Module 1: Review of Selfstudy

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• Module 1 Review of Self-study
• Overview

OSU College of Pharmacy Immunization Delivery
Certification Program National Immunization
Program Centers for Disease Control and Prevention
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Principles of Vaccination

• Active Immunity
• Passive Immunity
• Antigen
• Antibody

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Vaccination

• Active immunity produced by vaccine
• Immunity and immunologic memory similar to
  natural infection but without risk of disease

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Classification of Vaccines

• Live attenuated
• viral
• bacterial

• Inactivated
• Whole
• Viruses
• Bacteria
• Fractional
• Protein based
• Toxoid
• Subunit
• Polysaccharide based
• Pure
• Conjugate

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• Principles of Vaccination

General Rule
The more similar a vaccine is to the
disease-causing form of the organism, the better
the immune response to the vaccine.
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Live Attenuated Vaccines

• Attenuated (weakened) form of the "wild" virus or
  bacterium
• Must replicate to be effective
• Immune response similar to natural infection
• Usually effective with one dose

Except those administered orally
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Live Attenuated Vaccines

• Severe reactions possible
• Interference from circulating antibody
• Fragile must be stored and handled carefully

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Live Attenuated Vaccines

• Viral measles, mumps, rubella,
  vaccinia, varicella, yellow fever, intranasal
  influenza, (oral polio, rotavirus)
• Bacterial BCG, oral typhoid

Vaccines in (parenthesis) are not available in
the United States.
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Inactivated Vaccines

• Cannot replicate
• Less interference from circulating antibody than
  live vaccines
• Generally require 3-5 doses
• Immune response mostly humoral
• Antibody titer diminishes with time

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Inactivated Vaccines
Whole-cell vaccines

• Viral polio, hepatitis A, rabies
  (influenza)
• Bacterial (pertussis) (typhoid) (cholera)
  (plague)

Vaccines in (parenthesis) are not available in
the United States.
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Inactivated Vaccines
Fractional vaccines

• Subunit hepatitis B, influenza, acellular
  pertussis, (Lyme) (HPV)
• Toxoid diphtheria, tetanus

Vaccines in (parenthesis) are not available in
the United States.
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Polysaccharide Vaccines
Pure polysaccharide

• pneumococcal
• meningococcal
• Salmonella Typhi (Vi)
• Haemophilus influenzae type b
• pneumococcal
• meningococcal

Conjugate polysaccharide
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Pure Polysaccharide Vaccines

• Not consistently immunogenic in children lt2 years
  of age
• No booster response
• Antibody with less functional activity
• Immunogenicity improved by conjugation

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Vaccine Schedules

• Reading Vaccination Schedules
• Adult vs. Pediatric Schedule
• Vaccine Timing Spacing Issues

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Reading Adult Pediatric Vaccination
Schedules/Records

• Use current schedule for appropriate age group
  from CDC check schedule date!
• Pediatrics
• - Locate column corresponding to childs age.
• - Count number of doses at or to left of that
  age to determine number of doses needed.
• - Compare doses needed to the number
  documented in the immunization record.
• - Read schedule footnotes/CDC updates.
• - Record any doses given in patient record.

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Adult Immunization Schedule
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Adult Recommended Immunization Schedule (By
Disease State)
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Pediatric Immunization Schedule
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Pediatric Immunization Schedule
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Issues Regarding Timing and Spacing of Vaccines

• Timing of antibody-containing blood products and
  live vaccines
• Simultaneous and nonsimultaneous administration
  of different vaccines
• Interval between subsequent doses of the same
  vaccine

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Antibody and Live Vaccines
General Rule

• Inactivated vaccines are generally not affected
  by circulating antibody to the antigen
• Live attenuated vaccines may be affected by
  circulating antibody to the antigen

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Antibody and Live Vaccines
Product Given First Vaccine Antibody
Action Wait 2 weeks before giving antibody
Wait gt3 months before giving vaccine (See
Table, Appendix A)
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Simultaneous Administration
General Rule
There is NO contraindication to simultaneous
administration of any vaccines.
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Spacing of Vaccine Combinations Not Given
Simultaneously
Combination Two live parenteral, or live
intranasal influenza vaccine All other
Minimum Interval 4 weeks None
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Spacing of Live Vaccines Not Given Simultaneously

• If two live parenteral vaccines, or live
  intranasal influenza vaccine, are given lt4 weeks
  apart the vaccine given second should be repeated
• Exception is yellow fever vaccine given lt4 weeks
  after measles vaccine

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Spacing Different Vaccines

• Two inactivated vaccines
• no minimum
• Inactivated live vaccines
• no minimum
• Two live vaccines, if not simultaneously
  administered 4 week minimum interval (Varicella,
  MMR)

