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Update on Vaccines

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Title: Update on Vaccines


1
Update on Vaccines
  • Kimberly A. Kendall, PharmD
  • St. Elizabeth Regional Health
  • June 2007

2
Objectives
  • Discuss the history of vaccines.
  • Discuss different types of vaccines.
  • Identify different vaccines that are available on
    the market.
  • Identify the various vaccines that we carry at
    our facilities.
  • Identify appropriate vaccine doses for patients
    of different ages.

3
General
  • The introduction of vaccines has led to a
    significant decline in worldwide morbidity and
    mortality due to various diseases.
  • Vaccines have been shown to be generally safe
    and cost-effective.
  • Vaccines trick the immune system into producing
    antibodies or immune cells that protect against
    disease-causing organisms.

4
General
  • 1796- Edward Jenner, an English physician,
    observed that milkmaids stricken with cowpox
    rarely became infected with smallpox.
  • This led to the development of first vaccine.
  • He inoculated a young, healthy child with fluid
    from a cowpox pustule.
  • He later inoculated the child with fluid from a
    smallpox pustule.
  • The child remained disease free.

5
General
  • By 1980, an updated version of Jenners vaccine
    led to the eradication of smallpox
  • By the beginning of the 20th century, vaccines
    for rabies, diphtheria, typhoid fever and plague
    in addition to smallpox vaccine had been
    produced.
  • We now have vaccines against more than 20
    infectious diseases.

6
Types of Vaccines
  • Weakened microbes
  • Killed microbes
  • Inactivated toxins
  • Subunit vaccines
  • Conjugate vaccines
  • Vaccines from biotechnology

7
Weakened Microbes
  • Live microbes weakened by growing them for many
    generations in animals or tissue cultures
  • Inoculated into humans to provide protection from
    disease causing microbes
  • Ex Oral Polio Vaccine, Mumps, Measles, Rubella,
    Varicella

8
Killed Microbes
  • Derived from whole organisms that have been
    killed
  • Do not cause disease in people who receive them,
    but they can stimulate the immune system
  • Ex Polio and Influenza

9
Inactivated Toxins
  • Some bacteria cause disease by producing toxins
    that invade the bloodstream
  • Inactivated toxins are used to prevent the same
    diseases
  • Ex Tetanus and Diphtheria

10
Subunit Vaccines
  • Use only part of a bacterium or virus
  • Produce effective immune response without
    creating a separate and potentially harmful
    immune reaction to the other antigens on the
    microbe
  • Ex Typhoid and Hepatitis B

11
Conjugate Vaccines
  • Bacteria that cause certain diseases have an
    outer coat that cannot be recognized by the
    immature immune systems of infants
  • These vaccines link together proteins or
    inactivated toxins from a second organism to the
    outer coat of the bacteria
  • Allows the immune system to respond to the
    combined vaccine and produce antibodies
  • Ex Haemophilus Influenza Type B

12
Vaccines from Biotechnology
  • Made by altering an organisms genetic structure
    by cutting out a key gene
  • Allows the organism to produce immunity but not
    disease
  • Can also insert a gene into an organisms genetic
    material,causing it to mass produce foreign
    proteins or antigens which can induce an immune
    response
  • DNA is removed from an organism and modified so
    that it contains only a fragment of the original
    genetic material
  • When put into humans, the body generates antigens
    to protect against disease

13
Edible Vaccines
  • Edible vaccines have been developed to produce an
    immune response to E. coli bacterium and Norwalk
    virus
  • Potatoes, bananas, and tomatoes have been
    genetically engineered to initiate an immune
    response when eaten

14
Vaccine Administration
  • SQ injections
  • Thigh of infants
  • Deltoid area of older children and adults
  • IM injections
  • Upper thigh of infants and toddlers
  • Deltoid muscle of arm for children and adults
  • The buttock should not be used
  • Potential for inadequate response
  • Potential risk of injury to sciatic nerve.
  • Must be used for large doses of immunoglobulin.
    Use only the upper, outer quadrant.

15
Special Populations
  • Age of the recipient is a determining factor in
    vaccine and toxoid response.
  • In the first few months of life, passive immunity
    from the mother protects an infant and prevents
    adequate vaccine response to certain agents.
  • Premature infants should be vaccinated at the
    same chronologic age using the same schedule and
    precautions as full-term infants.
  • The full doses should be given regardless of age
    or birth weight. ( Hepatitis B vaccine should be
    given if the infant is 2,000 g or held until 2
    months old.)

