Download Immunization PHCL-B

Immunization
PHCL
Salha jokhab, MSC
Introduction
• Immunity
• Immunity
is the ability of the body to tolerate material that is
indigenous to it and eliminate material that is
foreign.
• The immune system is comprised of organs and
specialized cells that protect the body by
identifying harmful substances, known as
antigens, and by destroying them by using
antibodies and other specialized substances and
cells.
Introduction
• Immunity
• There are two basic ways to acquire this
protection – active immunity and passive
immunity.
• Active immunity is provided by a person’s own
immune system.
• This type of immunity can come from exposure to
a disease or from vaccination.
• Active immunity usually lasts for many years and
often is permanent.
Introduction
• Immunity
• Passive immunity results when antibodies are
transferred from one person or animal to another.
• The most common form of passive immunity occurs
when a fetus receives antibodies from his or her
mother across the placenta during pregnancy.
• Other sources of passive immunity include blood and
blood products, immune globulin, and animal
antitoxins.
• Passive immunity disappears over time, usually within
weeks or months.
Introduction
• What is Immunization?
• Immunization is the process of introducing an
antigen into the body to induce protection
against an infectious agent without causing
disease.
Introduction
• In 1796, Edward Jenner, a British physician
\observed that milkmaids often developed
small lesions that mimicked smallpox lesions.
These small lesions were caused by the
cowpox virus, to which exposure apparently
conferred immunity against smallpox.
Introduction
• He made two small cuts on the arm of an
eight-year-old boy, James Phipps, and inserted
material taken from a sore on a woman
infected with cowpox.
• Six weeks later, Jenner injected the boy with
fluid from a smallpox lesion, and James did
not contract smallpox.
Introduction
• With this experiment, Jenner discovered that
inoculation of a person with relatively harmless
disease material could protect the person from a
more dangerous disease.
• He called this process “vaccination”, derived from
the Latin name for cowpox, vaccinia.
• By the time the World Health Assembly declared
in 1980 that smallpox had been eradicated,
scientists had developed vaccines for many other
diseases.
Definitions
• Vaccines :
are substances administered to generate a
protective immune response.
• Toxoids:
are inactivated bacterial toxins. They retain the
ability to stimulate the formation of antitoxin,
which are antibodies directed against the
bacterial toxin.
Definitions
• Adjuvants :
are inert substances, such as aluminum salts which
enhance vaccine antigenicity by prolonging antigen
absorption.
• Additives:
Some ingredients are needed to make the vaccine.
Although these ingredients are removed, tiny
(residual) amounts are left in the final product. tiny
amounts of antibiotics (neomycin), and egg protein.
Immunization
Vaccines
Live
attenuated
Bacteria
inactivated
Virus
Bacteria
Virus
Vaccine Preparations
Live attenuated:
• Live attenuated vaccines are derived from
disease-causing viruses or bacteria that have
been weakened under laboratory conditions.
• They will grow in a vaccinated individual, but
because they are weak, they will cause either no
disease or only a mild form.
• Usually, only one dose of this type of vaccine
provides life-long immunity, with the exception
of oral polio vaccine, which requires multiple
doses.
Vaccine Preparations
Live attenuated
• Weakened form of pathogen
• Still replicates after administration
• Proper storage.
• Longer lasting immunity even with single dose
• More adverse effects especially in
immunocompromised persons
Vaccine Preparations Cont’d
Inactivated:
• Inactivated vaccines are produced by inactivation
of viruses or bacteria with heat or chemicals.
• Because they are not alive, they cannot grow in a
vaccinated individual and therefore cannot cause
the disease.
• They are not as effective as live vaccines.
• Multiple (booster) doses are required for full
protection because protection by these vaccines
diminishes over time.
Vaccine Preparations Cont’d
Inactivated
• Whole organism or antigenic fraction
• Antigenic fractions:
• Protein-based
• Polysaccaride-based
•
•
Less antigenic than protein-based especially at < 2 years old
May be conjugated to protein to increase immune response.
Vaccine Preparations
Form
Examples
Live Attenuated
Measles, Mumps, Rubella
Varicella, Zoster, Yellow Fever, Rotavirus
Intranasal Influenza, Oral Typhoid.
