ADULT
IMMUNIZATIONS – Answers
Case #4:
A 25-year old woman comes to
your office for a routine visit, and advice concerning immunization before her
summer trip to India.
What immunizations would you
offer this patient?
What
concerns would you have regarding immunizations and her reproductive history?
It
would be important to document first that she was up-to-date on her scheduled
pediatric immunizations. It would also
be essential to ask about her last menstrual history and possibility of
pregnancy. Obviously, any unnecessary
medications or procedures should be avoided, when possible, in pregnancy. However, most risks associated with vaccines
are largely theoretical, and one must look at potential benefit versus risk on
an individual basis. This is especially
the case when the exposure to infection is likely, the infection is
particularly dangerous to the mother or fetus, and the necessary vaccine is
unlikely to cause harm. Furthermore,
newer information continues to confirm the safety of vaccines given
inadvertently during pregnancy. In any
woman of reproductive age who is not pregnant, or likely to become pregnant in
the next 3 months, it would be worthwhile to document titers to rubella, and if
titers were negative, to offer the MMR vaccine. One could also screen for chickenpox as a child, and if the
patient could not remember having the childhood illness, checking titers and
immunizing against varicella as well.
This would offer protection against future perinatal exposure of the
infant, as well as prevent the severe illness that usually characterizes
varicella during pregnancy. In certain
high risk populations one could consider offering Hepatitis B vaccine as well.
This woman is planning a trip to India, an endemic area
for Hepatitis A. She should be offered
the Hep A vaccination. The first dose
should be given at least 4 weeks prior to departure, and a second dose offered
6-12 months later in persons requiring long-term protection. It is unclear whether there is any value in
administering Hep A vaccination in postexposure cases of people who have been
in contact with patients with Hep A, but it should replace the use of
immunoglobulin to prevent Hep A. Safety
during pregnancy has not been established, so benefits must outweigh the
risks. Breastfeeding is not a
contraindication to the use of this vaccine For all questions about which
vaccines and prophylaxis are recommended for travel to different regions of the
world, visit the very helpful CDC website http://www.cdc.gov/travel/
.
