response before the sexual debut
63 and involves a two-dose series administered at
intervals of 0 and 6-12 months for patients initiating vaccine before 15 years old.
Immunization against HPV is 90% effective in reducing persistent HPV infections
and 100% effective in preventing HPV-related diseases such as genital warts or
71 The quadravalent and nine-valent vaccines are recommended for females
aged 13 to 26 years, males 13 to 21 years, and it may be given to males 22 through 26
who are men who have sex with men or immunocompromised if they have not been
65 The bivalent vaccine is recommended for females aged 13
The current vaccination rates for HPV vaccination remain below goal for Healthy
People 2020, despite various strategies to improve rates and reduce the burden of
disease and cancer caused by HPV.
64 The CDC recommends immunization for
adolescent girls, regardless of current sexual activity, to decrease the lifetime risk of
cervical cancer and to protect against infection when the time comes that an
individual chooses to become sexually active.
recommendations, J.S. should receive the HPV vaccine.
QUESTION 1: M.T. is a 5-year-old boy with a history of asthma. His pediatrician recommends that he
receive the pneumonia vaccine. What is the evidence behind this recommendation?
S. pneumoniae (pneumococcus) infection can cause meningitis, pneumonia,
sinusitis, and otitis media, and it is a major source of illness and death among
Infants, young children, and older patients are at highest risk
for exhibiting pneumococcal infections.
73 The risk for disseminated pneumococcal
infections is increased by underlying medical conditions (heart failure, chronic
obstructive pulmonary diseases), chronic liver disease (e.g., cirrhosis), functional or
anatomic asplenia (e.g., sickle cell disease, splenectomy), and acquired or inherited
immunosuppressive conditions (e.g., HIV, cancer, immunosuppressive therapy).
Two pneumococcal vaccines are available: the original polysaccharide vaccine
(Pneumovax, PPSV 23) and a conjugate-pneumococcal vaccine (Prevnar, PCV
inconsistent in children younger than 2 years of age partially because the antigens
included in Pneumovax protect against strains that typically cause adult disease, but
not childhood disease. In contrast, the conjugate pneumococcal vaccines (Prevnar
13) improve immunogenicity and efficacy in infants and toddlers.
vaccine provides protection against the thirteen pneumococcal strains that cause 90%
of all pneumococcal invasive disease in children younger than 6 years of age.
recommends giving the conjugate 13 vaccine (PCV 13) to all children aged 2 to 59
months and children aged 60 to 71 months with underlying medical conditions that
place them at high risk for experiencing pneumococcal disease or its complications.
Because M.T. has already passed the recommended age for vaccination and has
asthma, he should receive the PCV 13 vaccine today.
Immunocompromised patients typically have an unreliable response to vaccines,
but because of the potential benefits the pneumococcal vaccines should be
administered. PCV 13 and PPSV23 is recommended for children 6 to 18 years old
and adult patients >19 years old with immunocompromising conditions, functional or
anatomic asplenia, cerebrospinal fluid leaks, or cochlear implants.
PCV 13 should be administered first, followed by PPSV 23 8 weeks later, and a
second PPSV 23 dose 5 years later.
77 Similarly, PCV 13 should be administered first
to adults aged 19 to 64 years with immunocompromising conditions, followed by
PPSV 23 8 weeks later, with a second PPSV 23 dose 5 years later. Additionally,
adults who received PPSV 23 before 65 years old should receive another PPSV 23
dose at 65 years old, or later if it has been 5 years since their last PPSV 23.
CASE 64-12, QUESTION 2: M.T.’s grandfather is a 68 years old who is a previous smoker and has
cardiovascular disease. Should M.T.’s grandfather receive pneumococcal vaccine?
In the adult population, PCV 13 and PPSV 23 are recommended for patients over
the age of 65 years and older.
78 Since S. pneumoniae causes significant morbidity and
mortality within the elderly population, the PCV 13 vaccine was studied for efficacy
in preventing pneumococcal community acquired pneumonia, non-bacteremic and
invasive community acquired pneumonia, and invasive pneumococcal disease.
community-acquired pneumonia from any cause. The Centers for Disease Control and
Prevention recommend adults >65 years old who have not received a pneumococcal
vaccine receive a dose of PCV 13 followed by a dose of PPSV 23 6 to 12 months
78 The vaccines cannot be coadministered, and the minimum interval
between the two vaccines should be at least 8 weeks. For patients >65 years old who
have already received a PPSV 23 vaccine should also receive a PCV 13 vaccine >1
year after the most recent PPSV 23. If a second PPSV 23 is indicated, then the PPSV
23 should be administered 6 to 12 months after the PCV 13 or >5 years since the
most recent PPSV 23. The 23-valent pneumococcal polysaccharide vaccine
(Pneumovax) is also recommended for patients aged 19 to 64 years with certain
underlying medical conditions.