Inactivated
Whole organism
Hepatitis A, Polio, Rabies, Cholera et al
Fractional
Pure polysaccharide
Pneumococcal (Pneumovax)
Meningococcal (Menomune)
Conjugate polysaccharide
Pneumococcal (Prevnar)
Meningococcal (Menactra)
Haemophilus influenzae type b
Protein
Acellular Pertussis, Tetanus, Diptheria
Hepatitis B, Influenza, Human
Papillomavirus
General rules for giving vaccines
• All vaccines can be administered simultaneously at
separate site Except:
1. Separate between two live vaccines by at least 4 weeks.
2. Separate between Cholera(killed) and Yellow fever(live) at
least three weeks.
• Separate administration of vaccines from antibodies
e.g. wait 3 months after antibody to give vaccine
• Vaccination is less effective if given too soon
*Before indicated age
*Giving 2nd dose of a multi dose series before due
– Will still be effective if given later than it is due
Vaccines in Pregnancy
• Live virus vaccines are generally contraindicated in
pregnant women.
• According to the Centers for Disease Control and
Prevention (CDC).
• No evidence shows an increased risk from vaccinating
pregnant women with inactivated virus or bacterial
vaccines or toxoids. Inactivated vaccines may be
administered when the benefits outweigh the risk.
• Hepatitis A, hepatitis B, meningococcal, inactivated polio,
and pneumococcal polysaccharide vaccines should be
administered to pregnant women who are at risk for
contracting these infections.
Vaccines in Immunocompromised
individuals
• Live virus vaccines are generally contraindicated
in severely immunocompromised individuals (e.g.
transplantation and / or disease (malignancy, HIV
).
• Patients on chemotherapy
• Wait at least one month before giving vaccine in
patient receiving corticosteroids at greater than
20 mg or 2 mg/kg/d or have had a course lasting
longer than 2 weeks.
Vaccine Adverse Reactions
• Local
– Pain, swelling, redness at site of injection
– Usually mild and self-limited
• Systemic
– Fever, malaise, headache
Vaccine Adverse Reactions
• Allergy
– Rare, due to vaccine or vaccine component
• Vaccine Adverse Event Reporting System
(VAERS) www.vaers.hhs.gov
Thimersol
• Mercury based preservative used for decades
• Concerns raised about autism risk
– Researched by federal agencies (FDA, CDC & NIH)
Found no association/increased risk
– To avoid controversy, removed from single dose
vials, still in multi-dose.
– No reduction in autism
Thimersol
• Since 2001, with the exception of some influenza
(flu) vaccines, thimerosal is not used as a
preservative in routinely recommended childhood
vaccines.
Guillain-Barre Syndrome (GBS)
• Rare (1-2 cases per 100,000 persons)
neurologic auto-immune disorder in which a
person's own immune system damages the
nerves, causing muscle weakness and
sometimes paralysis.
• Old influenza vaccines (1976) associated with
one additional case per 100,000
• New influenza vaccines add only 1:1,000,000
Syncope
• has been reported after vaccination and serious
injuries have occurred.
• ACIP currently recommends that "vaccine
providers should strongly consider observing
patients for 15 minutes after they are vaccinated.
• This increase coincides with the licensure and
recommendation of three vaccines for
adolescents:
– (MCV4),
– (TDaP),
– human papillomavirus (HPV) vaccine
H1N1 2009 monovalent vaccines
• Summary of “Adverse Events following
Influenza A (H1N1) 2009 monovalent
vaccines reported to the Vaccine Adverse
Event Reporting System, United States,
October 1, 2009 – January 31, 2010”
H1N1 2009 monovalent vaccines
• CDC-FDA concluded that:
• The safety profile of 2009-H1N1 influenza vaccines was
consistent with that of seasonal influenza vaccines.
• The vast majority (93%) of adverse events reported to
VAERS after receiving the 2009 monovalent H1N1
influenza vaccine were classified as non-serious (e.g.,
injection site).
• 7.2% were classified as “serious” health events
(defined as life threatening or resulting in death, major
disability, abnormal conditions at birth, hospitalization,
or extension of an existing hospitalization).
H1N1 2009 monovalent vaccines
• The most frequent type of non-fatal serious reports
were neurologic (34%) and respiratory conditions
(31%), respectively.
• There were 48 reports of death. Review of these
deaths revealed no pattern that would suggest a causal
association between the vaccine and deaths; there
were no deaths due to anaphylaxis.
• The most common reported cause of death was
cardiovascular conditions. Among individuals with this
reported cause of death, 94% had underlying medical
conditions and risk factors for cardiovascular disease.