16
Special Populations
  • Administration of live, attenuated vaccines
    should be avoided during pregnancy.
  • Inactivated vaccines should not be given until
    the 2nd trimester. (However, they have not been
    shown to be teratogenic during the first
    trimester.)
  • Administration of rubella vaccine during
    pregnancy is not a reason to interrupt pregnancy.

17
Special Populations
  • Diphtheria and tetanus vaccination should be
    carried out per usual schedule during pregnancy.
  • Hepatitis B, inactivated polio and pneumococcal
    vaccines are all recommended during pregnancy, if
    indicated.
  • Pregnant women in 2nd or 3rd trimester during flu
    season should get flu vaccine.

18
National Vaccine Injury Compensation Act (NVICA)
  • Passed in 1986.
  • Outlines compensation for vaccine-related
    injuries and limits size of awards to injured
    individuals.
  • Frees manufacturers from liability if adequate
    warnings for vaccines are provided.
  • Health care providers and manufacturers must
    report adverse reactions to vaccines to the FDA
    within 7 days of occurrence.

19
National Vaccine Injury Compensation Act (NVICA)
  • Mandatory record keeping by health care providers
    in the permanent medical record (the manufacturer
    and lot number, date of administration, and name,
    address, and title of the person giving the
    vaccine must be recorded).
  • Also mandates that healthcare providers report to
    their health department or the FDA any adverse
    reactions.
  • Vaccine Adverse Event Reporting System (VAERS)
    1-800-822-7967.
  • Policy at St Elizabeth Regional Health

20
Diphtheria Toxoid Adsorbed
  • Suspension of modified toxins which produce
    immunity against exotoxin of organism
  • Pediatric strength and adult strength (has less
    antigen than pediatric strength)
  • Given to kids with tetanus toxoid and acellular
    pertussis vaccines (DTap)
  • Dose- 0.5 ml IM given at 2,4,and 6 moa, then
    15-18moa, then 4-6 yoa
  • Boosters every 10 years
  • Component of ADACEL, BOOSTRIX, Pediarix,Tripedia,I
    nfanrix, and Daptacel

21
Diphtheria Antitoxin
  • Antitoxin derived from hyperimmunized horses
  • Used in patients with diphtheria
  • Given IM or IV
  • Dose is related to the severity and duration of
    illness

22
Tetanus Toxoid and Tetanus Toxoid Adsorbed
  • Suspensions of toxoid from bacterium
  • Tetanus Toxoid
  • Not preferred product
  • Tetanus Toxoid Adsorbed
  • DECAVAC- single agent
  • Adsorbed onto aluminum salts
  • Preferred product because it elicits greater
    response with fewer adverse reactions

23
Tetanus Toxoid Adsorbed
  • Children
  • Use DTap 0.5ml IM at 2,4,6 moa,15-18moa
  • gt 7yoa use Td (Tetanus Toxoid with Diphtheria
    Toxoid)- 0.5 ml IM
  • Adults
  • Same as for children gt7 yoa
  • Boosters every 10 years with Td
  • Also component of Pediarix, Tripedia, Infanrix,
    Daptacel, ActHib, ADACEL, and BOOSTRIX

24
Wound Management
  • Traumatic wounds require booster with Td if
    patient has not gotten booster in past 5 years.
  • Certain wounds also require administration of
    immunoglobulin.
  • Clean wounds require no treatment.

25
Tetanus Immunoglobulin
  • From hyperimmunized humans
  • Provides passive immunity to tetanus following
    traumatic wounds in nonimmunized or sub optimally
    immunized persons
  • Dose- prophylaxis 200-500 units IM
  • Dose- treatment 3,000-6,000 units IM

26
Hepatitis A Vaccine
  • Havrix and Vaqta
  • Inactivated virus
  • Havrix 2-18yo 0.5ml at 0 and 6-12 months
  • gt18 yo- 1ml at 0 and 6-12 months
  • Vaqta 2-17yo 0.5ml at 0 and 6-18 months
  • gt17 yo 1 ml at 0 and 6 months
  • Indicated for certain at risk populations and
    those who may expose large numbers of people if
    they became exposed.
  • Plan is to eradicate Hepatitis A by vaccinating
    all children 2 yoa or younger
  • TwinRx- combo product with Hepatitis B vaccine

27
Hepatitis B Vaccine
  • Engerix-B and Recombivax-HB- both inactivated
  • Vaccinate certain adult populations
  • Vaccinate all newborns (thimerisol free products)
  • Babies born to (-) moms
  • 5 mcg Recombivax or 10 mcg Engerix-B
  • 1st dose at 0-2 days old, 2nd dose at 1-2 moa,
    3rd dose at 6-18 moa or 2,4, and 6-18 moa
  • Babies born to () moms
  • 1st dose within 12 hours of birth, 1 moa and 6 moa

