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Health-System Pharmacists’
Practice Update on
Immunization and Preventable
Disease Management
Conducted during the 42nd ASHP Midyear Clinical Meeting
and Exhibition
Las Vegas, Nevada
Health-System Pharmacists’ Practice Update on Immunization and
Preventable Disease Management
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Health-System Pharmacists’ Practice Update on Immunization and
Preventable Disease Management
Program Overview
New developments in preventable disease research and immunization product development are
frequent, making it a challenge for busy health-system pharmacists to stay current. In 2007, the
Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (ACIP)
issued new recommendations for prevention and control of varicella (chicken pox), influenza,
meningococcal disease, and human papillomavirus (HPV) infection. In 2006, new vaccine
products for the prevention of herpes zoster (shingles) in the elderly, active booster immunization
against pertussis (whooping cough) in adults and adolescents, and prevention of rotavirus
gastroenteritis in infants were introduced. Considerable morbidity and mortality are associated
with these diseases. Ongoing research addresses the prevention of these and other diseases and
conditions with a large adverse impact on public health. A nicotine vaccine to help smokers quit
and a vaccine against the human immunodeficiency virus are the subject of ongoing research that
could yield immunization products with a large societal benefit.
This program will provide an overview of the prevalence, morbidity, and mortality in adults
associated with herpes zoster, influenza, meningococcal disease, pertussis, and HPV infection.
Recent changes to the ACIP recommendations for immunization and information about the
efficacy, safety, and administration of new immunization products also will be discussed. The
status of research efforts to develop immunization products with a large potential public health
benefit will be briefly described. Finally, the role of the health-system pharmacist as an advisor on
immunizations in preventing disease will be addressed.
Learning Objectives
At the conclusion of this program, participants should be able to:
• Discuss the prevalence, morbidity, and mortality associated with herpes zoster, influenza,
meningococcal disease, pertussis, and HPV infection.
•
Describe the recent changes to the ACIP recommendations for immunization against
influenza, meningococcal disease, and HPV infection, and characterize the efficacy, safety,
and administration of new vaccines against herpes zoster, pertussis (in adolescents and
adults), and HPV.
•
Name a potentially preventable disease state or condition with a large societal impact that
is targeted by current immunization research.
•
Explain the role of the health-system pharmacist as an advisor on immunizations in
preventing disease.
Program Faculty
Michael E. Klepser, Pharm.D., FCCP
Professor
Ferris State University
College of Pharmacy
Big Rapids, Michigan
Borgess Medical Center
Kalamazoo, Michigan
Health-System Pharmacists’ Practice Update on Immunization and
Preventable Disease Management
Disclosure Statements
In accordance with the Accreditation Council for Continuing Medical Education’s Standards for
Commercial Support, ASHP Advantage requires that all individuals involved in the development of
program content disclose their relevant financial relationships. A person has a relevant financial
relationship if the individual or his or her spouse/partner has a financial relationship (e.g.,
employee, consultant, research grant recipient, speakers bureau, or stockholder) in any amount
occurring in the last 12 months with a commercial interest whose products or services may be
discussed in the CME activity content over which the individual has control. The existence of these
relationships is provided for the information of participants and should not be assumed to have an
adverse impact on presentations.
All faculty and planners for ASHP Advantage education activities are qualified and selected by
ASHP Advantage and required to disclose any relevant financial relationships with commercial
interests. ASHP Advantage identifies and resolves conflicts of interest prior to an individual’s
participation in development of content for an educational activity.
The faculty and planners report the following relationships:
Michael E. Klepser, Pharm.D., FCCP
Dr. Klepser declares that he has no relationships pertinent to this activity.
Cathy C. Bowles, R.Ph.
Ms. Bowles declares that she has no relationships pertinent to this activity.
Susan R. Dombrowski, M.S., R.Ph.
Ms. Dombrowski declares that she has no relationships pertinent to this activity.
Health-System Pharmacists’ Practice Update on Immunization and
Preventable Disease Management
Michael E. Klepser, Pharm.D., FCCP
Professor
Ferris State University College of Pharmacy
Big Rapids, Michigan
Borgess Medical Center
Kalamazoo, Michigan
Michael E. Klepser, Pharm.D., FCCP, received his Doctor of Pharmacy degree from the University
of Michigan College of Pharmacy in 1992. He then completed a pharmacy practice residency at
Detroit Receiving Hospital and University Health Center and a fellowship in infectious diseases at
Hartford Hospital in Hartford, Connecticut.
