4. Medicine II_Adult Immunization_2014A

August 2, 2012

Adult Immunizations for Filipinos Dr. Solante

in the prevention of the common infectious diseases in our country. Outline: 1. Rationale for adult Vaccination Objectives 2. Classification of Vaccines 3. Contraindications/Precautions 4. Hepatitis B Vaccine 5. Tetanus-Diptheria Vaccine 6. MMR Vaccine 7. Varicella Vaccine 8. Influenza Vaccine Influenza H1N1 9. Pneumococcal Vaccine 10. Thypoid Fever Vaccine 11. Rabies Vaccine 12. Role of Passive Immunization 13. Routine Immunizations for Filipino Health Care Workers (HCW) 14.Summary

Note: Sir said we might not be able to find this topic in books; also he focused on the handout for adult immunization

RATIONALE FOR ADULT VACCINATION  Benefits of vaccination should be extended to adults o Starting immunization (never too late) o Updating immunization status  Adults are not invincible to vaccine preventable diseases o Increase exposure vs children o Presence of special populations at risk:  High risk adults with underlying co morbidities  Elderly o Adults at risk for acquiring and transmitting vaccine preventable diseases from other adults and children  We have 2012 guidelines coming this month, Sir said we’ll settle first with the 2009, but sir included from the 2012 guidelines, immunizations for health care workers, which is unique bec were the only country to give recommendations for individuals working in the hospitals  The rationale here is we want to protect any individual at risk of common infectious disease in our country. Thats the reason why you cannot find this in other articles because each country ahs specific immunization guidelines depending on the common infectious diseases in that particular country  You can decrease the transmission or vaccinepreventable diseases from other adults and children. Especially, doctors, interns, nurses, there’s a two way mode of transmitting infections. Either from you or the patient. So it is important to enumerate which vaccine will protect you and your patient.

OBJECTIVES To provide standards of care for the prevention of the common infectious diseases in the Philippines, with emphasis on the local epidemiology, vaccine dose, route, schedule, preparations and indication.  To be a useful reference of the practicing physicians, so as to be able to recommend the appropriate vaccines (J-group) K.A, KIMPOY and MAGSIE

Edited by: Constantino

CLASSIFICATION OF VACCINES  Before we go into the specific vaccines, we do classify vaccines as to its component, the ability to be immunogenic, the ability to induce antibodies, ability to protect, including the risk of complications, indications and contraindications

LIVE ATTENUATED VACCINES  Attenuated form of the virus or bacteria o What do you mean by live attenuated vaccine? You’re giving a vaccine for a particular infection, so you extract the microorganism causing the infection and you reduce it into a form into a less virulent form. This means you are mimicking an infection when you give this vaccine. When you give this vaccine, your immune system will produce an antibody.  Must replicate to be effective  Immune response similar to natural infection  Usually effective with one dose  Severe reaction possible  Interference from circulating antibody, unstable  Examples: Varicella, MMR, Yellow fever, Oral Typhoid -VoMYTting possible (severe reactions possible)

 For this group of vaccines, there is a possibility of sever on-site reactions; but the advantage of this vaccine is taht it usually takes only one dose for you to initiate antibody production  From 2014A trans o Examples: Trivalent Oral Polio, MMR (Measles, Mumps, Rubella), Chickenpox, BCG, Typhoid oral vaccine o Whole, non-pathogenic virus o After administration, viral replication occurs with little or no adverse host reaction o Replication of the virus in the vaccine is essential o Attenuated (weakened) form of the “wild” virus or bacteria o Immune response similar to natural infection o Usually effective with one dose

INACTIVATED VACCINES      

Not live and cannot replicate Minimal interference from circulating antibody Generally not as effective as live vaccines Generally requires 3-5 doses Immune response mostly humoral Antibody titer falls over time o Give additional doses when it falls to ineffective levels o Need to give boosters  These vaccines are not coming from live organisms and cannot replicate.That is why you need to give three doses. There is a cumulative antibody response with the second and subsequent doses. Because this vaccine is not live, immune response is mainly humoral. So you rely on the titer of the antibody. So you have to give additional doses, bec there will come a time wherein the antibody titer will not be in the protective titer. So that is why you need 1 of 7