73 These underlying medical conditions include
immunocompetent patients with chronic heart disease, chronic lung disease, diabetes
mellitus, cerebrospinal fluid leaks, cochlear implants, alcoholism, chronic liver
disease, functional or anatomic asplenia, cigarette smoking, or who reside in nursing
homes or long-term care facilities.
28–30,73 Specifically, adult patients with asthma and
those who are cigarette smokers are proven to benefit from the pneumococcal
73 A second dose of the vaccine should be administered 5 years after the first
dose in patients 19 to 64 years old with functional or anatomic asplenia or who are
immunocompromised who received the initial pneumococcal vaccine prior to 65
If a patient is uncertain as to the accuracy of their vaccination, or when
they received it, they should not receive revaccination because of lack of clinical
evidence regarding the benefit of revaccination safety and benefit.
grandfather (a previously unvaccinated 68-year-old man) should receive one dose of
PCV 13, followed by a dose of PPSV 23 6 to 12 months after receiving the PCV 13
Annual influenza vaccination is the most effective method for preventing influenza
viral infections, complications, and sequelae.
80 Recommendations for influenza
vaccination include anyone older than 6 months of age who does not have a
81 Routine vaccination has been supported since 2010, and clinical
evidence confirms that annual influenza vaccination is a safe and effective
preventative health measure with potential benefit for all ages of the population.
Vaccination should occur before the onset of influenza virus within the community
and patients should receive their dose as soon as available.
Each year, the influenza vaccine is formulated to contain three or four inactivated
influenza virus strains (usually, two type A and
one or two type B) predicted to be in circulation within the United States during
81 The vaccine is available in intramuscularly administered
formulations including the following: inactivated vaccine (IIV) in both trivalent and
quadrivalent standard-dose formulations, a trivalent recombinant hemagglutinin
influenza vaccine (RIV3), a trivalent cell-cultured based inactivated vaccine
(ccIIV3), and a trivalent inactivated high-dose formulation. There is a standard-dose
trivalent intradermal inactivated vaccine and a quadrivalent intranasal live attenuated
81 Each season the composition of the vaccine is
evaluated, and the trivalent formulations contain two influenza type A strains with
one type B strain, whereas the quadrivalent formulations contain two type A strains
The injectable IIV is indicated for use in children at least 6 months old to adults,
including those with high-risk conditions.
81 The LAIV4 (intranasal) is indicated for
use in healthy nonpregnant patients aged 2 to 49 years old.
with a history of anaphylactic egg allergy, the trivalent recombinant influenza vaccine
(RIV3) and the cell-cultured based inactivated influenza vaccine (ccIIV3) are
Influenza vaccine should be administered annually for adequate protection.
Children younger than 9 years of age require two doses of the vaccine administered 1
month apart to achieve adequate antibody response during the first season they are
Influenza vaccine contains a small amount of egg protein, and
historically it has been contraindicated in patients with a severe egg allergy.
Evidence indicates that even patients with severe egg allergies, including hives, or
those who can eat lightly cooked eggs can safely receive the influenza vaccine in the
setting of health care personnel in case anaphylactic treatment is necessary. The RIV3
and ccIIV3 are alternatives to patients with egg allergies.
The intradermal IIV is recommended for patients aged 18 to 64 years delivered via
a microinjection system into the dermis.
Increased injection site reactions occur
with this formulation compared to the intramuscular route.
QUESTION 1: H.N. is a 72-year-old man inquiring about a new high-dose influenza vaccine. Is this a
recommended vaccine for H.N.? Could he be given the LAIV instead?
