ADULT
IMMUNIZATIONS – Answers
Case #1:
A 23-year-old male comes to see you for a complete
physical examination required by his new job as a laboratory technician. He has recently immigrated to New York from
his home in Ecuador.
The Answer is I) Hepatitis B, Td, and MMR
A review of all immunizations
needs to be done in new immigrants.
It is important to establish if the patient has any underlying medical
conditions such as hypertension, diabetes or asthma, as this may sway you to
offer additional vaccinations. Occupational
risks may also factor into your offering of vaccines.
HEPATITIS B VACCINE
n recombinant vaccine grown in
yeast; deltoid muscle is the preferred
intramuscular site;
n series of 3 injections at
time 0, 1 month and 6 months after the first dose.
n 85-95% effective in
preventing infection in healthy young adults.
n protective levels of
antibody are elicited in only 70% of persons age 50-59, and 50% of persons
greater than 60 years old. Antibody
response is decreased in patients with renal failure, diabetes, chronic liver
disease, HIV disease, smoking and obesity. Women have a slightly better
response rate than men.
n Of those who do not respond
after the initial series:
25-40% respond after a single additional dose
50-70% respond after another 3-dose series.
The duration of protection
by the vaccine remains uncertain.
n 7 years after immunization with
the plasma-derived vaccine 30-50% of young adults have inadequate or
undetectable antibody levels.
n Protection against
clinically overt acute HBV infection persists for at least 7 years.
n Subclinical infections can
occur, it is unclear at this time whether they can lead to a chronic HBV
infection.
n The decrease in antibody
levels have prompted some hospitals to screen vaccine recipients after 5-7
years, and give booster doses when antibody levels have waned.
n Immunocompromised patients
should have annual measurements of antibodies to determine need for doses.
Who should receive vaccination?
n All adolescents.
n Health care workers.
n High risk populations
including heterosexuals with multiple sexual partners, homosexuals and
intravenous drug users, patients
receiving hemodialysis, or with chronic renal disease that may need dialysis in
the future.
n As of 1997 the NIH Consensus
Development Conference recommended that hepatitis B vaccine be given to all
anti-HCV positive patients.
Because HBV predisposes to
hepatocellular cancer, the Hep B vaccine can be considered the first anticancer
vaccination.
It is also the first
commercial available vaccination against a sexually transmitted disease.
A new policy for universal immunization of infants with the Hep B vaccine has
been adopted because of the risks of hepatitis, plus the fact that at least
30 % of infected persons have no recognized risk factors for HBV.
Despite the existence of a safe and effective vaccine since
1982, the annual incidence of hepatitis B infection rose by 37% for 1979 to
1989.
*In the US there are approximately 300,000 new infections each
year, with 6-10% resulting in a chronic carrier state, about 250 deaths yearly
from fulminant hepatitis, 4000 deaths from cirrhosis, and 800 deaths from liver
cancer.
*Underutilization of the
vaccine may be secondary to theoretical misgivings about viral contamination of
the initial plasma-derived vaccine, insufficient recognition of high-risk
populations, and the relatively high cost of the vaccine.
Side effects and adverse
reactions:
Mild local reaction in
10-20% of persons, occasional systemic symptoms of fever, headache, fatigue and
nausea.
Contraindications:
Safety to fetus unknown,
pregnancy is NOT a contraindication in high-risk person.
Cost: $42.83 per dose.
TETANUS-DIPTHERIA TOXOID
These have both become rare diseases in the US thanks mainly to
effective immunization programs in children.
Almost all cases of tetanus and diptheria occur in adults who never completed
a primary immunization series.
–There is a poor record of compliance with the current
recommendation that tetanus-diptheria toxoid (Td) boosters be administered
every 10 years throughout adult life.
This is proven by seroprevalence studies that half the adults in the US
lack protective antibody levels. Yet, infection in adults is rare in those who
had received primary immunizations.