to give another vaccine to boost the antibody production.  Examples: Hepatitis A/B, Influenza, Pneumococcal, Meningococcal, TetanusDiptheria -HIP MDs inactivate infections  From 2014A: o o

o o o

o

Viral - influenza, polio SALK, rabies vaccine Verocell, duck embryo vaccine Bacterial – pertussis, pneumococcal conjugate and polysaccharide, H. Influenza, Hib, meningococcal polysaccharide, yellow fever, typhoid Vi capsular Organisms cannot replicate Requires sufficient amount of antigenic mass to induce the desired immune response Inactivated vaccines are not alive and cannot replicate. The entire dose of antigen is administered in the injection. These vaccines cannot cause disease from infection, even in an immunodeficient person. Inactivated antigens are less affected by circulating antibody than are live agents, so they may be given when antibody is present in the blood (e.g. in infancy or following receipt of antibody-containing blood products). Inactivated vaccines always require multiple doses. In general, the first dose does not produce protective immunity, but “primes” the immune system. A protective immune response develops after the second or third dose. In contrast to live vaccines, in which the immune response closely resembles natural infection, the immune response to an inactivated vaccine is mostly humoral. Little or no cellular immunity results. Antibody titers against inactivated antigens diminish with time. As a result, some inactivated vaccines may require periodic supplemental doses to increase, or “boost,” antibody titers.

CONTRAINDICATIONS AND PRECAUTIONS

C- Contraindication

P-Precaution V-Vaccinate if indicated

 Do not give it to pregnant women bec it may induce teratogenic effects and infections. Do not give to immunocompromised hosts because it can induce infections, you cannot give to patients who are allergic to the vaccine.  Severe illness and recent blood product are the most common misconceptions. Illness is not a contraindication even in the presence of fever. So is any transfusion of blood products.

 Uncommonly known is the contraindication of inactivated vaccines in patient with encephalopathy

SCREENING QUESTIONS Important to remember to ASK:  Feeling ill?  Allergies to food? Or medicines / vaccines?  Received vaccine within the past 4 wks?  Co-morbid problems? o Cancer - immunosuppressive treatment?  Other drugs taken now?  Previous illnesses? o History of seizures?  Blood transfusion?  For women: Pregnant?

HEPATITIS B VACCINE PREVALENCE

 In 1997, the Philippines is included in the geographic pattern of >8% for HBsAg carriers. A law was then made in the Philippines that all babies born should automatically receive Hepatitis B vaccine. This is because infection with Hepatitis B is a common cause of hepatic carcinoma  HBsAg positivity prevalence : 2% to 16.5%, with an average of 12% in a study of rural villagers (Lansang, Gut 1996)  5-16%, with two age-specific incidences: o 55-68% among 3-4 y.o.  More common among 3-4 y/o are hepatitis carriers  comes from mothers that did not know they were Hepatitis B carriers.  If you are pregnant, before you will deliver you have to screen for HIV, hepatitis B, hepatitis C and Syphilis  Screen all women for HepB along with other TORCHS infections (e.g. HIV) o 5-16% among 30-40 y.o. (Guan, Sollano et al, J Gastro & Hepatol, 2000)

INDICATIONS (J-group) K.A, KIMPOY and MAGSIE

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Routine Universal immunization of all:  Infants  Adolescents  Adults

Special Situations Strongly recommended in subjects who are at increased risk of exposure:  Health care personnel  Patients receiving frequent blood transfusions or clotting factor concentrates (hemodialysis and oncology units)  Organ transplant recipients  Thalassaemics, sickle-cell anemics, cirrhotic and hemophiliacs  anemic, cirrhotic and hemophiliacs.  Personnel and residents of institutions  Persons at increased risk due to their sexual practices (persons with multiple partners, STD patients, prostitutes, homosexually active males)  Illicit users of addictive injectable drugs  Travelers to high endemic areas  Infants born of mothers who are carriers  Police, brigade, and armed forces personnel  Household contacts of any of the above groups  College entrants to healthcare associated courses

o Patients at high risk o e.g. dialysis, immunodeficient patients o Certain health care workers IMMUNOGENICITY, EFFICACCY, REACTOGINICITY of HB Vaccine  In healthy persons, the duration of immunity after primary immunization is at least 15-20 years (the period since implementation of HB vaccine)  Currently no recommendation for routine booster immunization  The vaccine is highly effective in preventing acute and chronic HB disease, the vaccine is considered the first anti-cancer vaccine (prevention of primary liver cancer)

