ADULT IMMUNIZATION

ADULT IMMUNIZATION “What Family Physicians Need to Know” Dr. Marie Andrades Senior Instructor Family Medicine ADULT IMMUNIZATION Under emphasized and under appreciated Under utilized Important preventive strategy to decrease morbidity and mortality ADULT IMMUNIZATION Recommendation ROUTINE Tetanus and Diptheria ( Td ) Pneumococcal ( Age >65 ) Influenza ( Age >50 ) Hepatitis B MISSED CHILDHOOD VACCINES Mumps, Measles and Rubella ( MMR ) Varicella ADULT IMMUNIZATION Other vaccines when indicated Hepatitis A vaccine Polio BCG Meningococcal Typhoid Rabies Yellow fever Anthrax Plague Hib ADULT IMMUNIZATION In Special Cases Pregnancy Lactation Health care workers Animal handlers HIV positive patients Immunocompromised states ADULT IMMUNIZATION General Guidelines Administration of multiple vaccines Immunoglobulins combined with Toxoids Inactivated vaccines Polysaccharide vaccines Live virus vaccines ADULT IMMUNIZATION Assessment History of previous immunization Hypersensitivity reactions to vaccine or their component Specific allergies Acute febrile illness Contraindications to live vaccine ADULT IMMUNIZATION Hepatitis B Vaccine Case Study Correct A 22 year old patient comes to the clinic for advice. He has missed his last dose of Hepatitis B vaccination which was due 4 months back. Should he repeat the series? ADULT IMMUNIZATION Hepatitis B Vaccine Recombinant DNA vaccine Dose. 1 ml I/M in deltoid at 0, 1 and 6 months Booster dosing and serological testing High risk group: Test for AntiHBs 1-4 months after completion of series Poor responders: AntiHBs 10-100mIU/ml Non responders: Anti HBs < 10mIU/ml ADULT IMMUNIZATION Hepatitis B High Risk Group Health care professionals Homosexuals Family member or sexual partner of chronic hepatitis B carrier Prostitutes Drug abusers Patient frequently receiving blood or its products Patients with chronic renal failure Travelers ADULT IMMUNIZATION Hepatitis B Decreased Immunological Response If given in the gluteus muscle (needle length important) Immunodeficient Smokers Elderly Obese Chronic renal failure ADULT IMMUNIZATION Hepatitis B Adverse Effects Pain Rash Fever > 37.7 C Influenza like syndrome Arthritis, arthralgia, myalgia ADULT IMMUNIZATION Case Study • Correct A final year medical student presents with a history of needle stick injury a few hours ago while giving an injection to a patient. The patient’s Hep B status is not known. What advise would you give to this student who is not vaccinated? ADULT IMMUNIZATION Hepatitis B Percutaneous Exposure Source Unvaccinated Vaccinated ADULT IMMUNIZATION Hepatitis B Percutaneous Exposure Source HBs Ag+ Unvaccinated Vaccinated HBIG 0.06ml/kg Test for Anti HBs Begin HB vaccine If inadequate HBIG + Vaccine series series ADULT IMMUNIZATION Hepatitis B Percutaneous Exposure Source HBs Ag+ Unvaccinated Vaccinated HBIG 0.06ml/kg Test for Anti HBs If inadequate Begin HB vaccine HBIG + Vaccine series series Nothing required Unknown Begin HB vaccine series source ADULT IMMUNIZATION Tetanus Diphtheria (Td) Vaccine Toxoids Dose: 0.5 ml I/M at 0, 1 and 6-12 months Seroconversion 100% Booster 10 yearly ADULT IMMUNIZATION Tetanus Diphtheria (Td) Vaccine Adverse Effects Persistent nodule Pain, redness swelling Headache, lethargy, malaise, myalgia Urticaria, anaphylaxis ADULT IMMUNIZATION Case Study • Correct A 30 year old is brought to the clinic after a road traffic accident in which he has sustained laceration of his leg. On questioning he says that he has received all his childhood immunizations. How would you manage this patient? ADULT IMMUNIZATION Tetanus prophylaxis in wound management TT Immunization Clean Minor Wound T.T TIG Large Dirty Wounds T.T TIG T.T Tetanus Toxoid TIG Tetanus Immunoglobulin ADULT IMMUNIZATION