Dr. Klepser has been Professor of Pharmacy at Ferris State University since 2001. Prior to joining
Ferris, he was Associate Professor at the University of Iowa College of Pharmacy (1995-2001).
While at the University of Iowa, Dr. Klepser had an active research program and focused on
antifungal/antibacterial pharmacodynamics and resistance. Since joining Ferris, Dr. Klepser has
redirected his scholarly efforts towards multi-media and technology-enhanced instruction.
Dr. Klepser has published extensively on these topics and has more than 80 peer-reviewed
manuscripts to his credit. He serves as a reviewer for several scientific conferences and journals.
Dr. Klepser is active in many professional organizations including the Society of Infectious
Diseases Pharmacists, the American College of Clinical Pharmacy, the American Society for
Microbiology, and the Infectious Diseases Society of America.
Learning Objectives
Health-System Pharmacists’ Practice
Update on Immunization and
Preventable Disease Management
Michael E. Klepser, Pharm.D., FCCP
Professor
Ferris State University
Borgess Medical Center
Big Rapids, Michigan
Update on Immunization and
Preventable Disease Management
• Discuss the prevalence, morbidity, and mortality
associated with influenza, herpes zoster,
meningococcal disease, pertussis, and HPV.
• Describe recent changes to the ACIP immunization
recommendations.
• Name a potentially preventable disease state or
condition that is targeted by current immunization
research.
• Explain the role of pharmacists as advisors on
immunizations in preventing disease.
Vaccine-Preventable
Diseases
History of Vaccines
• The transfer of pus from
smallpox lesions from an
infected individual to a
non-infected one was
practiced since the 1600s.
• Edward Jenner took pus
from a cowpox lesion and
vaccinated James Phipps
in 1796.
Vaccine comes from the Latin word “vacca” which
means cow.
•
•
•
•
•
•
•
•
•
•
•
•
•
Anthrax
Diphtheria
Hepatitis A and B
H. influenzae type b
Human papillomavirus
Influenza
Japanese Encephalitis
Lyme Disease
Measles
Meningococcal disease
Monkeypox
Mumps
Pertussis
•
•
•
•
•
•
•
•
•
•
•
•
Pneumococcal disease
Poliomyelitis
Rabies
Rotavirus
Rubella
Shingles
Smallpox
Tetanus
Tuberculosis
Typhoid Fever
Varicella
Yellow Fever
www.cdc.gov/vaccines/vpd-vac/default.htm
Vaccine-Preventable
Diseases
• Over 40,000 adults die annually from
vaccine-preventable diseases.
DTP Vaccine
Measles Vaccine
• Many patients leave hospitals and
physicians’ offices without receiving
recommended vaccines.
• Always ask patients about vaccination
history.
Influenza Vaccine
1
Vaccines
Live vs. Inactivated Vaccines
• Live attenuated vaccines
• Contained live but weakened bacteria or virus
• Stimulate an immune response similar to the
actual disease
• Durable immunity
• Inactivated vaccines
• Contain killed whole microbes, toxoids, or
antigenic subunits
• Cannot cause active disease
• Immunity tends to wane
Spacing Live vs. Inactivated
Vaccines
Antigen combination
Recommended minimum
interval between doses
Two or more inactivated
Simultaneously or at any
interval
Simultaneously or at any
interval
4-week minimum interval,
if not administered
simultaneously
Inactivated and live
Two or more live
Live
Inactivated
Varicella (VZV and HZ)
Parenteral influenza
Intranasal influenza
Pneumococcal
MMR
Meningococcal
Rotavirus
Tdap
Smallpox
Hepatitis A/B
Vaccine Recommendations
• Immunization schedules are updated
each year by the Advisory Committee
on Immunization Practices (ACIP).
• Provide advice that will lead to a reduction
in the incidence of vaccine-preventable
diseases in the U.S. and increase the safe
use of vaccines and related biological
products.
MMWR 2006;55:RR-15.