Management of Nonresponse to HepB vaccine

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SCHEDULE Route: Intramuscular A. Conventional: 3 doses:  0,1,6 months or: B. Rapid schedule of Administration :4 doses:  0,1,2,12 months C. Very Rapid Schedule Of Administration  0; 7 ; 21 days + 12 months  The difference here is you will be giving 4 doses  Booster is not routinely recommended; once you received any of these regimens, booster is not recommended bec that will be protective for a long period of time

POST IMMUNIZATION SEROLOGIC TESTING  Because 95% of healthy persons will develop protective anti-HBsAg titers, testing following immunization is not recommended in case of routine immunization of infants, children, adolescents, or most adult  Testing following immunization is recommended for o Infants born to HBsAg+ mothers o Why? Because if they don’t develop the antibodies that means they are carriers of hepatitis B (J-group) K.A, KIMPOY and MAGSIE

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What about for those who you try to elicit antibodies, but you don’t get an antibody response? Complete a second series of three doses Should be given on the usual 0,1 and 6 months Test 1 to 2 months after completing the second series Persisten NonResponse to Hep B Vaccine If patient was given the second series of three doses and there is still no response: do not repeat anymore. o There may be a possibility that the immune system is not adequate causing the nonresponse. < 5% of vaccinees do not develop anti-HBsAg after 6 valid doses May be nonresponder or “hyporesponder” o They may have the antibody but it is detected based on threshold of detection Check HBsAg status o If and when you do not develop antibodies, and you are in an endemic country, chances are you may also be a carrier of hepatitis B If exposed, treat as nonresponder with postexposure prophylaxis

[Notes from Dr. Dimla’s lecture last year:] Hepatitis B vaccine:  induces specific humoral response (anti-HBs antibodies)  antibody titre level of 10 IU correlates with protection to HBV infection  PP: protective efficacy is at ≥96% for those who followed the 0,1,6 schedule

TETANUS-DIPTHERIA TOXOID  Inactivated vaccine, Intramascular (IM)  A vaccine with both tetanus and diptheria toxoid  Diptheria is commonly acquired among health care workers in the hospital, through respiratory

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route. So when you give your tetanus, you have to combine it with your diptheria.

doses >3 doses No1 No 1 Yes, if >5 years since last booster 2 Yes, if >10 years since last booster

Target Individuals  Recommended for all susceptible adults particularly: a. pregnant women b. healthcare workers  It is recommended for susceptible adults especially pregnant womens and healthcare workers.

Schedule

Precautions/Contraindications  Severe allergic reactions to vaccine component or following prior dose  Moderate to severe illness

Wound Classification

MMR (Measles, Mumps, Rubella) VACCINE  Live Attenuated Vaccine (LAV), Subcutaneous (SQ)  Given to adults without documentation of previous infection or those who were not previously immunized. o Rubella vaccine important for nonpregnant susceptible women of childbearing age

Risk  Travelers who are not fully immunized against measles are at risk when visiting countries or areas where vaccine coverage is incomplete  All susceptible adolescents and adults without documented evidence of immunity to any one of the components (especially non-pregnant women of childbearing age) Schedule  Given in 2 doses  0,1 month Contraindications  Severe allergic reaction to a vaccine component or to a previous dose  Moderate or severe acute illness  Pregnancy  Immunosuppression

Tetanus Prophylaxis in Routine Wound Management

Uncertain or 13 years - 2 doses’ 1 month apart

Contraindications  Severe allergic reaction to a vaccine component (gelatin or neomycin) or to a previous dose  Moderate or severe acute illness  Pregnancy  Immunosuppression  Recently received a blood product  Untreated active tuberculosis  Adolescents in aspirin therapy

INFLUENZA VACCINE  One of the most common vaccine  Dependent on the strain available and common in that country  Vaccine from one country is different from other country  INACTIVATED VACCINE containing 3 strains (2 type A and 1 type B), Intramuscular (IM)