28
Hepatitis B Vaccine
  • Adults/older children
  • lt19yoa 5 mcg Recombivax or 10mcg Engerix at
    0,1,and 6 months
  • 11-15 yoa 10mcg Recombivax (only) and 0 and 6
    months
  • gt/ 19yoa 10mcg Recombivax or 20mcg Engerix at
    0,1,and 6 months

29
Hepatitis B Vaccine
  • Combination products
  • Twinrx - with Hep A
  • Pediarix- with diphtheria,pertussis, tetanus and
    polio

30
Hepatitis B Immunoglobulin
  • NABI-HB
  • Post exposure
  • From pooled plasma from human donors
  • Passive immunity following exposure
  • Infants born to Hep B carrier Moms
  • Give within 24 hours of exposure
  • Not recommended beyond 14 days of exposure

31
Haemophilus Influenza Type B Vaccines
  • Conjugate products (linked to a protein carrier)
  • Recommended for routine use only for patients up
    through 59 months of age
  • ActHIB, HibTiter, PedvaxHib,OmniHIB,ProHIBiT,DTaP-
    Hib
  • Peds- 2-6 months of age 0.5ml IM x 3 doses at 2
    month intervals. Booster at 15 months or older.
  • 0.5ml IM at 2,4 and 6 moa. Booster at 12-15moa
  • Not for kidslt6 weeks old
  • Do not give shotslt 2 months after previous dose

32
Human Papillomavirus Vaccine Quadrivalent
  • Gardasil
  • Protects against certain cervical cancers and
    genital warts
  • 0.5 ml IM at 0,2 and 6 months
  • Not evaluated in patients gt26yoa or lt9 yoa
  • Does not prevent all cervical cancers
  • Not recommended for pregnant patients
  • Cervarix- pending FDA licensure

33
Influenza Virus Vaccine
  • Fluarix, FluLaval, Fluzone
  • Antigenic composition of vaccine is determined
    year to year by the predominant circulating
    strains
  • Inactivated virus
  • Recommended for pts gt 6 moa with chronic medical
    conditions and all people over 50 yoa and other
    designated populations
  • Adult dose 0.5ml IM
  • October-November is the optimum time for
    immunization

34
Influenza Virus Vaccine
  • Split-virus vaccine used for children
    6moa-12yoa-less reactogenic than whole virus
  • Children 6-35moa receive 0.25ml
  • All children lt9 yo need 2 doses at least 1 month
    apart if receiving vaccine for first time

35
Measles Vaccine
  • MMR-II (measles, mumps and rubella)
  • Live attenuated viral vaccine
  • Peds 0.5 ml SQ at 12-15 months and 4-6 yoa
  • Give 1 month before or after administration of
    other live viral vaccines
  • Revaccination should be considered for students
    entering college

36
Meningococcal Vaccine
  • Polysaccharide vaccine-Menomune
  • Adult gt 55 yoa- 0.5ml sq as a single dose-
    primary or revaccination
  • Pediatric
  • 19 moa-10 yoa 0.5 ml SQ as single dose
  • 3-18 moa 0.5 ml SQ for 2 doses

37
Meningococcal Vaccine
  • Diphtheria conjugate- Menactra
  • Adults up to 55 yoa- 0.5ml IM
  • Pediatric 11yoa or older- 0.5 ml IM
  • Provides longer lasting immunity
  • Recent push to get adolescents and college
    freshmen vaccinated

38
Mumps Vaccine
  • Live attenuated vaccine
  • Usually given as MMR
  • Dose 0.5ml SQ
  • First dose at 12-15 moa with 2nd dose prior to
    entry into elementary school
  • Vaccinate previously unvaccinated adults, those
    vaccinated with killed mumps vaccine or those
    with questionable hx of infections
  • Should not be given to pregnant women
  • Avoid conception for 3 months following
    vaccination

39
Pertussis Vaccine
  • Acellular vaccines contain the toxin and some
    contain additional bacterial components
  • Given at 2,4,6 and 15-18 moa
  • Fifth dose at 4-6 yoa
  • Administered in combination with Diphtheria and
    tetanus (DTaP)
  • BOOSTRIX- 10-18 yoa- 0.5 ml IM
  • ADACEL- 11-64 yoa- 0.5 ml IM
  • Combo products Tripedia, Infanrix, Daptacel,
    Pediarix

