Immunizations

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Immunizations

• MAJ Christine Lettieri
• Dewitt Army Community Hospital
• The Capital Conference
• 5 June 2007

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Overview

• Infant and toddler
• Young child
• Pre-teen
• Adults
• Geriatric patients
• Special considerations

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Infant and Toddler Vaccinations

• You are the Clinic Preceptor and one of your
  interns come to staff a 2 month old well baby
  check. He looks thoroughly confused when
  attempting to decipher what shots the infant
  needs today..

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Infant Immunizations

• Hepatitis B
• Diptheria, Tetanus, Pertussis
• Haemophilus influenza type B (Hib)
• Pneumococcal
• Rota Virus
• Influenza
• MMR
• Varicella
• Hepatitis A

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Hepatitis B Vaccination

• All newborns prior to discharge
• Infants of infected mothers (HBsAg ) -Hepatitis
  B 1
• -0.5ml of hepatitis B immune globulin
• -Separate sites
• -Within 12 hours of birth

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RotaTeq

• Rota virus is responsible for 40-50 of all
  pediatric diarrhea admissions
• Live, oral vaccine
• Licensed in February 2006
• 3 doses at 2, 4, and 6 months
• All 3 doses by 32 weeks

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RotaShield

• Introduced in 1999
• Increased risk of intussusception
• 70,000 patients testing current vaccine without
  increased rates of complications

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Influenza Vaccination

• Previously, children from 6 to 23 months
• 2007- 6-59 months (5 years)
• All children close contacts of all children
  from 0-59 months
• ½ dose from 6-36 months
• Initial dose only- second shot at 4 weeks

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Hepatitis A Vaccination

• New in January 2006 guidelines for all children
• Previously only high risk groups
• Recommended at 12 months
• 2 shot series, initial with repeat in 6-12/18
  months

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Young Child Immunizations

• Another resident comes to the preceptor room with
  a 5 year old girl for a kindergarten school
  physical. She received her shots at age 4 and
  her mother has assured her that she does not need
  any more today..

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Young Child Immunizations (4-6 years)

• DTaP 5
• IPV 4
• MMR 2
• Varivax 2
• Hepatitis A series if not previously given
• Annual influenza

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Revised Varivax Recommendations

• Updated in 2007
• Initial shot at 12-15 months
• Booster at 4-6 years
• May receive prior to 4-6 years - 3 months
  since first dose
• - Both doses 12 months of age

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Influenza

• Inactivated injection
• Live intranasal mist (FluMist)
• Age range- 5-49 years
• 2 shot series for initial vaccination of either
  IM or intranasal form

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LAIV (FluMist) Contraindications

• -Hypersensitivity to eggs
• -Children on aspirin therapy or aspirin
  containing therapy
• -History of Guillain-Barre syndrome
• -Known or suspected immune deficiency
• -Pregnancy
• -Chronic underlying medical conditions- asthma,
  COPD, diabetes
• -Close contacts of immunosuppressed individual

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Pre-Teen Immunizations

• A 12 year old female presents to you for her
  required sports physical for soccer. At this
  appointment, her mother has multiple questions
  regarding whether she should receive the HPV
  vaccine

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Pre-Teen Immunizations

• 2007 Guidelines
• Tdap
• HPV (Gardasil)
• MCV4- Meningococcal vaccine

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Tdap

• Protection against tetanus, diphtheria, pertussis
• Licensed in 2005
• First vaccine offering protection against all 3
  for adolescents and adults
• 25,000 US cases of pertussis in 2004
• Childhood immunity fades over time

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HPV Vaccine

• Gardasil
• Non-infectious HPV-like particles
• Serotypes 6,11,16,18
• 70 of cervical cancers
• 90 of genital warts
• Tested in 11,000 females to date
• Nearly 100 efficacy in prevention of
• pre-cancerous lesions

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HPV Vaccine

• 3 shot series
• 0,2,6 months
• Range- 9 to 26 years
• Recommended at 11-12 years
• Prior to age 18 if missed earlier target

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Meningococcal Vaccine

• 2005 Recommendations
• Pre-adolescent- 11-12 years
• High school entry
• Others- college freshmen living in dorms,
  microbiologists, military recruits, travelers to
  endemic areas- especially travel to Mecca,
  asplenia

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Adult Immunizations

• Tetanus booster- Td or Tdap
• Every 10 years
• Tdap in place of one booster dose of Td
• Adults with close contact of infant of age
• Postpartum mothers
• Healthcare workers
• 2 years after last Td suggested but not required

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Geriatric Immunizations

• You are doing a routine physical on a 65 year old
  male. You inquire about shots and with the
  exception of his flu shot which he diligently
  receives annually, the last time he received
  others was when he retired from active duty 20
  years ago

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Geriatric Immunizations

• Td or Tdap booster
• Pneumococcal Vaccine
• Shingles Vaccine

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Pneumococcal Vaccine

• Pneumovax
• Contains mixture of 23 types
• Over 65 years of age
• Consider booster after 5- 10 years

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Shingles Vaccine

• Zostavax
• Licensed 25 May 2006
• More potent Varivax
• General Statistics
• Lifetime risk of 30
• At age 85, approximately 50
• 10-33 risk of postherpetic neuralgia

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Shingles Vaccine

• Adults 60 years
• Limited data for use in pts 80 years old
• One time dose
• Approximately 150
• Unknown length of protection
• Studies demonstrated a greater than 50 reduction
  in number of cases
• 60 reduction in postherpetic neuralgia

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Contraindications to Shingles Vaccine

• Live vaccine
• HIV/AIDs
• Immunocompromised by medication (MTX, chronic
  steriods) or by other condition
• Cancer treatment- chemotherapy, radiation
• History of leukemia, lymphoma
• Pregnant
• Active, untreated TB

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Special Considerations

• Catch-up immunization schedules
• Pneumococcal vaccine
• Anatomic or functional asplenia
• Pregnancy

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Catch Up Schedules

• Separate catch up schedules -0-7 years
• -7-18 years
• Accelerated schedules
• Require at least 4 week intervals
• Hib, Pneumococcal vaccines are not recommended
  for healthy children 5 years

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High Risk Individuals for Pneumococcal Vaccine

• Chronic pulmonary disease- excluding asthma
• Cardiovascular disease
• Diabetes
• Chronic liver disease- including ETOH
• Chronic renal failure/nephrotic syndrome
• Functional/ anatomical asplenia
• Immunosuppression- HIV- at time of diagnosis,
  leukemia, lymphoma, bone marrow or organ
  transplantation, long term corticosteriods
• Alaska Natives
• Residents of nursing homes, long term care
  facilities

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Pneumovax Booster Guidelines

• One-time revaccination
• Consider 5- 10 years
• High risk individuals
• -Meet all 3 conditions
• 1- Initial vaccination 5 years ago
• 2-
• 3- Currently 65 years of age

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Asplenia

• Anatomic or functional
• Particular risk with encapsulated organisms
• Pneumococcal vaccine
• Meningococcal vaccine
• Hib
• Annual flu vaccine

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Pregnancy

• Avoid live vaccines
• High risk for influenza
• Influenza in any trimester

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Summary

• Age appropriate vaccinations
• General overview
• Updated new recommendations
• Resources