–Thus, clinical-epidemiological data suggest boosters every 10
years are of marginal value and that the primary vaccine series gives long-term
protection despite undetectable antibody levels.
**The main emphasis should be on ensuring that everyone receives a
primary immunization series and Td boosters for patients with tetanus-prone
wounds.
–Primary immunization consists of 3 doses of tetanus and
diptheria toxoids, with the first 2 doses given at least 4 weeks apart, and the
third dose given 6-12 months after the second.
–Combined Tetanus and Diptheria Toxoid Absorbed (for adult
use) [Td], rather than single-antigen tetanus or diptheria toxoids, is the
recommended preparation for routine immunization or general wound management in
persons 7 years old or older.
–There is no need to repeat doses if the schedule for the
primary series or booster doses is interrupted.
–Persons who have received 3 or more booster doses as wound
prophylaxis can be considered to have completed a primary series.
–Patients recovering from tetanus or diptheria require a
primary immunization series because the clinical illness does not reliably
evoke protective levels of antibody.
Side-effects:
Local tenderness and
erythema are common at the injection site, but severe reactions are rare.
because Arthus-type hypersensitivity reactions occur most often
after multiple boosters, Td boosters
should NOT be given to anyone within a previous 5 year history of completing a
primary series or receiving a booster.
Contraindications:
Previous anaphylactic or
neurologic reaction to this vaccine or any of its components.
Moderate or severe acute
illness.
NOTE: pregnancy and breastfeeding are not
contraindications to the use of this vaccine.
MEASLES-MUMPS-RUBELLA VACCINE (MMR)
The introduction of
effective attenuated, live-viral vaccines against measles, mumps, and rubella
in the 1960’s resulted in dramatic reductions in the incidence of these
diseases in the US. From a low in 1983
of 1500 cases, there was an almost 20-fold resurgence of measles to almost
28,000 cases in 1990, as well as increases in cases of mumps and rubella.
—most of these cases
were in unimmunized preschool children, but previously vaccinated adolescents
and college age students who apparently did not respond to their primary
vaccine also played a role in the outbreak.
In 1990-adults over the age
of 20 accounted for 22% of the approximately 28,000 cases of measles in the US
and 28% of the deaths from measles.
–The number of cases of
mumps has doubled since 1985 with a shift to older age groups.
–The number of cases of rubella
rose fivefold between 1988-1990 with the sharpest increase among those 15 years
old or older.
**It is now strongly
recommended–and required in public schools and in many colleges– that
everyone born after 1956 receive a 2-dose measles immunization. Because the same epidemiological
characteristics apply to mumps and rubella as well, MMR rather than the
monovalent measles vaccine is the vaccination of choice.
–-Rubella vaccination is
particularly recommended for nonpregnant women of childbearing age as a
means to reduce the risk of congenital rubella syndrome in the fetus.
There is no evidence to suggest adverse consequences occur from
giving MMR to a person immune to one or more of its components from and earlier
vaccine or natural infection.
Side-effects:
measles component:
low grade fevers may occur, transient rash.
mumps component:
mild allergic reactions uncommon, parotitis is rare.
Rubella component:
joint pains, and transient arthralgias in up to 40%, beginning 3-25 days
after vaccination, lasting 1-11 days.
Frank arthritis in less than 2% of cases. Frequency and duration of these symptoms are less than with
natural occurring rubella.
Contraindications:
MMR is contraindicated in
pregnancy and severely immunocompromised hosts. Breastfeeding is not a contraindication to the use of this
vaccine. HIV positive is NOT a
contraindication to MMR except for those that are severely immunocompromised.
NOTE: MMR is not contraindicated if a PPD was
recently planted. If PPD and MMR are
not given on the same day, delay the PPD for 4-6 weeks after the MMR vaccine.
Influenza vaccine would be discretionary depending on his exposure to other workers and
patients, as well as to his own underlying medical conditions. If he is in contact with patients, another
consideration would be Varicella vaccine,
if he has never had the chicken pox or has negative titers.