2007-2008 Immunization
Schedules
• Adult
• MMWR 2007;56:Q1-Q4.
• Children and adolescents
• www.cdc.gov/vaccines/recs/schedules/chil
d-schedule.htm
http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm
2
Important changes for 2007-2008
• Adults
• Zoster vaccine recommended for persons > 60
years of age
• HIV column split into CD4+ of <200 cells/µL and
>200 cells/µL
• Health-care workers can receive inactivated or live
attenuated influenza vaccine
• Revaccination after 3-5 years with meningococcal
conjugate (MCV4) vaccine may be indicated if
previously received polysaccharide vaccine
• Varicella vaccine indicated for all adults without
evidence of immunity
http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm
• Evidence of varicella immunity:
• Documentation of vaccination
• U.S.-born before 1980
• History of diagnosed varicella
• History of diagnosed herpes zoster
• Laboratory evidence of immunity or
laboratory confirmation of disease
http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm#printable
Select Vaccine-Preventable
Diseases
Important Changes for 2007-08
• Children
• All adolescents age 11-18 should be vaccinated with
the meningococcal conjugate vaccine (MCV4)
• All toddlers 12-23 months should receive Hep A
vaccine
• All children should receive 2 doses of the varicella
vaccine (1st dose 12-15 mo, 2nd dose 4-6 yr)
• Children should get one dose of Tdap when their next
Td booster is due
• Children 6 months-8 years who received only 1 dose
of influenza vaccine their first year should receive 2
doses the following year.
• Females 13-26 yr should receive HPV series
•
•
•
•
•
Influenza
Zoster
Meningococcal disease
Pertussis
Human Papillomavirus Infection
3
Influenza
Influenza Infections
• Seasonal influenza and related
complications result in approximately
36,000 deaths and 226,000
hospitalizations each year in the U.S.
• Worldwide approximately 250,000500,000 deaths occur each year as a
result of severe influenza infections.
• Each year 1-6% of the U.S. population
demonstrates serologic evidence of
infection.
• Risk of severe influenza and
complications is higher at extremes of
age and among those with various
underlying medical conditions.
WW Thompson, et al., JAMA 2003;289:179-86.
WW Thompson, et al., JAMA 2004;292:1333-40.
World Health Organization Influenza fact sheet no. 211
Differences Among Types of
Influenza Viruses
Influenza A
Influenza B
Genetics
8 gene segments
8 gene segments
7 gene segments
Structure
10 viral proteins
M2 unique
11 viral proteins
9 viral proteins
Host Range
Humans, swine,
equine, avian, marine
mammals
Humans only
Humans and swine
Epidemiology Antigenic shift and
drift
Antigenic drift
Antigenic drift
Clinical
features
Severe disease
generally confined to
older patients and
persons at high risk;
pandemics not seen
Mild disease without
seasonality
May cause large
pandemics with
significant mortality in
young persons
Influenza Virus
Influenza C
• Hemagglutinin (H) and
neuraminidase (N) are
the major antigenic
determinants of
influenza A viruses.
Principles and Practice of Infectious Diseases, 6th edition
Hemagglutinin
• Mediates the attachment and entry of the
virus into the host cells by binding to sialic
acid receptors.
• Humans - α-2,6 linkages in respiratory tract.
• Avian - α-2,3 linkages in intestinal tract.
• Swine - α-2,6 and α-2,3 linkages both present in tracheal
epithelium.
• The main viral target of humoral immunity.
• There are 16 distinct hemagglutinin
variations.
4
Influenza Virus - Clinical
Course
Influenza Virus
• Virus generally enters humans via
inhalation of virus-containing
respiratory secretions.
• Virus is internalized in respiratory tract
epithelial cells.
• Replicates within cells and is then
released.
• 1-2 days of incubation.
• Abrupt onset of symptoms
• Fever (100-104o F) , chills, headache, myalgia persist for ~3 days
• Respiratory symptoms may persist 3-4 days after
fever subsides.
• Duration of infectivity is 5 days after illness
onset for adults. Children shed virus for
several days before onset to >10 days after
onset of symptoms.
• Convalescence 1-2 weeks
Secondary Infections
Influenza Vaccination
• Vaccination period begins in October and
lasts until late spring.
• Bacterial pneumonia
is a common
complication of
influenza.