Indications

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TARGET INDIVIDUALS: Recommended for all adult particularly:  Persons >13 years of age without history of varicella infection or vaccination  All health care workers  Teachers of young children o For them not to transmit the disease to their students Non-pregnant women of childbearing age o Because of complications of varicella during pregnancy International travelers Military \ POST EXPOSURE PROPHYLAXIS  Given within 72 hours after history of previous varicella vaccination.  Especially to the healthcare workers who have been taking care of patients positive for varicella, and you have not been vaccine or (J-group) K.A, KIMPOY and MAGSIE

Edited by: Constantino

INFLUENZA ETIOLOGIC AGENT:  Influenza virus o 3 virus strains in the Phils:  type A; moderate to severe illness  type B: milder illness  type C: rare  In the phils, we have type a and type b. And type a is the one causing the severe type of flu THE DISEASE:  incubation period: 1-3 days  causes fever, chills, myalgia, cough and sore throat  complications: pneumonia, may lead to death in immuno-compromised

EPIDEMIOLOGY

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 Occurrence of flu is usually indicated and pacified according to: a)Southern Hemisphere b)Tropical c) Northern Hemisphere.  Eg: If you are in northern hemisphere there are TWO occurrence of flu per year, on the first and on the last quarter of the year.  If in tropical, it occurs in middle and last part of the year.  If in the southern hemisphere, there is only one peak season of flu and that is in the middle part of the year.  Which among the hemisphere do Philippines belong? It’s not the tropical hemisphere but the SOUTHERN hemisphere where Philippines belong, because every month RITM collects data among patients with flu, and occurrence of flu peaks on May, June, July, August and September. If you want to receive your vaccine, you have to receive it on the first quarter of the year, but it is usually available during month of March and April.

Influenza in the Philippines  One of the leading causes of morbidity o Causes of consultation and hospitalization  4th in 2005, 5th in 2006  650 to 1220 per 100,000 cases  500, 000 to 700,000 cases every year  One out of 100 Filipinos gets sick of influenza every year- DOH  Peak incidence: July – October  INACTIVATED VACCINE containing 3 strains (2 type A and 1 type B) o Current recommendation (in the Philippines) is to use Southern hemisphere formulation

Complications  Bacterial superinfections o Bacterial pneumonia o Respiratory disorders  Most common is viral etiology  Decompensation of chronic diseases o Pulmonary disease o Heart disease o Renal insufficiency o Metabolic disease

INFLUENZA VACCINE EFFICACY  One of the highly indicated, highly used vaccine in our country  Vaccine’s benefit: preventing hospitalization and death o Reduces hospitalization: 50-70% o Reduces death: 50-85% (J-group) K.A, KIMPOY and MAGSIE

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Reduces illness: 30-70% Reduces lower respiratory involvement: 70-90%

tract

Indications of Influenza Vaccine Routine  Individuals > 50 years of age  Anyone who wants to reduce the chance of falling ill  International travelers  Persons providing essential services  Students or other persons in institutional settings Special Situations  Persons at high risk for severe flu or complications o Residents of chronic care facilities and nursing home o Those with chronic cardiovascular disorders (hemodynamically significant cardiac disease) o Those with chronic pulmonary diseases (including asthma) o Those with chronic disorders:  Diabetes mellitus  Renal dysfunction  Hemoglobinopathies  Other chronic metabolic disorders o Those who are immunocompromised  HIV/AIDS  Immunosuppressed due to medications o Those pregnant in the 2nd or 3rd trimester o Those who can transmit influenza to those at risk for complications  Household members of persons in high-risk group  Physicians, nurses and other healthcare workers who come in contact with patients  Healthcare workers in nursing homes and chronic care facilities who come in contact with patients

Schedule and Dosing  Annually o Preferably from February – June (local)  Peak season – July to October  Formulation for the Southern Hemisphere o Preferably from October – November (CDC)  Influenza season from December – March  Formulation for the Northern Hemisphere  1 dose given INTRAMUSCULARLY o for Immunocompromised: 2 doses at least 4 weeks apart

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 When given, mild local and/or systemic reactions are common o The reason why some people wouldn’t want to receive influenza vaccine

PNEUMOCOCCAL VACCINE  There are two types of pneumococcal vaccine: o 23 valent polysaccharide vaccine o 13 valent conjugate vaccine

