{"id":1218,"date":"2013-10-10T19:35:36","date_gmt":"2013-10-10T19:35:36","guid":{"rendered":"http:\/\/jacobimed.org\/NS\/?page_id=1218"},"modified":"2013-10-10T19:35:36","modified_gmt":"2013-10-10T19:35:36","slug":"case-1-answer","status":"publish","type":"page","link":"https:\/\/jacobimed.org\/old\/ambulatory\/mlove\/curriculumprevention\/immunizations\/case-1-answer\/","title":{"rendered":"Case 1 answer"},"content":{"rendered":"

 <\/p>\n

\n

 <\/span><\/p>\n

ADULT  
\n<\/span>IMMUNIZATIONS – Answers<\/span><\/span><\/h2>\n

     <\/span>                                                                                                       <\/span><\/h1>\n

 <\/span><\/span><\/p>\n

Case #1:<\/span><\/span><\/span><\/p>\n

            <\/span>A 23-year-old male comes to see you for a complete
\nphysical examination required by his new job as a laboratory technician.  <\/span>He has recently immigrated to New York from
\nhis home in Ecuador.<\/span><\/p>\n

 <\/span><\/p>\n

            <\/span>The Answer is I) Hepatitis B, Td, and MMR<\/span><\/p>\n

 <\/span><\/p>\n

           <\/span><\/span> <\/span>A review of all immunizations
\nneeds to be done in new immigrants<\/strong>. 
\n<\/span>It is important to establish if the patient has any underlying medical
\nconditions such as hypertension, diabetes or asthma, as this may sway you to
\noffer additional vaccinations.  <\/span>Occupational
\nrisks<\/strong> may also factor into your offering of vaccines.<\/span><\/p>\n

 <\/span><\/p>\n

HEPATITIS B VACCINE<\/span><\/h6>\n

 <\/p>\n

n      <\/span><\/span>recombinant vaccine grown in
\nyeast;  <\/span>deltoid muscle is the preferred
\nintramuscular site;  <\/span><\/span><\/p>\n

n      <\/span><\/span>series of 3 injections at
\ntime 0, 1 month and 6 months after the first dose.<\/span><\/p>\n

n      <\/span><\/span>85-95% effective in
\npreventing infection in healthy young adults.<\/span><\/p>\n

n      <\/span><\/span>protective levels of
\nantibody are elicited in only 70% of persons age 50-59, and 50% of persons
\ngreater than 60 years old.  <\/span>Antibody
\nresponse is decreased in patients with renal failure, diabetes, chronic liver
\ndisease, HIV disease, smoking and obesity. Women have a slightly better
\nresponse rate than men.<\/span><\/p>\n

n      <\/span><\/span>Of those who do not respond
\nafter the initial series:<\/span><\/p>\n

      <\/span>25-40% respond after a single additional dose<\/span><\/p>\n

      <\/span>50-70% respond after another 3-dose series.<\/span><\/p>\n

 <\/span><\/p>\n

The duration of protection
\nby the vaccine remains uncertain<\/span><\/strong>.<\/span><\/p>\n

n      <\/span><\/span>7 years after immunization with
\nthe plasma-derived vaccine 30-50% of young adults have inadequate or
\nundetectable antibody levels.<\/span><\/p>\n

n      <\/span><\/span>Protection against
\nclinically overt acute HBV infection persists for at least 7 years.<\/span><\/p>\n

n      <\/span><\/span>Subclinical infections can
\noccur, it is unclear at this time whether they can lead to a chronic HBV
\ninfection.<\/span><\/p>\n

n      <\/span><\/span>The decrease in antibody
\nlevels have prompted some hospitals to screen vaccine recipients after 5-7
\nyears, and give booster doses when antibody levels have waned.<\/span><\/p>\n

n      <\/span><\/span>Immunocompromised patients
\nshould have annual measurements of antibodies to determine need for doses.<\/span><\/p>\n

 <\/span><\/p>\n

Who should receive vaccination?<\/span><\/strong>    <\/span><\/span><\/p>\n

n      <\/span><\/span>All adolescents.<\/span><\/p>\n

n      <\/span><\/span>Health care workers.<\/span><\/p>\n

n      <\/span><\/span>High risk populations
\nincluding heterosexuals with multiple sexual partners, homosexuals and
\nintravenous drug users,  <\/span>patients
\nreceiving hemodialysis, or with chronic renal disease that may need dialysis in
\nthe future.            <\/span><\/span><\/p>\n

n      <\/span><\/span>As of 1997 the NIH Consensus
\nDevelopment Conference recommended that hepatitis B vaccine be given to all
\nanti-HCV positive patients.<\/span><\/p>\n

      <\/span><\/span><\/p>\n

Because<\/span><\/strong> HBV predisposes to
\nhepatocellular cancer, the Hep B vaccine can be considered the first anticancer
\nvaccination.<\/span><\/p>\n