60
% of Years with Peak
Activity
• Suppression of
neutrophil function
• Enhanced cytokine
production
• Cell destruction or
functional impairment
40
20
0
Nov
Dec
Jan
Feb
Mar
Apr
May
Month of Peak Activity (1976-2006)
MMWR 2007;56:RR-6.
Influenza Vaccinations
Population Group
Influenza Vaccines
Influenza
Vaccination Level
Persons with any indication
•Aged 6-23 months
•Aged 50-64 years
•Aged >65 years
33.4%
22.9%
59.6%
Persons with high-risk conditions
•Aged 2-17 years
•Aged 18-49 years
•Aged 50-64 years
•Aged >65 years
28.4%
18.0%
34.2%
25.3%
Healthcare workers
33.5%
• Vaccines are formulated
annually.
• Contain two influenza A and
one influenza B strains.
• A/Solomon Islands/3/2006 (H1N1)
• A/Wisconsin/67/2005 (H3N2)
• B/Malaysia/2506/2004
http://en.wikipedia.org/wiki/Image:InfluenzaNomenclature
Diagram.png
MMWR 2007;56:RR-6.
5
Influenza Vaccines
• Inactivated
• Brand names: Fluzone®, FluvirinTM,
FluarixTM, FluLuvalTM
• Not identical. Approved for different age
groups
• Live attenuated
• FluMistTM
• No longer requires frozen storage
Influenza Vaccination
Recommendations
• All persons who wish to reduce the risk of becoming
ill with influenza.
• Those at high risk for influenza-related complications
• Children 6-59 months
• People >50 years of age
• Pregnant women
• Chronic medical conditions (e.g., cardiac, pulmonary,
renal, hepatic, metabolic, and hematological
disorders)
• Immunosuppressed
• Residents of long-term care facilities
• Conditions that can increase risk for aspiration
MMWR 2007;56:RR-6.
Influenza Vaccination
Recommendations
Influenza Vaccines
Factor
LAIV
Route of Administration
• Persons who live with or care
for high-risk persons
• Health-care workers
• Household contacts of those
<5 and >50 years, particularly
those <6 months
• Household contacts of those
with other high-risk conditions
IM
Healthy 2-49 yr
> 6 mos
Interval between doses for
children being vaccinated for the
first time
6-10 weeks
4 weeks
Administer to close contacts of
immunosuppressed not requiring
a protected environment
Yes
Yes
Administer to close contacts of
immunosuppressed requiring a
protected environment
No
Yes
Generally yes
Yes
Approved Age
Administration with other
vaccines
MMWR 2007;56:RR-6.
Live Attenuated vs.
Inactivated Influenza Vaccine
• LAIV is highly effective in select
patient populations, such as
pediatrics.
• Safe and significantly more efficacious
(p<0.001) in kids 12 to 59 months.
• May facilitate school-based vaccination
programs.
TIV
Intranasal
LAIV = live attenuated influenza virus
TIV = trivalent inactivated influenza virus
MMWR 2007;56:RR-6.
Who Should Not Receive LAIV?
• Persons <2 and >50 years of age
• Persons with high-risk medical
conditions
• Children receiving aspirin therapy
• Persons with a history of GuillainBarré Syndrome
• Pregnant women
Belshe RB, et al. NEJM 2007;356:685-96.
King JC, et al. NEJM 2006;355:2523-32.
6
Varicella-Zoster Virus
• Transmitted by direct contact
or inhalation of aerosols from
vesicular or respiratory fluid.
• Enters host via upperrespiratory tract or
conjunctiva.
• Average incubation is 14-16
days.
• Period of contagiousness is
1-2 days prior to rash until all
lesions are crusted
(4-7 days).
Varicella Vaccine
Nguyen HQ, et al. NEJM 2005;352:450-8.
MMWR 2007;56:RR-4.
Immune Response to
Vaccination
Breakthrough Rates by Number of
Years Following Vaccination
• A comparative study of 1- versus 2-dose
regimens.
1 Dose
2 Doses
Serconversion Rate
85.7%
99.6%
Mean Titers
(gpELISA units µ/ml)
12.5*
588*
Breakthrough
infection
7.3%*
2.2%*
Estimated Efficacy
94.4%*
98.3%*
*P < 0.001
Kuter B, et al. Pediatr Infect Dis J 2004;23:132-7.