THE DISEASE    

types and brand names of influenza vaccine

Etiologic agent: Streptococcus pneumoniae incubation period: 1-3 days Pneumonia: cough, fever, pleuritic chest pain Invasive disease includes bacteremia, meningitis, endocarditis o The vaccine is given not only for pneumonia but also for invasive diseases that can cause bacteremia and meningitis  Transmission: through droplet transmission  Epidemiology: worldwide

VACCINE

CONTRAINDICATIONS  Any prior anaphylactic reaction to vaccine or components (e.g., egg)  History of GBS

H1N1 NOVEL INFLUENZA VIRUS VACCINE  Monovalent type, but the current flu vaccines available now contains this H1N1, type A and Type B.  If you received this vaccine, you will be protected from the three stated above *IN PPT but Not discussed:  Target groups: o Pregnant women o Persons who live with or provide care for infants aged < 6 months (e.g., parents, siblings, and daycare providers) o Health-care and emergency medical services personnel o Persons aged 6 months - 24 years o Persons aged 25 - 64 years who have medical conditions that put them at higher risk for influenza-related complications  Current formulation *H1N1 novel influenza virus: o Southern hemisphere (2010)  A/California/7/2009 (H1N1)-like virus  A/Perth/16/2009 (H3N2)-like virus  B/Brisbane/60/2008-like virus o Northern hemisphere (2009-2010)  A/Brisbane/59/2007 (H1N1)-like virus  A/Brisbane/10/2007 (H3N2)-like virus  B/Brisbane/60/2008-like virus o Northern hemisphere (2010-11)  A/California/7/2009 (H1N1)-like virus  A/Perth/16/2009 (H3N2)-like virus  B/Brisbane/60/2008-like virus (J-group) K.A, KIMPOY and MAGSIE

Indication  Routine Use o Age > 50 years o 23-valent NOT for routine use in children o 13 valent conjugate: use in children less than 2 years  Special Situations: o For Patients at High Risk of Invasive disease (seen in): 1. Functional or anatomic asplenia 2. Patients with chronic illnesses: a. chronic cardiovascular disease b. chronic pulmonary disease c. diabetes mellitus d. alcoholism e. chronic liver disease (including cirrhosis) 3. Cerebrospinal fluid leaks 4. Immunocompromised persons a. HIV/AIDS, lymphoma, leukemia, multiple myeloma, malignancy b. chronic renal failure or nephrotic c. those receiving chemotherapy, including corticosteroids d. solid organ or bone marrow transplant 5. Those living in special environments which put them at risk: a. military recruits b. nursing home residents 6. Smokers: latest addition to the guidelines

Schedule  Single dose IM or SQ 0.5 ml dose

Booster Doses  Not routinely recommended  May be given to the following: o Those > 65* years who received their first dose > 5 yrs ago and before they reached age 65

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o

Persons < 64 years who received the vaccine > 5 yrs ago and who have the following:  Asplenia  HIV, leukemia, lymphoma, malignancy, multiple myeloma  chronic renal failure or nephrotic syndrome  receiving immunosuppressive therapy  received solid organ or bone marrow transplant

o immunocompromised o pregnant women  Parenteral vaccine o children below 2 years old o persons with bleeding disorders o immunocompromised persons o pregnant women o intradermally

Contraindications   

An immediate anaphylactic reaction to a previous dose of pneumococcal vaccine Moderate or severe acute illness with or without illness Allergy to a vaccine component

TYPHOID FEVER THE DISEASE  One of the common cause of infection in the Philippines. There is a surge of typhoid especially in children  Etiologic Agent: Salmonella typhi  Incubation period: 1-3 weeks  Insiduous onset, prolonged fever, headache in 70% of cases  diarrhea or constipation, abdominal discomfort, malaise, anorexia, vomiting  Complications: intestinal perforation, encephalitis,septicemia  Transmission: fecal oral route, ingestion of contaminated food

Epidemiology    

Endemic in the Philippines morbidity 30.5/100,00 population mortality 1.7/100,000 outbreak of Chloramphenicol, TMP/SMX resistance in 1993-94

THYPOID FEVER VACCINE Indications Routine:  Hospital personnel involved in food handling: most important  Microbiology lab technicians  Persons with intimate exposure to a documented S. typhi carrier/patient  Any person who wants to get protected