A high-dose IIV (Fluzone High-Dose) is indicated for patients aged 65 years and
older. Standard-dose inactivated trivalent influenza vaccines contain a total of 45
mcg (15 mcg of each of the three recommended strains) of influenza virus
hemagglutinin antigen per 0.5-mL dose. In contrast, Fluzone High-Dose has 4 times
the activity and is formulated to contain a total of 180 mcg (60 mcg of each strain) of
influenza virus hemagglutinin antigen in each 0.5-mL dose. The older than 65
population is targeted to receive the high-dose formulation because older patients
respond with a lower antibody titer to the conventional IIV.
were measured after patients received the high-dose vaccine, significantly higher
antibody titers for all three influenza strains were present.
that the high-dose influenza IIV improves protection against laboratory confirmed
illness, the high-dose IIV produced higher antibody response and provided improved
protection compared to the standard-dose IIV.
86 The high-dose recipients rates for
pneumonia, cardiorespiratory conditions, hospitalizations, non-routine medical
visits, and medication use were lower than the standard-dose recipients, thus
concluding an estimate of improved relative efficacy for the high-dose IIV versus the
The LAIV4 (FluMist) is available for use in healthy, nonpregnant patients 2 to 49
years of age. After administration, recipients become infected with attenuated virus
strains, which stimulates both local IgA and circulating IgG antibodies.
live attenuated influenza viral particles are present within the LAIV4, recipients may
experience mild signs or symptoms related to influenza infection, such as rhinorrhea,
nasal congestion, fever, or sore throat.
91 The LAIV4 is indicated for nonpregnant
patients aged 2 to 49 years old without medical conditions that predisposes to
complications from the influenza virus. However, the LIAV is not recommended to
be preferenced for use over the use of IIV3 at this time.
receive or may not be able to receive the live vaccine include patients
with a severe allergy to eggs, or inactive ingredients monosodium glutamate,
gelatin, arginine, sucrose, dibasic potassium phosphate, monobasic potassium
with previous life-threatening reactions to previous influenza vaccinations
currently wheezing or have a history of wheezing if under 5 years of age
pediatric and adolescent patients currently taking aspirin therapy
known or suspected immunodeficiency
history of Guillain–Barré syndrome
have a history of heart, kidney, or lung disease or diabetes
Because of his age, HN should not be given the intranasal vaccine, but he could
receive either the standard or high-dose inactivated vaccine.
Besides the live attenuated flu vaccine discussed previously, there are several other
live attenuated vaccines currently available for use (Table 64-1).
Rotavirus is a major cause of gastroenteritis and subsequent dehydration in the
United States. Almost all children in the United States will experience rotavirus
gastroenteritis within the first 5 years of their lives and up to 50% of hospitalizations
secondary to gastroenteritis in children are caused by rotavirus infection.
AAP and the CDC currently recommend routine immunization of infants with the
27 There are two oral, live attenuated rotavirus vaccines currently
commercially available: Rotateq (RV5), a pentavalent vaccine, and Rotarix (RV1), a
95 Both vaccines are believed to be equally effective despite
Initial vaccination should begin at a minimum of 6 weeks
of age and the maximum age at which to administer the last dose is at 8 months of
It is preferred that all doses be administered with the same product; however,
if a combination of RV5 and RV1 is used, a total of three doses should be
95 Although immunization against rotavirus does not prevent all future
episodes of rotavirus infection, it can significantly reduce the severity of infections
and reduce hospitalization rates.
as well as cause “bowel problems” for her baby.
Because the rotavirus vaccine is a live attenuated vaccine and infants can shed the
virus after administration, the immunocompromised person (the grandmother) should
avoid contact with the infant’s feces and adhere to good handwashing procedures,
particularly during the first week after vaccine administration.
immunized infant can spread the rotavirus to an immunocompromised person, the risk
is believed to be small relative to the benefits and risks to the immunocompromised
individual. For example, if not immunized the infant may become infected with
rotavirus and shed much higher amounts of the virus in their stool with a greater
potential of spreading the illness to others. Thus, rotavirus immunization of infants
under this circumstance still is strongly encouraged.
The immunization of infants who themselves are immunocompromised is more
controversial. Rotavirus immunization in this circumstance requires the medical
practitioner to discuss risks and benefits with the infant’s parents.
Despite being a live attenuated vaccine, the rotavirus vaccine may be administered
at any time relative to the administration of blood products and antibody-containing
95 There appears to be no interference with the antibody response to the
vaccine with the use of these products because much of the immune response is local
within the gastrointestinal tract, which leads to protection from gastroenteritis.