Kuter B, et al. Pediatr Infect Dis J. 2004;23:132-7.
7
Varicella Vaccination
Recommendations
• Childhood vaccination
should consist of 2 doses
• 1st dose 12-15 months
• 2nd dose 4-6 years
• HIV-infected individuals should get 2
doses, 3 months apart if their CD4+ is
> 200 cells/µL
• All adults without evidence of immunity
Evidence of varicella immunity:
•
•
•
•
•
Documentation of vaccination
U.S.-born before 1980
History of diagnosed varicella
History of diagnosed herpes zoster
Laboratory evidence of immunity or
laboratory confirmation of disease
MMWR 2007;56:RR-4.
Herpes Zoster
• 15-30% of people experience zoster during
their lifetime
• Risk factors
• Aging
• Immunosuppression
• Varicella infection in utero or <18 months of age
• Complications
All adults > 60 years of age
should receive one dose of the
zoster vaccine.
• Post-herpetic neuralgia
• Herpes ophthalmicus
• Disseminated disease
www.iceh.org.uk/files/tsno8/slides/s08.11.jpg
Meningococcal Disease
• Neisseria meningitidis
•
became a leading cause of
meningitis following
vaccination against
H. influenzae type b and
S. pneumoniae.
• Prior to 2004 1,400-2,800 cases of
meningococcal disease
occurred annually in the
U.S.
Meningococcal Disease
Risk factors
• Deficiencies in the
complement pathway
• Antecedent viral
infections
• Household crowding
• Chronic underlying illness
• Active and passive
smoking
MMWR 2005;54:RR-7.
MMWR 2005;54:RR-7.
8
Meningococcal Disease
• Transmitted by direct
contact with large
droplet respiratory
secretions.
• Case fatality ranges
from 10-14%.
• 11-19% of survivors
have sequelae (e.g.,
neurologic disability,
hearing loss, limb loss).
Meningococcal Disease
MPSV4
MCV4
Brand Name
Menomune
Menactra
Serogroups
A, C, Y, W-135
A, C, Y, W-135
Indicated Ages
Immunity
11-55 years
Short-lived, no
reduction in
nasopharyngeal
carriage
Strong anamnestic
response, may reduce
asymptomatic
carriage
MMWR 2005;54:RR-7.
MMWR 2005;54:RR-7.
Pertussis
Meningococcal Disease
• Vaccination recommendations
• 2-10 years, vaccinate high-risk
groups with MPSV4
• 11-18 years, vaccinate ALL
persons with MCV4
2-10 years
•
•
•
•
Caused by Bordetella pertussis.
Spread via aerosolized respiratory droplets.
Incidence had decreased 98% since the 1940s.
Waning immunity resulted in resurgence in the late
1990s.
MMWR 2005;54:RR-7.
MMWR 2007;56:794-5.
Pertussis
Human Papillomavirus
• Mortality and complications are highest
among infants.
• In 2001, the Global Pertussis Initiative
recommended universal adolescent and
adult vaccinations.
• Administer one dose of Tdap (Boostrix® or
Adacel®) at age 11-12 years.
• Administer one dose of Tdap (Adacel®) if
not previously received between 19-65
years.
• Estimated that 6.2 million persons are
newly infected in the U.S. each year.
• >80% of sexually active women have
acquired HPV by age 50 years.
• High-risk HPV types have been detected in
99% of cervical cancers.
• 70% of cervical cancers are caused by
types 16 and 18.
Forsyth KD, et al. Clin Infect Dis 2004;39:1802-9.
MMWR 2007;56:Q1-Q4.
Weinstock H, et al. Perspect Sex Reprod Health 2004;36:6-10.
Bosch FX, et al. J Natl Cancer Inst Monogr 2003;31:3-13.
9
HPV Vaccine
HPV Vaccine
• Quadrivalent HPV vaccine
• L1 major capsid protein
• Contains types 6, 11, 16, and 18
• Three-dose series (0, 2 mo, 6 mo)
• Highly effective
• 100% (CI=80.9%-100%) for preventing HPV 16
and 18 cervical intraepithelial neoplasia
• ACIP recommends vaccination of females
11-12 years of age and catch-up through
26 years.