H1N1 2009 monovalent vaccines
• Death, GBS and anaphylaxis reports to VAERS
after 2009-H1N1 vaccine were rare (each < 2
per million doses administered).
Screening Questions
• Has the child taken cortisone, prednisone, other
steroids, or anticancer drugs, or in the past 3
months?
• Has the child received a transfusion of blood or
blood products, or been given a medicine called
immune (gamma) globulin in the past year?
• Is the child/teen pregnant or is there a chance
she could become pregnant during the next
month?
• Has the child received vaccinations in the past 4
weeks?
Tetanus, diptheria ,Pertussis disease
• Tetanus is an acute, often-fatal disease of the nervous
system . caused by nerve toxins produced by the bacterium
Clostridium tetani. This bacterium is found throughout the
world in animal and human intestines.
• Diphtheria is an acute respiratory infection caused by
Corynebacterium diphtheriae, and its toxin. This is a serious
infection with a high mortality rate
• Pertussis, commonly known as whooping cough is a
respiratory tract infection characterized by a paroxysmal
cough. the causative organism, Bordetella pertussis.
Tetanus, diptheria (Td) +/- Acellular
Pertussis (Tdap)
• Minimum age 6 weeks
• Child primary vaccination = 4 doses of DTaP:
– Child: 2,4,6 months then 15 to 18 months and 4 to
6 years of age
• Adult primary vaccination
• Adult booster Td* every 10 years
Measles, Mumps, Rubella disease
Mumps is a viral infection caused by the paramyxovirus
that primarily affects the parotid glands located.
Measles is a common infection of the respiratory system
caused by a virus, specifically a paramyxovirus Causes
cough, runny nose, inflamed eyes, sore throat, fever and
a red, blotchy skin rash
Rubella (German Measles) is usually a mild viral illness
involving the skin, the lymph nodes, and, less commonly,
the joints.
Measles, Mumps, Rubella (MMR)
• Child primary vaccination
– 2 separate doses 1st 12 months
2nd 4- 6 years.
• Adults born after 1957 without reliable history
of immunity
– Single dose
Hepatitis A
• Hepatitis A (Havrix, Vaqta)
• Children: all at > 1 year as 2 separate doses
• Adults: High risk adults healthcare workers as
2 separate doses 6 months apart. No booster
needed
Hepatitis B
• Hepatitis B (Engerix-B, Recombivax-HB)
• Children: at birth
• (HBsAg)-positive, administer HepB and 0.5 mL of
hepatitis B immune globulin (HBIG) within 12 hours of
birth.
• If mother’s HBsAg status is unknown, administer HepB
within 12 hours of birth. Determine mother’s HBsAg
status as soon as possible and, if HBsAg-positive,
administer HBIG (no later than age 1 week).
• Adults: Medical, occupational or behavioral risk as 3-4
separate doses 6 months apart. No booster needed
• Combined A/B (Twinrix)
Pneumococcal Vaccine
• Vaccine against Streptococcus pneumoniae
• Children:
– all at > 2 months as 4 separate dose series using
pneumococcal conjugate vaccine (PVC7)
– at > 2 years give single pneumococcal polysaccharide
vaccine (PPSV23) to high risk children
• Adults: PPSV
– > 65 years old or < 65 years old and asthma, smoker,
chronic illness (diabetes, heart disease, pulmonary
disease, liver disease, kidney disease, asplenic)
– Single revaccination after 5yrs in high risk patients.
Poliovirus vaccine
• Polio (poliomyelitis) mainly affects children
under five years of age.
– inactivated vaccine IPV is the recommended
vaccine for the primary series and booster dose
for children in the United States 4 dose series for
all children after 2 months
– a live attenuated, oral vaccine OPV is
recommended in areas of the world that have
circulating poliovirus
Rotavirus
• Rotavirus Gasteroenteritis is the leading cause
of moderate and severe vomiting and diarrhea
in infants and children
• 3 dose series for all children
• 1st dose at 6-14 weeks should not be initiated
after 15 wks
• The maximum age of the final dose is 8
months
Influenza Vaccines
• 70% effective in preventing infection
• > 60% reduction in influenza-associated
morbidity
• New formulation each year.
• Flu vaccines are available either as:
– Injection of trivalent (three strains; usually A/H1N1,
A/H3N2, and B) inactivated (killed) vaccine) or
– LAIV: (nasal spray) of live attenuated influenza
vaccine.
