ADULT
IMMUNIZATIONS – Answers
Case #2:
A 67-year-old
female comes to see you in your office for her regular fall follow-up physical
examination. She has a history of
hypertension and asthma, and is on chronic medications.
What
immunizations would you offer at this visit, or insure that she has
received?
The
Answer is D, pneumococcal vaccine and influenza vaccine
INFLUENZA VACCINE
n Developed in the 1950s as a
way to deal with the yearly winter epidemic of influenza
n Influenza vaccine is made
from highly purified, egg-grown viruses that are inactivated.
n Antigenic variations among
influenza viruses, as well as a short period of immunity, require that
high-risk populations receive the flu vaccine each fall. Worldwide surveillance
and antigenic characteristics provide the basis for the yearly selection of 2
strains of influenza A and 1 strain of influenza B.
n 65-80% protection against an
illness caused by an influenza virus with antigenic characteristics represented in the vaccine in young adults.
n 30-40% effective in
preventing clinical illness in elderly population; provides greater benefit by
lessening the severity of disease and preventing hospital admissions and death.
n Recently
available—intranasal flu vaccine (flu mist), reportedly the same efficacy, more
expensive (~$25/dose, whereas intramuscular vaccine is much less expensive, and
subsidized by the government)
19 of the annual flu
epidemics since 1957 have been associated with more than 10,000 excess deaths,
with 40,000 excess deaths in 2 of the epidemics. About 80-90% of the excess deaths occurred in people > 65 or
older, especially in those patients with underlying cardiac or pulmonary
disease.
Who should receive the vaccination?
§
Persons
age 50 or greater. This was recently
changed from age 65 and greater because this group has an increased prevalence
of persons with high-risk conditions, and by including a larger population for
“blanket” vaccination will help to improve the low vaccination rate among
persons in this age group with high-risk medical conditions.
§
Residents
in nursing homes or chronic care facilities.
§
Children
and adults with chronic pulmonary or cardiovascular disease including asthma.
§
Children
and adults with chronic medical conditions including diabetes, renal disease,
hemoglobinopathies, and immunosuppression.
§
Pregnant
women with any underlying medical conditions should be vaccinated prior to
influenza season, regardless of the stage of pregnancy.
Vaccination is also
indicated for those people who may transmit the infection to high risk groups,
such as health care workers, employees of chronic care facilities or day care
workers, home health aides, and household members of high risk persons.
In addition to the two
groups listed above, the flu shot is indicated for any person who wishes to
have the vaccine to decrease the likelihood of getting the flu.
Side-effects:
Because the influenza vaccine contains only inactivated virus it CANNOT
cause the flu!!
Most commonly, soreness at the injection site. Occasional systemic reaction of malaise and
myalgias beginning 6 to 12 hours after receiving the shot and lasting 1 to 2
days.
Rarely, an allergic reaction can occur, most likely due to the
residual egg proteins in the vaccine. There have been no further adverse
neurological events since the association of Guillian-Barre syndrome with the
1976 “swine flu” vaccine.
Contraindications:
Anaphylaxis in response to
eggs. Moderate or severe acute
illness. Pregnancy and breastfeeding
are not contraindications to the use of this vaccine.
To follow the progress of
the annual flu epidemic visit the CDC/WHO flu tracker website: CDC flu-tracker
PNEUMOCOCCAL VACCINE
The currently licensed
vaccine in the US contains polysaccharide capsular antigens from 23 of the more
than 80 different pneumococcal serotypes.
These 23 serotypes are responsible for 88% of bloodstream isolates in
infections in the US.
n Primary vaccination with 0.5 cc subcutaneously or intramuscularly.
n Routinely given as a
one-time dose, revaccinate if previous vaccination history is unknown.
n One-time revaccination is
recommended for patients at highest risk of fatal pneumococcal infection or
rapid antibody loss (ie renal disease), and for people over the age of 65 years
(if the first dose was given before the age of 65 and 5 years has elapsed).
n Overall protective efficacy of 56%
o
among
immunocompetent vaccine recipients, the protective efficacy is 61% but this
varies greatly with age, from 93% in patients less than 55 years old to 46% in
patients greater than 85 years old.
o
the
protective efficacy is poor in immunosuppressed recipients.
**Thus, even full implementation of the vaccine would only
prevent about 1/2 the cases of pneumococcal disease. This however would not be inconsequential, as current estimates
are of 40,000 deaths per year.
Who should receive the vaccine?
·
All
persons 65 year old or greater.
·
Immunocompetent
adults at increased risk of pneumococcal disease because of chronic illnesses
such as cardiovascular disease, pulmonary disease, diabetes, alcoholism or cirrhosis,
chronic renal failure or nephritic syndrome.
·
ALL
HIV-infected persons.
·
Asplenic
patients such as those persons with sickle cell disease, or s/p splenectomy.
·
Immunosuppressed
patients secondary to being transplant recipients.
Side-effects:
Erythema and pain at injection site in about 50% of patients.
Systemic symptoms in less than 1% of recipients.
Arthus-like reaction with booster doses less than 4 years after
initial dose.
Contraindications:
Previous anaphylactic reaction to the vaccine or any of its
components.
Breast- feeding and
pregnancy are not contraindications to the use of this vaccine.
Cost:
$9.57 per dose.
