsive episodes (HHE) strange shocklike state
with old vaccine high fever, terribly crying, HHE
TETANUS
Clostridium tetani
anaerobic, gram pos, spore forming
found in soiil, feces,
multiple toxins produced with growth of bact
tetanospasmin, 2.5ng/kn i estimated human lethal dose
generalized rigidity and spasm of skeletal muscle
lock jaw, neck paralysis
spores resistant to heat and anti-septics
trans: wound contamination, heroin users, nosocomial
grow in anaerobic conditions
toxins act in CNS, blocks neurotranmitter release to block inhibitor impulses
incub: 8 days
longer incub with puncture farther from CNS
fever, sweat, high BP, erpisodic heart rate
haryngospasm, spine fx and long bones from convulsions
there is a therapy: tetanus immunogolubulin therapy TIG
give as single dose ASAP after exposure
rusty nail-->TIG and tetanus booster
don't give other vaccines with booster
given IM never IV because it causes type 3 immune response
immediate short term protection from TIG
peaks in 2-3 days and lasts 3 weeks
TIG->mild soreness at site, rare allergic rxn, angioneurotic edema or kidney sx
ABX are ineffective
disease does not result in immunity
incidence in US decreasing since 1950
most cases in young boys stepping on rusty things
the rest from car accidents, one nosocomial
tetanus around horses and livestock, farming risk
reservoir: soil and intestine
trans: wounds, tissue injury
pattern: peak in summer or wet season
not contagious
immunization does not confer immunity
small dose of toxin mediates dz
VACCINE
toxoid 1964
same today
formaldehyde
given IM
same adverse effects plus GUILLAIN BARRE syndrome (from thimerosal or other?)
one batch caused allergies in 1960's none since then
PROS
combo vaccine gets good response due to pertussis driving diptheria and tetanus
response is to diptheria toxoid
herd immunity protects even those who are not vaccinated
CONS
additives: contains formaldehyde, thimerosal in some
10.
HAEMOPHILUS INFLUENZAE TYPE B (Hib)
Hib vaccine generally is not recommended for persons aged 5 years and older
vaccine not contraindicated in: pts w/ sickle cell dz, leukemia, HIV infx, splenectomy
PROS
CONS
we don't need it
IMMUNOCOMPROMISED CONSIDERATIONS
use inactivated vaccines (e.g., pneumococcal, meningococcal, and influenza [trivalent inactivated influenza vaccine])
avoid live vaccines
http://www.cdc.gov/vaccines/pubs/acip-list.htm
SOURCES
http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm
my notes from Heather Zwickey lectures
http://www.zostavax.com/
http://www.cdc.gov/vaccines/vpd-vac/shingles/default.htm
Additional CDC information is available as follows:
schedule at http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm
adult vaccination at http://www.cdc.gov/vaccines/default.htm
ACIP statements for specific vaccines at http://www.cdc.gov/vaccine/pubs/acip-list.htm
adverse events reporting at http://www.vaers.hhs.gov or by telephone, 800-822-7967
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.
ASSORTED NOTES
CMV VACCINE
squalene (in chol syn pathway) has been used as adjuvant in vaccines
some veterans say it causes Gulf War Syndrome
(study published 2002, use discontinued Oct 04)