Influenza Vaccines Cont’d
• Vaccinate 6m through 18yrs.
• Beginning with the 2010–11 influenza season,
vaccination is recommended for all adults.
(This includes healthy adults ages 19–49yrs
without risk factors.)
Influenza Vaccines Cont’d
• Healthy, nonpregnant persons aged 2 to 49
years without high-risk medical conditions can
receive either intranasally administered live,
attenuated influenza vaccine.
• Adults aged 65 years or older can receive the
standard- dose IIV or the high-dose IIV
(Fluzone High-Dose).
Haemophilus influenzae type b
conjugate vaccine (Hib)
• prevents meningitis , pneumonia, and other
serious infections caused by Haemophilus
influenzae type b.
• (Minimum age: 6 weeks) 4 doses
Haemophilus influenzae type b
conjugate vaccine (Hib)
• One dose of Hib vaccine should be administered
to persons who have functional or anatomic
asplenia or sickle cell disease or are undergoing
elective splenectomy if they have not previously
received Hib vaccine.
• Recipients of a hematopoietic stem cell
transplant should be vaccinated with a 3-dose
regimen 6 to 12 months after a successful
transplant, regardless of vaccination history; at
least 4 weeks should separate doses.
Varicella [Chickenpox]
• Varcilla is an acute, highly contagious disease
caused by the varicella zoster virus (VZV).
• Children over 12 months: 2 separate doses
• High risk adults (healthcare workers without
evidence of immunity): 2 doses separated by 4
weeks
Zoster [Shingles]
• Herpes zoster is caused by the varicella zoster
virus (VZV)
• Introduced in 2006 for the prevention of
herpes zoster in persons 60 years of age or
older.
• The vaccine significantly reduced the burden
of illness (i.e., the severity and duration of
pain and discomfort) by 61%
Zoster [Shingles]
• A 51% reduction in the incidence of herpes
zoster also was associated with vaccination.
• Immuno-competent persons > 60 years old:
single dose
Human Papillomavirus [HPV]
• Sexually transmitted, very frequent in young
women
• Vaccine prevents most common types of HPV
that cause cervical cancer
Human Papillomavirus [HPV]
Who should vaccinate?
• For females, either HPV4 or HPV2 is
recommended in a 3-dose series for routine
vaccination at age 11 or 12 years and for those
aged 13 through 26 years, if not previously
vaccinated.
Human Papillomavirus [HPV]
Who should vaccinate?
• For males, HPV4 is recommended in a 3-dose
series for routine vaccination at age 11 or 12
years and for those aged 13 through 21 years, if
not previously vaccinated. Males aged 22 through
26 years may be vaccinated.
• HPV4 is recommended for men who have sex
with men through age 26 years for those who did
not get any or all doses when they were younger.
Meningococcal vaccine
• Neisseria meningitidis (N. meningitidis) one of
the causes of bacterial meningitis
• Meningococcal conjugate vaccine (MCV)
• Meningococcal polysaccaride vaccine (MPSV)
– (Menactra (adds diphtheria toxoid), Menomune)
• Children MCV4 (2–10 years )
– Asplenic or similar risk: single dose; may need
booster
Meningococcal vaccine
• Adults
– anatomic or functional asplenia, 1st year college students
living in dormitories, lab personel, military recruits,
travelers (i.e. Hajj!)
– Single dose, MCV preferred in adults < 55 years old
• MCV4 is preferred for adults with any previous
indication <55 yr old
• MPSV4 >56 yrs
• Revaccination after 3 to 5 years with MCV4 may be
indicated for adults who previously received the MPSV
or MVC4 and remain at risk for meningococcal disease
Vaccination Schedules
• Annually updated vaccination schedules from
CDC (www.cdc.gov)
– Age 0 – 6
– Age 7-18
– Adults
Why might some adults need
vaccines?
• Some adults incorrectly assume that the
vaccines they received as children will protect
them for the rest of their lives. Generally this is
true, except that:
• Some adults were never vaccinated as children
• Newer vaccines were not available when some
adults were children
• Immunity can begin to fade over time
• As we age, we become more susceptible to
serious disease caused by common infections
(e.g., flu, pneumococcus)
Pharmacist Role
• Vaccine administration.
• Pharmacists who do not administer vaccines can
promote immunization through six types of
activities:
(1) history and screening,
(2) patient counseling,
(3) documentation,
(4) formulary management,
(6) public education