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Intervals Between Doses
General Rule
Increasing the interval between doses of a
multidose vaccine does not diminish the
effectiveness of the vaccine Decreasing the
interval between doses of a multidose vaccine may
interfere with antibody response and protection
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Minimum Intervals and Ages
Vaccine doses should not be administered at
intervals less than the recommended minimum
intervals or earlier than the minimum ages
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Violation of Minimum Intervals or Minimum Age

• ACIP recommends that vaccine doses given up to
  four days before the minimum interval or age be
  counted as valid
• Immunization programs and/or school entry
  requirements may not accept all doses given
  earlier than the minimum age or interval

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Extended Interval Between Doses

• Not all permutations of all schedules for all
  vaccines have been studied
• Available studies of extended intervals have
  shown no significant difference in final titer
• It is not necessary to restart the series or add
  doses because of an extended interval between
  doses

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Vaccine Adverse Reactions

• Adverse reaction
• extraneous effect caused by vaccine
• "side effect"
• Adverse event
• any event following vaccination
• could be true adverse reaction
• could be only coincidental

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Vaccine Adverse Reactions

• Local
• pain, swelling, redness at site of injection
• common with inactivated vaccines
• usually mild and self-limited

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Vaccine Adverse Reactions

• Systemic
• fever, malaise, headache
• nonspecific
• may be unrelated to vaccine

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Live Attenuated Vaccines

• Must replicate to produce immunity
• Symptoms usually mild
• Occur after an incubation period(usually 7-21
  days)

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Vaccine Adverse Reactions

• Allergic
• due to vaccine or vaccine component
• very rare
• risk minimized by screening

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Contraindications and Precautions
Permanent contraindications to vaccination

• Severe allergic reaction to a vaccine component
  or following a prior dose
• Encephalopathy not due to another identifiable
  cause occurring within 7 days of vaccination

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Contraindications and Precautions
Live C --- C C P P
Inactivated C C V V P V
Condition Allergy to component Encephalopathy Pre
gnancy Immunosuppression Severe illness Recent
blood product
Ccontraindication Pprecaution Vvaccinate if
indicated MMR and varicella only
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Immunosuppression
Disease

• Congenital immunodeficiency
• Leukemia or lymphoma
• Generalized malignancy

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Immunosuppression
Drugs and Therapy

• Alkylating agents
• Antimetabolites
• Radiation

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Immunosuppression
Corticosteroids

• 20 mg or higher per day
• 2 mg/kg or higher per day, for 14 days or longer
• NOT aerosols, topical, alternate-day, short (lt14
  days), high-dose courses

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Special populations

• HIV infected children
• Hematopoietic stem cell transplant recipients
• Household contacts of immunosupressed persons

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Invalid Contraindications

• Minor illness
• Antimicrobial therapy
• Disease exposure or convalescence
• Pregnancy or immunosuppression in the household
• Breastfeeding
• Premature birth
• Non-vaccine-related allergies
• Nonanaphalactic allergy to vaccine component
• Family history (unrelated to immunosuppression)
• Need for TB skin testing

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Invalid ContraindicationsMinor Illness

• Low grade fever
• Upper respiratory infection
• Otitis media
• Mild diarrhea
• Only one small study has suggested decreased
  efficacy of measles vaccine in children with URI
• Findings not replicated by multiple prior and
  subsequent studies
• No evidence of increased adverse reaction

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Vaccination Screening Questions

• Does the patient have a copy of his/her
  immunization records?
• Is the patient sick today?
• Allergy to food, medication or vaccine?
• Serious reaction to a vaccine in the past?
• Has the patient had a seizure or a brain problem?

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Vaccination Screening Questions

• Does the patient have cancer, leukemia, AIDS, or
  any other immune system problem?
• Has the patient taken cortisone, prednisone,
  other steroids, or anticancer drugs, or had x-ray
  treatments in the past 3 months?
• Has the patient received a transfusion of blood
  or blood products, or been given a medicine
  called immune or gamma globulin in the past year?

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Vaccination Screening Questions

• Is the patient pregnant? Is there a chance she
  could become pregnant during the next month?
• Has the patient received any vaccinations in the
  past 4 weeks?

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Vaccination Screening Questions

• Standardized screening questionnaires are
  available from many state immunization programs,
  and from the Immunization Action Coalition
  website at lthttp//www.immunize.orggt

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Vaccination During Acute Illness

• No evidence that acute illness reduces vaccine
  efficacy or increases vaccine adverse reactions
• Vaccines should be delayed until the illness has
  improved
• Mild illness, such as otitis media or an upper
  respiratory infection, is NOT a contraindication
  to vaccination

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Always remember

• Know where to look up current information
• Guidelines change keep current!
• http//www.cdc.gov/vaccines
• APhA Immunizing Pharmacist Listserv
• Email mrothholz_at_aphanet.org