Gardasil® [package insert], Merck & Co., Inc.; 2007.
MMWR 2007;56:RR-2.
On the Horizon
•
•
•
•
Nicotine
Candida
Staphylococcus
HIV
Pharmacists
• Highly accessible
• Estimated 224,500 active pharmacists or
75 per 100,000-population by 2010.
• Even in rural areas, 70% of Medicare
patients live within 15 miles of a pharmacy.
• Highly educated
• Roughly 8,000 new graduates annually by
2010.
Gershon et al. www.hhs.gov/pharmacy/phpharm/howmany.html. Accessed 9/6/07.
SK&A Healthcare Information Solutions. www.pcmanet.org/newsroom/2007. Accessed 9/6/07.
What Can Pharmacists Do?
• Serve as vaccine advocates and
immunizers.
• Establish and manage triage
centers.
• Participate in disease surveillance.
• Serve as a community resource for
information.
Vaccine
Advocates/Immunizers
• Levels of advocacy
• Educator - motivate patients to be immunized
• Facilitator - organize immunization clinics
• Immunizer
• Incorporate determination of patient
vaccination status into routine practice
• Identify high-risk patients
10
Impact of Pharmacists on
Vaccination Rates
• Pharmacy-based immunization programs
increase influenza vaccination rates among
target populations.
• 4.7% increase among patients > 65 years of age.
• 10.6% increase among individuals with chronic
diseases (p=0.05).
• 13.5% higher vaccination rates among those
unvaccinated the previous year (p=0.01).
www.aphanet.org. Accessed 9/10/07.
Impact of Pharmacists on
Vaccination Rates
• Target high-risk populations in
various settings
•
•
•
•
•
•
•
Community pharmacies
Nursing homes
Clinics
Daycare settings
Schools
Senior centers
Retirement communities
Grabenstein JD, et al. Med Care. 2001;39:340-8.
Pharmacists on the Frontline
• Screen for populations at high risk for disease
or complications.
• Routinely obtain immunization and exposure
histories.
• Triage patients with suspected communicable
diseases.
• Keep abreast of local disease activity.
Stay Informed
• www.cdc.gov/vaccines/recs/acip/default.htm
End of Presentation
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11
Health-System Pharmacists’ Practice Update on Immunization and
Preventable Disease Management
Selected References
Kroger AT, Atkinson WL, Marcuse EK, et al. General recommendations on immunization:
recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm
Rep. 2006;55(RR-15):1-48.
Centers for Disease Control and Prevention (CDC). Update: influenza activity--United States and
worldwide, May 20-September 15, 2007. MMWR. 2007;56(38):1001-4.
Thompson WW, Shay DK, Weintraub E, et al. Influenza-associated hospitalizations in the United
States. JAMA. 2004;292(11):1333-40.
Belshe RB, Edwards KM, Vesikari T, et al. Live attenuated versus inactivated influenza vaccine in
infants and young children. N Engl J Med. 2007;356(7):685-96.
King JC Jr, Stoddard JJ, Gaglani MJ, et al. Effectiveness of school-based influenza vaccination.
N Engl J Med. 2006;355(24):2523-32.
Nguyen HQ, Jumaan HO, Seward JF. Decline in mortality due to varicella after implementation of
varicella vaccination in the United States. N Engl J Med. 2005;352(5):450-8.
Kuter B, Matthews H, Heyse JF, et al. Ten year follow-up of healthy children who received one or
two injections of varicella vaccine. Pediatr Infect Dis J. 2004;23(2):132-7.
Centers for Disease Control and Prevention (CDC). Direct and indirect effects of routine
vaccination of children with 7-valent pneumococcal conjugate vaccine on incidence of invasive
pneumococcal disease--United States, 1998-2003. MMWR. 2005;54(36):893-7.
Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization
Practices. Revised recommendations of the Advisory Committee on Immunization Practices to
Vaccinate all Persons Aged 11-18 Years with Meningococcal Conjugate Vaccine. MMWR.
2007;56(31):794-5.
Forsyth KD, Campins-Marti M, Caro J, et al. Global Pertussis Initiative. New pertussis vaccination
strategies beyond infancy: recommendations by the global pertussis initiative. Clin Infect Dis.
