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Transcript
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