Precautions and Contraindications  Oral vaccines: Should NOT be given to o children below 6 years of ag o patients with diarrhea or vomiting o patients taking antibiotics within 7 days o persons taking anti-malarial prophylaxis (J-group) K.A, KIMPOY and MAGSIE

RABIES  High rate of Rabies in the country led to presence of animal bite centers.  HDCV- Human diploid cell vaccine  PVRV- purified vero cell rabies vaccine  PDEV- purified duck embryo vaccine  PCECV – purified chick embryo vaccine Intramuscular / Intradermal  What were using now are the PVRV and HDCV. The advantage of PVRV you only give a very low amount f the vaccine,0 .5 ml, this is also costeffective

Schedule  Primary: series of 3 injections on days 0,7,21 or 28  Intramuscular: on the deltoid o PVRV - 0.5 ml o PCECV, HDCV, PDEV – 1.0 ml.  Intradermal-on the deltoid o PVRV, PDEV, PCECV – 0.1 ml.  Some give intra-dermal because of the dose, you only need 0.1 mL. That is why most people go to San Lazaro or RITM, or East Ave because most of the health care personnel there are trained to give it intradermally. So the cost of the vaccine is lower, because with one vial you can give the vaccine to at least 5 patients, unlike in the IM route.  Booster-single dose IM or ID every 2 years  For post-exposure prophylaxis- refer to Standard guidelines

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Routine: Pre-exposure vaccination  Healthcare workers in hospitals that handle dog bites and rabies  Rabies research and diagnostic lab workers  Rabies biologic production workers  Veterinarians and vet students  Field workers (bill collectors, mailman, delivery man)

 It is recommended that all adults be immunized against DPT, Hepatitis B, Varicella, MMR, Influenza and Pneumococcal disease with Typhoid and Rabies vaccines as additional vaccines for HCWs  All HCWs should be included in these recommendations  Susceptibility to serious infections increases as we grow older, especially among those with underlying problems or comorbidities.

Routine: Post-exposure vaccination  All persons exposed to rabid and or suspect rabid animals categorized as follows: o Category I : touching or feeding of animal , licks on broken skin o Category II : nibbling of uncovered skin, minor scratches or abrasion without bleeding, licks on broken skin o Category III: single or multiple transdermal bites or scratches, contamination of mucous membranes with saliva, all category II exposures in the head, face or neck

ROLE OF PASSIVE IMMUNIZATION Immune globulins are administered to:  All patients with category III exposure  All category II exposure patients who are immunocompromised

Recommended Immunizations for Filipino Health Care Workers (HCW) 2012  Healthcare workers (HCW) are commonly exposed to infectious agents and are possible vectors for spread of infectious disease to patients  Minimizing the risk of disease acquisition is based on strict adherence to three key recommended interventions: 1) Appropriate hand hygiene 2) Rapid institution of appropriate isolation precautions for patients with known on suspected communicable diseases 3) Appropriate immunizations

Vaccines Recommended for HCW’s  General recommendations for Adults with additional vaccines for health care workers have been published by PSMID

(J-group) K.A, KIMPOY and MAGSIE

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Explanation for the figure on the last page: On the first row (white) are a list of vaccines: 1st column: tetanus diphtheria accecular pertussis vaccine (Tdap), 2nd column: HepB vaccine, 3rd column: Influenza vaccine, 4th column: Varicella Vaccine 5th column: Measles Mumps Rubella Vaccine, 6th column: Pneumococcal Polysaccharide Vaccine, 7th column: Rabies Vaccine,  2nd row (yellow) are a list of jobs requiring first line vaccines: Barangay health workers, Clinical pharmacist, Doctors, Nurses, Nursing aides, Phlebotomist, Pulmonary therapist, Rad tech, Students on clinical rotation  3rd row(yellow): Support Services (Hospital Based) Admitting, Ambulance driver, Dietary nutritionists, Engineering, Info-tech personnel, Janitorial services, Lab personnel, Linen, Morgue, Office workers, Pharmacist Public health specialist, security, social workers, other med personnel Pink= strongly recommended Green= Recommended if they want it Blue= recommended (selected) SUMMARY Approprite protection, through proper vaccinations, could reduce the risk of infections, lower down the likehood of hospitalization and decrease antibiotics

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(J-group) K.A, KIMPOY and MAGSIE

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