2004;39(12):1802-9.
Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth:
incidence and prevalence estimates, 2000. Perspect Sex Reprod Health 2004;36(1):6-10.
Bosch FX, de Sanjose S. Human papillomavirus and cervical cancer– burden and assessment of
causality. J Natl Cancer Inst Monogr. 2003;(31):3-13.
Lehtinen M, Apter D, Dubin G, et al. Enrollment of 22,000 adolescent women to cancer registry
follow-up for long-term human papillomavirus vaccine efficacy: guarding against guessing. Int J
STD AIDS. 2006; 17:517-21.
Mao C, Koutsky LA, Ault KA, et al. Efficacy of human papillomavirus-16 vaccine to prevent cervical
intraepithelial neoplasia: a randomized controlled trial. Obstet Gynecol. 2006; 107:18-27.
Health-System Pharmacists’ Practice Update on Immunization and Preventable
Disease Management
This program is located at http://esymposia.ashp.org/cemornings
There are 11 questions associated with this self-assessment test.
1. Live attenuated vaccines differ from inactivated vaccines in that they:
a. Contain killed whole microbes, toxoids, or antigenic subunits.
b. Do not stimulate an immune response similar to the actual disease.
c. Must be administered parenterally.
d. Produce durable immunity.
2. Which of the following is a live attenuated (not inactivated) vaccine?
a. Hepatitis A vaccine.
b. Meningococcal vaccine.
c. Pneumococcal vaccine.
d. Varicella.
3. Which of the following is an important change in immunization recommendations of the
Advisory Committee on Immunization Practices for adults in 2007-08?
a. Varicella vaccine is contraindicated in adults without evidence of immunity.
b. Zoster vaccine is recommended for all adults without evidence of immunity.
c. Zoster vaccine is recommended for adults 60 years of age or older.
d. Varicella and zoster vaccine both are recommended for HIV-infected persons with
CD4+ T lymphocyte count <200cells/µL.
4. Which of the following is an important change in immunization recommendations of the
Advisory Committee on Immunization Practices for children in 2007-08?
a. Children 6 months to 8 years of age who received only 1 dose of influenza vaccine
their first year should receive 2 doses the following year.
b. Adolescents 11-18 years of age should receive the meningococcal polysaccharide
vaccine (MPSV4).
c. Adolescents should receive two Tdap doses, with the first dose at the age of 11-12
years and the second dose 5 years later.
d. Catch-up vaccination with the HPV vaccine is recommended for women 60 years of
age or older who were not previously immunized.
5. For which of the following age groups at high risk for complications from influenza is
immunization recommended by the Advisory Committee on Immunization Practices for
2007-08?
a. School-age children 5-11 years of age.
b. Adolescents 11-18 years of age.
c. Adults 18-49 years of age.
d. Adults ≥50 years of age.
6. Seasonal influenza and related complications result in approximately 36,000 deaths and
226,000 hospitalizations each year in the United States.
a. True.
b. False.
7. The lifetime prevalence of herpes zoster is:
a. 1% to 2%.
b. 5% to 10%.
c. 15% to 30%.
d. 85% to 90%.
8. The case fatality rate from meningococcal disease is:
a. 1% to 4%.
b. 10% to 14%.
c. 25% to 30%.
d. 75% to 80%.
9. The resurgence of pertussis in the late 1990s has been attributed to:
a. Waning immunity.
b. Sexual activity at increasingly young ages.
c. Reduced immunization rates.
d. Vaccine shortages.
10. Which of the following statements is true regarding human papillomavirus (HPV)?
a. An estimated 2.6 million persons are newly infected in the United States each year.
b. Less than 20% of sexually active women have acquired HPV by age 50 years.
c. High-risk HPV types have been detected in 99% of cervical cancers.
d. ACIP recommendations advise vaccination of females only when 11-12 years of
age.
11. Which of the following is an immunization product in development with the potential for
great societal benefit that was mentioned in this program as coming on the horizon?
a. A vaccine to prevent age-related blindness.
b. A vaccine to help cigarette smokers quit.
c. A vaccine to prevent obesity.
d. A vaccine to manage chronic alcoholism.