40
Poliovirus Vaccines
  • Inactivated vaccine recommended.
  • Oral vaccine not routinely used in the US
  • Ipol- poliovirus vaccine, inactivated
  • Adults- 0.5ml IM/SQ x 3 doses at 0,1-2 months and
    6-12 months (not routinely recommended because of
    high level of immunity in ths age group)
  • Pediatrics- not tested in childrenlt6 weeks
  • 0.5ml IM/SQ x 4 doses at 2,4,6 moa with booster
    at 4-6 yoa
  • Component of Pediarix

41
Pneumococcal Vaccine
  • Recommended for personsgt/ 65yoa and certain
    other populations
  • Polyvalent polysaccharide- Pneumovax23 and
    Pnu-Imune 23
  • Adult- 0.5ml IM /SQ as single dose
  • Pediatrics- not tested lt2 yoa- 0.5ml IM/SQ as
    single dose
  • Pneumococcal vaccine, diphtheria conjugate-
    Prevnar
  • Not for adults
  • Pediatrics- 0.5ml IM x 4 doses- 2,4,6 mo and
    booster at 12-15 Mo
  • not for childrenlt 6 weeks old

42
Rabies Vaccine
  • Killed Vaccine
  • Imovax Rabies and Rabavert
  • Adult- post exposure prophylaxis- unvaccinated
  • 1 ml IM x 5 doses, days 0,3,7,14 and 28
  • Human Rabies Immune Globulin (HRIG, Imogam) on
    Day 0 20 international units/ kg IM
  • Adult- post exposure prophylaxis-previously
    vaccinated
  • 1 ml IM x 2 doses , Days 0 and 3

43
Rabies Vaccine
  • Pre-exposure prophylaxis
  • 1 ml IM x 3 doses, Days 0,7, and 21-28
  • Booster- depends on titers
  • Does not eliminate need for post exposure
    prophylaxis
  • Peds dose same as adults.

44
Rubella Vaccine
  • Contains attenuated virus- German Measles
  • Available alone or in combo with measles and
    mumps vaccines
  • Meruvax II- single agent
  • MMR II- combination product
  • Children 1 yoa or older 0.5 ml sq
  • All women of childbearing potential should have
    documentation of receiving at least one dose or
    lab evidence of immunity

45
Varicella Vaccine
  • Live, attenuated vaccine
  • Varivax, Zostavax
  • Varivax-
  • gt/ 13 yoa- 0.5ml SQ x 2 doses at 0 and 4-8 weeks
  • 12 moa-12 yoa-0.5ml SQ at 12-18moa and 4-6 yoa
  • Not studied in children lt 12 moa
  • Can be used for post-exposure prophylaxis w/in 3
    (possibly 5 days) of exposure
  • Contraindicated in pregnancy

46
Varicella Vaccine
  • Zostavax
  • prophylaxis of herpes zoster and post herpetic
    neuralgia
  • adults gt/ 60 yoa 0.65ml SQ x1
  • Not approved in kids
  • Targets herpes zoster manifestations of the
    varicella zoster virus (VZV)
  • Same viral component as in Varivax, but at a 14-
    fold higher concentration

47
Varicella-Zoster Immunoglobulin
  • Passive immunity to susceptible immunodeficient
    patients exposed to chickenpox
  • Children with immunodeficiency, neoplastic dz, or
    who are on immunosuppressive therapy
  • Neonates whose moms develop varicella within 5
    days before or 2 days after delivery
  • Preterm infants who are exposed to chickenpox in
    hospital
  • Susceptible pregnant women
  • Immunosuppressed adults and adolescents

48
Varicella-Zoster Immunoglobulin
  • Give within 48-96 hours post-exposure
  • IM route 125units/10kg up to 625 units
  • Newborns 125 units

49
Rotavirus Vaccine
  • RotaTeq
  • Viral gastroenteritis due to Rotavirus 2ml
    orally at 2 months, 4 months and 6 months of age
  • First dose between 6 and 12 weeks of age, with
    all doses received by 32 weeks
  • Should be separated by 4 to 10 week intervals
  • Should not start series in children gt 12 weeks of
    age

50
Respiratory Syncytial Virus Vaccine
  • Synagis
  • Prophylaxis 15mg/kg IM monthly during RSV season
    (November-April) for up to 5 doses
  • Who?-
  • Certain preemies
  • Certain infants and children with chronic lung
    disease
  • Certain infants and children with congenital
    heart disease