It is also the first
\ncommercial available vaccination against a sexually transmitted disease<\/strong>.<\/span><\/p>\n

 <\/span><\/p>\n

  <\/span>    <\/span>A new policy for <\/span>universal<\/span> <\/span>immunization of infants<\/span> with the Hep B vaccine has
\nbeen adopted because of the risks of hepatitis, plus the fact that at least
\n30 % of infected persons have no recognized risk factors for HBV<\/strong>.<\/span><\/p>\n

      <\/span>Despite the existence of a safe and effective vaccine since
\n1982, the annual incidence of hepatitis B infection rose by 37% for 1979 to
\n1989.<\/span><\/p>\n

      <\/span>*In the US there are approximately 300,000 new infections each
\nyear, with 6-10% resulting in a chronic carrier state, about 250 deaths yearly
\nfrom fulminant hepatitis, 4000 deaths from cirrhosis, and 800 deaths from liver
\ncancer.<\/span><\/p>\n

  <\/span>    <\/span>*Underutilization of the
\nvaccine may be secondary to theoretical misgivings about viral contamination of
\nthe initial plasma-derived vaccine, insufficient recognition of high-risk
\npopulations, and the relatively high cost of the vaccine.<\/span><\/p>\n

 <\/span><\/p>\n

Side effects and adverse
\nreactions:<\/span><\/em><\/strong><\/span><\/p>\n

Mild local reaction in
\n10-20% of persons, occasional systemic symptoms of fever, headache, fatigue and
\nnausea.<\/span><\/p>\n

 <\/span><\/p>\n

Contraindications:<\/span><\/em><\/strong><\/span><\/p>\n

Safety to fetus unknown,
\npregnancy is NOT a contraindication in high-risk person.<\/span><\/p>\n

 <\/span><\/p>\n

Cost<\/span><\/em><\/strong>:    <\/span>$42.83 per dose.

\n<\/span><\/p>\n

 <\/span><\/strong><\/p>\n

TETANUS-DIPTHERIA TOXOID<\/span><\/h6>\n

      <\/span><\/span><\/p>\n

      <\/span>These have both become rare diseases in the US thanks mainly to
\neffective immunization programs in children. 
\n<\/span>Almost all cases of tetanus and diptheria occur in adults who never completed
\na primary immunization series.<\/span><\/p>\n

 <\/span><\/p>\n

      <\/span>–There is a poor record of compliance with the current
\nrecommendation that tetanus-diptheria toxoid (Td) boosters be administered
\nevery 10 years throughout adult life. 
\n<\/span>This is proven by seroprevalence studies that half the adults in the US
\nlack protective antibody levels. Yet, infection in adults is rare in those who
\nhad received primary immunizations.  <\/span><\/span><\/p>\n

 <\/span><\/p>\n

      <\/span>–Thus, clinical-epidemiological data suggest boosters every 10
\nyears are of marginal value and that the primary vaccine series gives long-term
\nprotection despite undetectable antibody levels.<\/span><\/p>\n

 <\/span><\/p>\n

**The main emphasis should be on ensuring that everyone receives a
\nprimary immunization series and Td boosters for patients with tetanus-prone
\nwounds.<\/strong><\/span><\/p>\n

 <\/span><\/p>\n

      <\/span>–Primary immunization consists of 3 doses of tetanus and
\ndiptheria toxoids, with the first 2 doses given at least 4 weeks apart, and the
\nthird dose given 6-12 months after the second. <\/span><\/p>\n

      <\/span>–Combined Tetanus and Diptheria Toxoid Absorbed (for adult
\nuse) [Td], rather than single-antigen tetanus or diptheria toxoids, is the
\nrecommended preparation for routine immunization or general wound management in
\npersons 7 years old or older.<\/span><\/p>\n

      <\/span>–There is no need to repeat doses if the schedule for the
\nprimary series or booster doses is interrupted.<\/span><\/p>\n

      <\/span>–Persons who have received 3 or more booster doses as wound
\nprophylaxis can be considered to have completed a primary series.<\/span><\/p>\n

      <\/span>–Patients recovering from tetanus or diptheria require a
\nprimary immunization series because the clinical illness does not reliably
\nevoke protective levels of antibody.<\/span><\/p>\n

 <\/span><\/p>\n

Side-effects<\/span><\/em><\/strong>:  <\/span><\/span><\/p>\n

Local tenderness and
\nerythema are common at the injection site, but severe reactions are rare.<\/span><\/p>\n

      <\/span>because Arthus-type hypersensitivity reactions occur most often
\nafter multiple boosters, Td boosters
\nshould NOT be given to anyone within a previous 5 year history of completing a
\nprimary series or receiving a booster.<\/strong><\/em><\/span><\/p>\n

 <\/span><\/em><\/strong><\/p>\n

Contraindications:<\/span><\/em><\/strong>  <\/span><\/span><\/p>\n

Previous anaphylactic or
\nneurologic reaction to this vaccine or any of its components.<\/span><\/p>\n

Moderate or severe acute
\nillness.<\/span><\/p>\n

NOTE:  <\/span>pregnancy and breastfeeding are not
\ncontraindications to the use of this vaccine.