Tetanus prophylaxis in wound management TT Immunization Clean Minor Wound T.T None, incomplete, Unknown TIG Large Dirty Wounds T.T TIG Begin Pre Exp Series No Yes Yes T.T Tetanus Toxoid TIG Tetanus Immunoglobulin ADULT IMMUNIZATION Tetanus prophylaxis in wound management Clean Minor Wound T.T Begin Pre Exp Series Booster TIG No TT Immunization Large Dirty Wounds T.T Yes TIG Yes None, incomplete, Unknown Last booster >5 years No Yes Yes T.T Tetanus Toxoid TIG Tetanus Immunoglobulin ADULT IMMUNIZATION Tetanus prophylaxis in wound management TT Immunization Clean Minor Wound T.T Begin Pre Exp Series Booster No TIG No Large Dirty Wounds T.T Yes TIG Yes None, incomplete, Unknown Last booster >5 years Complete Last booster within 5 years No No Yes No Yes No ADULT IMMUNIZATION Mumps, Measles & Rubella Vaccine Live attenuated vaccine Dosage: 0.5 ml subcutaneous Seroconversion 95% Lifelong immunity ADULT IMMUNIZATION Mumps, Measles & Rubella Vaccine Adverse Effects Fever Rash Arthralgia Lymphadenopathy ADULT IMMUNIZATION Case Study Correct A 32 year old lady, 8 weeks pregnant presents with a history of recent exposure to German Measles. On inquiring she reveals that she was immunized with MMR after the birth of her first child. What would you advise this patient? ADULT IMMUNIZATION Rubella Exposure All pregnant women with suspected rubella or exposure to rubella must be investigated serologically irrespective of a history of rubella immunization, clinical rubella or previous positive rubella antibody result ADULT IMMUNIZATION Case Study What immunization would you recommendfor a 55 year old patient with congestive cardiac failure and no previous immunization? Correct ADULT IMMUNIZATION Influenza Vaccine Inactivated trivalent vaccine Dosage: 0.5 ml I/M yearly usually October Efficacy: 70-90% in healthy subjects <65 In elderly, prevents disease in 30-40% and death in 80% ADULT IMMUNIZATION Influenza Vaccine Indications Healthy adults > 50 Residents of nursing homes Chronic respiratory, heart and renal disease Immunosuppressed including diabetics Health care workers Travelers ADULT IMMUNIZATION Pneumococcal Vaccine Polyvalent vaccine Dosage: 0.5 ml I/M Single booster after 5 years Efficacy: Prevents disease in 70% of immunized adults ADULT IMMUNIZATION Pneumococcal Vaccine Indications Healthy adults >65 Comorbids Asplenia or splenic dysfunction Chronic heart, lung or liver disease Chronic renal disease including nephrotic syndrome Immunosuppressed states including DM and HIV positive individuals ADULT IMMUNIZATION Typhoid Vaccine Monovalent whole cell Typhoid vaccine 2 doses 4-6 weeks apart Booster 3 yearly Typhoid Vi polysaccharide antigen vaccine Single dose Booster 3 yearly Live attenuated oral Typhoid vaccine 4 doses, 1 capsule on alternate days Booster 3 yearly ADULT IMMUNIZATION Typhoid Vaccine Adverse Effects Whole cell vaccine Pain, swelling, redness, malaise, fever, headache Vi polysaccharide vaccine Mild local and systemic symptoms Oral vaccine nausea, vomiting, abdominal cramps, diarrhea, urticaria ADULT IMMUNIZATION Varicella Vaccine Live attenuated vaccine Dosage: 0.5 ml s/c. 2 doses 4-6 weeks apart Seroconversion in 97% Indications Health care workers Workers at day care centers Non pregnant women ADULT IMMUNIZATION Post Exposure Varicella Zoster Immunoglobulin Immunosuppressed Neonates whose mother develops chicken pox 7 days before to 28 days after delivery Pregnant women with significant exposure to chicken pox or herpes zoster Dosage: 1000mcg (4 vials) within 10 days of exposure ADULT IMMUNIZATION Conclusion Vaccination is an important tool in disease prevention Adult immunization should be given priority Vaccination needs based on occupation, lifestyle, and health condition should be considered