51
Anthrax Vaccine
  • Biothrax
  • Post exposure 0.5 ml sq immediately with repeat
    doses at 2 and 4 weeks in conjunction with
    chemoprophylaxis (Cipro 500 or doxycycline 100mg
    po bid)
  • Continue antibiotics until exposure is excluded
    or confirmed
  • If confirmed, continue therapy at least 14 days
    after 3 rd vaccine dose

52
Anthrax Vaccine
  • Chemoprophylaxis without vaccine is 60 days
  • Pre-exposure 0.5 ml sq x 3 doses at 0,2,and 4
    weeks. Followed by 3 additional doses at 6,12
    and 18 months.
  • Boosters every year
  • Not FDA approved for kids
  • Use different sq sites for sequential injections

53
Smallpox Vaccine
  • Dryvax
  • Intradermal administration only
  • Children 12moa and older- not part of routine
    vaccinations
  • Contraindicated in pregnancy

54
Combination Vaccines
  • Boostrix and ADACEL
  • Tetanus toxoid, reduced diphtheria toxoid and
    acellular pertussis
  • Infanrix-diphtheria tetanus toxoids acellular
    pertussis vaccine, adsorbed
  • Twinrix- Hep A and Hep B
  • Pediarix- diphtheria, petussis, tetanus, polio
    Hep B
  • ProQuad and MMRV- measles, mumps and rubella with
    varicella

55
Vaccines At St. Elizabeth Regional Health
  • Prevnar
  • Hibtiter, ActHib
  • Hepatitis immune globulin- NabiHib
  • Engerix B and Recombivax
  • Flulaval
  • MMR II
  • Menomune
  • Infanrix
  • ADACEL
  • Pneumovax 23
  • IPOL
  • Imogam Rabies HT
  • Rabavert
  • Meruvax II
  • DECAVAC
  • Tetanus toxoid/diphtheria adsorbed
  • Synagis

56
Link to Autism
  • No proof of a link
  • Suspect thimerosal/mercury used as a preservative
    in vaccines (especially the MMR Vaccine)
  • Why? Similarity between autism and symptoms of
    mercury poisoning

57
Specific Recommendations
  • Splenectomy patients
  • Pneumococcal, H flu, Meningococcal vaccines plus
    annual flu vaccine
  • HIV patients
  • Pneumococcal and annual flu vaccines
  • Community acquired pneumonia-prevention
  • Pneumococcal and annual flu vaccines

58
Under Investigation
  • Cancer vaccines- potential advantage of
    controlling systemic disease using the bodys own
    innate ability to destroy unwanted cells with
    minimal toxicity
  • Colorectal cancer - Breast cancer
  • Melanoma
  • Others
  • HIV/AIDS - TB
  • Plague - Alzheimer's
  • Lyme Disease - Bird Flu

59
References
  • Aberg JA, Gallant JE, Anderson J. et al. Primary
    Care Guidelines for HIV. CID 200439 (1
    September).
  • Bertino JS and MS Hayney. Vaccines, Toxoids, and
    Other Immunobiologics. Pharmacotherapy A
    Pathiophysiologic Approach. 5th ed. Dipiro, JT,
    Talbert, RL, and GC YEE, eds. New York Appleton
    and Lange 2002 2123-2142.

60
References
  • CDC Homepage. Resource on World Wide Web. URL
    www.cdc.gov. Available from Internet. Accessed
    2007 Jan 21.
  • Gardasil Home Page. Resource on the World Wide
    Web. URL www. Gardasil.com. Available from
    Internet. Accessed 2007 Jan 28.
  • Gardner P, Pickering LK, Orenstein WA. Quality
    Standards of Immunization. CID 200235 (1
    September).

61
References
  • Mandell LA, Wunderink RG, Anzueto, Antonio et al.
    IDSA/ATS Guidelines for CAP in Adults. CID
    200744 (Suppl 2).
  • Micromedex Healthcare Series. Resource on World
    Wide Web. URL www.thomsonhc.com Available from
    Internet. Accessed 2007 Jan 28.
  • Pharmacists Letter Home Page. Resource on World
    Wide Web. URL www.pharmacistsletter.com.
    Available from Internet. Accessed 2007 April 18.

62
References
  • Reisinger KS, Block SL, Laycano-Ponce E et al.
    Safety and Persistent Immunogenicity of a
    Quadrivalent Human Papillomavirus Types
    6,11,16,18 Virus. Journal of Pediatric Infectious
    Disease. 2007 26(3) 201-209.
  • TACA Home Page. Resource on World Wide Web.
    URL www.tacanow.com. Available from Internet.
    Accessed 2007 Jan 2007.
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