Measles, historically a highly contagious and common disease of childhood, often
is associated with symptoms such as high fever, rash, cough, rhinitis, and
Complications, although uncommon, include pneumonia and encephalitis. Live
attenuated measles virus vaccine produces a benign infection that is thought to
produce lifelong immunity. Infections with measles, mumps, or rubella are uncommon
in the United States secondary to a significant decrease in the incidence of measles
when American children were required to receive the vaccine before entering
97 During the 1985 to 1988 epidemic, most measles transmission occurred
in areas with 95% immunization rates, indicating that some children fail to respond
adequately to the initial vaccine dose.
In addition, up to 47% of reported cases of
measles in the United States result from international importation; the remaining
cases result from outbreaks in school-age children who did not receive a second
99 Unfortunately, many parents are refusing immunization of
their infants with the MMR vaccine because of media reports (now proven
unfounded) about the risk of autism.
The concern regarding the risk from autism after vaccination with the MMR
vaccine stems from a report by Wakefield et al. published in 1998. This report
identified a causal relationship with the administration of the MMR vaccine and the
subsequent development of autism in 12 children.
100 The results of this report became
highly publicized and sparked fear in parents across the world. Further investigation
revealed numerous counts of scientific misconduct for financial gains by Dr.
Wakefield, which led to 10 of the 12 coinvestigators retracting their claims. The
CDC has coordinated numerous investigations to uncover any relationship between
the vaccine and autism, but despite years of research have been unable to find any
association. Regrettably, efforts to counter the negative publicity for the MMR
J.C.’s mother should be counseled regarding the lack of an association between
autism and the MMR vaccine. If she still decides to refuse vaccination, appropriate
forms for documenting such are available through the respective state’s Department
The first dose of the MMR vaccine should be administered to children at 12 to 15
months of age, followed by a second dose at entrance to grade school (age 4 to 6
97 Studies indicate that infants receiving the vaccine may be at higher risk
of exhibiting a febrile seizure during the 2 weeks after vaccination when peak virus
101 The risk appears to be higher with the combination vaccine
ProQuad. Because of this concern, the CDC recommends the preferential use of the
MMR vaccine in children aged 12 to 47 months. Although studies have not shown a
benefit with the use of antipyretics for preventing febrile seizures from the vaccine, it
is recommended that caregivers be counseled regarding the management of fever. No
increased risk of febrile seizures has been noted with the second dose of the vaccine
administered at 4 to 6 years of age, thus the use of the combination vaccine is
recommended at this age to reduce the number of injections and enhance
Adult vaccination with MMR vaccine is also important to protect from epidemics.
Adults should receive a second dose of MMR if they were born between 1963 and
1967, previously vaccinated with killed measles vaccine, are students in
postsecondary institutions, work in health care facilities, travel internationally, or
were recently exposed to a measles outbreak.
97 Persons born after 1957 should
receive one dose of a measles-containing vaccine.
28–30,97 Health care workers must
show documentation of having receipt of the appropriate number of doses or
laboratory evidence of immunity to comply with infection control policies.
Mumps and rubella antigens are combined with measles in the MMR vaccine in
the United States. Mumps illness in children rarely produces complications.
Meningoencephalitis generally is a benign meningitis, and postinfectious
encephalitis, a serious complication, is extremely rare (1 of 6,000). Deafness,
commonly considered a risk of mumps, occurs rarely (1 of 15,000) and is usually
unilateral. Orchitis, another complication, occurs in approximately 3% to 10% in
postpubertal males since the postvaccine era and rarely causes sterility. The most
significant consequences of rubella infection occur in pregnant women (e.g.,
spontaneous abortions, miscarriages, stillbirths, fetal anomalies), especially when
infection occurs during the first trimester.
QUESTION 1: J.T. is a 6-year-old girl who comes home from school with a note from the school nurse
concerned because J.T. has not been immunized with the varicella vaccine. She wants to know whether
administration of the vaccine at this time will protect J.T. from becoming infected.
Varivax, a live attenuated vaccine against varicella-zoster (chickenpox), is the
first herpesvirus vaccine to be widely tested in healthy and high-risk children and
103–105 Chickenpox is a highly contagious, mild childhood disease in healthy
children, but it can be severe and even fatal, especially in the immunocompromised
Comments
Post a Comment
اكتب تعليق حول الموضوع