“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

ROUTINE

Tetanus and Diptheria ( Td )

Pneumococcal ( Age >65 )

Influenza ( Age >50 )

Hepatitis B

MISSED CHILDHOOD VACCINES

Mumps, Measles and Rubella ( MMR )

Varicella

ADULT IMMUNIZATION Recommendation

Hepatitis A vaccine

Polio

BCG

Meningococcal

Typhoid

Rabies

Yellow fever

Anthrax

Plague

Hib

ADULT IMMUNIZATION Other vaccines when indicated

Pregnancy

Lactation

Health care workers

Animal handlers

HIV positive patients

Immunocompromised states

ADULT IMMUNIZATION In Special Cases

Administration of multiple vaccines

Immunoglobulins combined with

ToxoidsInactivated vaccinesPolysaccharide vaccines

Live virus vaccines

ADULT IMMUNIZATION General Guidelines

History of previous immunization

Hypersensitivity reactions to vaccine or their component

Specific allergies

Acute febrile illness

Contraindications to live vaccine

AssessmentADULT IMMUNIZATION

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

Case Study

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 Vaccine

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

High Risk Group

If given in the gluteus muscle (needle length important)

Immunodeficient

Chronic renal failure

Smokers

Elderly

Obese

ADULT IMMUNIZATIONHepatitis B

Decreased Immunological Response

Pain

Rash

Fever > 37.7 C

Influenza like syndrome

Arthritis, arthralgia, myalgia

ADULT IMMUNIZATIONHepatitis B

Adverse Effects

• 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 IMMUNIZATIONCase Study

Source Unvaccinated Vaccinated

ADULT IMMUNIZATIONHepatitis B

Percutaneous Exposure

Source Unvaccinated Vaccinated

HBs Ag+HBIG 0.06ml/kgBegin HB vaccine

series

Test for Anti HBsIf inadequate

HBIG + Vaccineseries

ADULT IMMUNIZATIONHepatitis B

Percutaneous Exposure

Source Unvaccinated Vaccinated

HBs Ag+HBIG 0.06ml/kg

Begin HB vaccineseries

Test for Anti HBsIf inadequate

HBIG + Vaccineseries

Unknownsource

Begin HB vaccineseries

Nothing required

ADULT IMMUNIZATIONHepatitis B

Percutaneous Exposure

Toxoids

Dose: 0.5 ml I/M at 0, 1 and 6-12 months

Seroconversion 100%

Booster 10 yearly

ADULT IMMUNIZATIONTetanus Diphtheria (Td) Vaccine

Persistent nodule

Pain, redness swelling

Headache, lethargy, malaise, myalgia

Urticaria, anaphylaxis

ADULT IMMUNIZATIONTetanus Diphtheria (Td) Vaccine

Adverse Effects

• 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 IMMUNIZATIONCase Study

TTImmunization

CleanMinor Wound

LargeDirty Wounds

T.T TIG T.T TIG

ADULT IMMUNIZATIONTetanus prophylaxis in

wound management

T.T Tetanus Toxoid

TIG Tetanus Immunoglobulin

TTImmunization

CleanMinor Wound

LargeDirty Wounds

T.T TIG T.T TIGNone,incomplete,Unknown

BeginPre ExpSeries

No Yes Yes

ADULT IMMUNIZATIONTetanus prophylaxis in

wound management

T.T Tetanus Toxoid

TIG Tetanus Immunoglobulin

TTImmunization

CleanMinor Wound

LargeDirty Wounds

T.T TIG T.T TIGNone,incomplete,Unknown

BeginPre ExpSeries

No Yes Yes

Last booster>5 years Booster No Yes Yes

ADULT IMMUNIZATIONTetanus prophylaxis in

wound management

T.T Tetanus Toxoid

TIG Tetanus Immunoglobulin

TTImmunization

CleanMinor Wound

LargeDirty Wounds

T.T TIG T.T TIGNone,incomplete,Unknown

BeginPre ExpSeries

No Yes Yes

Last booster>5 years Booster No Yes Yes

CompleteLast boosterwithin 5 years

No No No No

ADULT IMMUNIZATIONTetanus prophylaxis in

wound management

Live attenuated vaccine

Dosage: 0.5 ml subcutaneous

Seroconversion 95%

Lifelong immunity

ADULT IMMUNIZATIONMumps, Measles & Rubella

Vaccine

Fever

Rash

Arthralgia

Lymphadenopathy

ADULT IMMUNIZATIONMumps, Measles & Rubella Vaccine

Adverse Effects

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 IMMUNIZATIONCase Study

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 Rubella Exposure

What immunization would you recommendfor a 55 year old patient with congestive cardiac failure and no previous immunization?

Correct

ADULT IMMUNIZATION Case Study

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 IMMUNIZATIONInfluenza Vaccine

Healthy adults > 50

Residents of nursing homes

Chronic respiratory, heart and renal disease

Immunosuppressed including diabetics

Health care workers

Travelers

ADULT IMMUNIZATIONInfluenza Vaccine

Indications

Polyvalent vaccine

Dosage: 0.5 ml I/M

Single booster after 5 years

Efficacy: Prevents disease in 70% of immunized adults

ADULT IMMUNIZATIONPneumococcal Vaccine

Healthy adults >65

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 IMMUNIZATIONPneumococcal Vaccine

Indications

Comorbids

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

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 IMMUNIZATIONTyphoid Vaccine Adverse Effects

Live attenuated vaccine

Dosage: 0.5 ml s/c. 2 doses 4-6 weeks apart

Seroconversion in 97%

Health care workers

Workers at day care centers

Non pregnant women

ADULT IMMUNIZATION Varicella Vaccine

Indications

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 IMMUNIZATIONPost Exposure Varicella Zoster

Immunoglobulin

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

ADULT IMMUNIZATION Conclusion