\n<\/span><\/p>\n

 <\/span><\/strong><\/p>\n

MEASLES-MUMPS-RUBELLA VACCINE (MMR)<\/span><\/span><\/strong><\/span><\/span><\/p>\n

      <\/span><\/span><\/p>\n

The introduction of
\neffective attenuated, live-viral vaccines against measles, mumps, and rubella
\nin the 1960’s resulted in dramatic reductions in the incidence of these
\ndiseases in the US.  <\/span>From a low in 1983
\nof 1500 cases, there was an almost 20-fold resurgence of measles to almost
\n28,000 cases in 1990, as well as increases in cases of mumps and rubella.<\/span><\/p>\n

 <\/span><\/p>\n

      <\/span>—most of these cases
\nwere in unimmunized preschool children, but previously vaccinated adolescents
\nand college age students who apparently did not respond to their primary
\nvaccine also played a role in the outbreak.<\/strong><\/span><\/p>\n

 <\/span><\/p>\n

In 1990-adults over the age
\nof 20 accounted for 22% of the approximately 28,000 cases of measles in the US
\nand 28% of the deaths from measles.<\/span><\/p>\n

–The number of cases of
\nmumps has doubled since 1985 with a shift to older age groups.<\/span><\/p>\n

–The number of cases of rubella
\nrose fivefold between 1988-1990 with the sharpest increase among those 15 years
\nold or older.<\/span><\/p>\n

 <\/span><\/p>\n

      <\/span>**It is now strongly
\nrecommended–and required in public schools and in many colleges– that
\neveryone born after 1956 receive a 2-dose measles immunization.<\/strong>  <\/span>Because the same epidemiological
\ncharacteristics apply to mumps and rubella as well, MMR rather than the
\nmonovalent measles vaccine is the vaccination of choice.<\/span><\/p>\n

 <\/span><\/p>\n

      <\/span>–-Rubella vaccination is
\nparticularly recommended for nonpregnant women of childbearing age<\/strong> as a
\nmeans to reduce the risk of congenital rubella syndrome in the fetus.<\/span><\/p>\n

 <\/span><\/p>\n

      <\/span>There is no evidence to suggest adverse consequences occur from
\ngiving MMR to a person immune to one or more of its components from and earlier
\nvaccine or natural infection.<\/span><\/p>\n

 <\/span><\/p>\n

Side-effects<\/span><\/em><\/strong>:  <\/span><\/span><\/p>\n

      <\/span>measles component<\/span>: 
\n<\/span>low grade fevers may occur, transient rash.<\/span><\/p>\n

      <\/span>mumps component<\/span>: 
\n<\/span>mild allergic reactions uncommon, parotitis is rare.<\/span><\/p>\n

      <\/span>Rubella component<\/span>:  
\n<\/span>joint pains, and transient arthralgias in up to 40%, beginning 3-25 days
\nafter vaccination, lasting 1-11 days. 
\n<\/span>Frank arthritis in less than 2% of cases.  <\/span>Frequency and duration of these symptoms are less than with
\nnatural occurring rubella.<\/span><\/p>\n

 <\/span><\/p>\n

Contraindications:<\/span><\/em><\/strong>    <\/span><\/span><\/p>\n

MMR is contraindicated in
\npregnancy and severely immunocompromised hosts.  <\/span>Breastfeeding is not a contraindication to the use of this
\nvaccine.  <\/span>HIV positive is NOT a
\ncontraindication to MMR except for those that are severely immunocompromised.<\/span><\/p>\n

NOTE:  <\/span>MMR is not contraindicated if a PPD was
\nrecently planted.  <\/span>If PPD and MMR are
\nnot given on the same day, delay the PPD for 4-6 weeks after the MMR vaccine.<\/span><\/p>\n

 <\/span><\/p>\n

Influenza vaccine<\/span><\/strong> would be discretionary depending on his exposure to other workers and
\npatients, as well as to his own underlying medical conditions.  <\/span>If he is in contact with patients, another
\nconsideration would be Varicella vaccine<\/strong>,
\nif he has never had the chicken pox or has negative titers.<\/span><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

    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….<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1212,"menu_order":0,"comment_status":"open","ping_status":"open","template":"","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"class_list":["post-1218","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1218","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/comments?post=1218"}],"version-history":[{"count":1,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1218\/revisions"}],"predecessor-version":[{"id":1223,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1218\/revisions\/1223"}],"up":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1212"}],"wp:attachment":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/media?parent=1218"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}