The Philippine Obstetrical and Gynecological Society (POGS) has a clinical practice guideline on Immunization for Filipino Women. Foremost is the recommendation on immunization for tetanus-diptheria, influenza and hepatitis B during pregnancy, and immunization with MMR and Varicella before discharge which has yet to be implemented. Lecturing to third year medical students, I hope that they may be encouraged to include immunzation in their clinical practice to eliminate vaccine-preventable diseases.

1. IMMUNIZATION FOR
FILIPINO WOMEN
Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
August 17, 2016

2. THIS LECTURE IS LIFTED FROM
THE PHILIPPINE OBSTETRICAL
AND GYNECOLOGICAL SOCIETY
(POGS)
CLINICAL PRACTICE GUIDELINES
ON IMMUNIZATION FOR
FILIPINO WOMEN
(NOVEMBER 2011)
@helenvmadamba

3. General Considerations for
Vaccination
• Never administer vaccines in the
buttock.
• Confirm completion of childhood (or
more recent) primary vaccine series
for measles, mumps, rubella (MMR)
and tetanus-diptheria (Td) before
initiating adult recommended
vaccine schedules.
@helenvmadamba

4. General Considerations for
Vaccination
• Maintain vaccine administration
record in patient’s chart, including
date, site and route of
administration, manufacturer and
lot number of vaccine.
@helenvmadamba

5. General Considerations for
Vaccination
• Knowing the route of vaccine
administration, needle size, and
vaccine storage and handling are
critical components of a quality,
office-based vaccine program.
@helenvmadamba

6. General Considerations for
Vaccination
• Simultaneous use of any vaccines is
not contraindicated.
• Antibiotic therapy or breastfeeding
are not contraindications to
vaccination. Likewise, the presence
of a pregnant woman or
immunosuppressed person in the
household is not a reason to withold
an indicated vaccine to a family
member.
@helenvmadamba

7. General Contraindications to
Vaccination
• Severe allergy to vaccine
components.
• Pregnancy (or if planning pregnancy
within four weeks) for live
attenuated vaccines.
• Severe immune attenuation (for live
attenuated vaccines only) –
consultation with infectious disease
specialist is advised.
@helenvmadamba

8. General Contraindications to
Vaccination
• Moderate or severe acute illness.
• If a live attenuated vaccine is given
simultaneously with another
vaccine, a four week separation
interval should be used between
vaccinations.
@helenvmadamba

9. HUMAN PAPILLOMAVIRUS

10. Target Population - HPV
• The bivalent HPV vaccination and
the quadrivalent HPV vaccination
can protect women aged 15-25
years and 16-45 years respectively,
from persistent HPV infection and
≥cervical intraepithelial neoplasia
(CIN) 2+.
Level 1, Grade A
@helenvmadamba

11. Target Population - HPV
• The bivalent HPV vaccine can be
given to patients age 10-14 years
and 26-55 years while the
quadrivalent HPV vaccine can be
given to patients age 9-45.
Level 1, Grade A
@helenvmadamba

12. Target Population - HPV
• The bivalent HPV vaccination and
quadrivalent HPV vaccination can
protect women aged 15 to 25 years
and 9-45 years respectively, from
developing vulvar intraepithelial
neoplasia (VIN) and vaginal
intraepithelial neoplasia (VAIN).
Level 1, Grade A
@helenvmadamba

13. Target Population - HPV
• The quadrivalent HPV vaccination
can protect women aged 16 to 45
years from developing anogenital
warts.
Level 1, Grade A
@helenvmadamba

14. Target Population - HPV
• The bivalent HPV vaccine can protect
women aged 15-25 years from ≥CIN
2+ associated with combined
nonvaccine oncogenic HPV types
(HPV 33, 45).
Level 1, Grade A
@helenvmadamba

15. Target Population - HPV
• HPV vaccination can be given in
women with the following special
situations: abnormal Papanicolau
(Pap) smear, history of genital warts,
breastfeeding and
immunocompromised.
• Papsmear and HPV infection status is
not a prerequisite for HPV
vaccination.
GPP
@helenvmadamba

16. Dose Regimen - HPV
• The bivalent HPV vaccine is injected
intramuscularly at 0, 1, 6 months,
while the quadrivalent HPV vaccine
is injected intramuscularly at 0, 2, 6
months.
• The bivalent and quadrivalent HPV
vaccines are not interchangeable to
complete the 3 doses.
Level I, Grade A
@helenvmadamba

17. Dose Regimen - HPV
• The quadrivalent HPV vaccine can be
given concomitantly with diphtheria,
tetanus, pertussis, and poliomyelitis
vaccine in healthy adolescents 11 to
17 years of age.
Level I, Grade A
@helenvmadamba

18. Dose Regimen - HPV
• The bivalent HPV vaccine can be
given concomitantly with diphtheria-
tetanus-acellular pertussis (tdap),
inactivated polio vaccine (IPV),
hepatitis A inactivated vaccine
(HepA) and Hepatitis B inactivated
vaccine (HepB).
GPP
@helenvmadamba

19. Contraindications - HPV
• HPV vaccines cannot be given to
pregnant women.
• HPV vaccines can be given to women
with minor illnesses.
• Women who receive HPV vaccination
should be observed for syncope in the
clinic for 15 minutes.
• HPV vaccination should not be given to
patients with a history of adverse
reactions to any vaccine component.
GPP
@helenvmadamba

20. Available Preparations - HPV
Vaccine Formulation
Bivalent HPV Vaccine 0.5 ml/syringe
Quadrivalent HPV
Vaccine
0.5 ml/syringe
@helenvmadamba

21. VARICELLA

22. Target Population - Varicella
• Persons aged >13 years
• School-aged children, college
students, and students in other post-
secondary educational institutions
• Other healthy adults
Level I, Grade A
@helenvmadamba

23. Postpartum Vaccination -
Varicella
• Women who do not have evidence
of varicella immunity should receive
the first dose of vaccine before
discharge from the health-care
facility. The second dose should be
administered 4-8 weeks later.
• Women should be counseled to
avoid conception 1 month after each
dose of varicella vaccine.
Level I, Grade A
@helenvmadamba

24. Dose Regimen - Varicella
• Eligible recipients should receive two
0.5 mL doses of single-antigen
varicella vaccine administered
subcutaneously, 4-8 weeks apart. If
>8 weeks elapsed after the first
dose, the second dose may be
administered without restarting the
schedule.
Level I, Grade A
@helenvmadamba

25. Contraindications - Varicella
• Persons with history of anaphylactic
reaction to any component of the
vaccine, to neomycin
• Persons with malignant condition
• Family history of congenital or
hereditary immunodeficiency
Level I, Grade A
@helenvmadamba

26. Contraindications - Varicella
• Persons receiving high-dose systemic
immunosuppressive therapy
• Pregnant women
Level I, Grade A
@helenvmadamba

27. Precautions - Varicella
• Vaccination of persons who have
acute severe illness, including
untreated, active tuberculosis,
should be postponed until recovery.
• Varicella vaccines should not be
administered for the same intervals
as measles vaccine, after
administration of blood, plasma or
immunoglobulin.
Level I, Grade A
@helenvmadamba

28. Available Preparation -
Varicella
Vaccine Formulation
Varicella Virus Vaccine,
live-attenuated, freeze-
dried with separate
diluent, to be
reconstituted right
before administration
0.5 mL
@helenvmadamba

29. MUMPS, MEASLES, RUBELLA

30. Target Population - MMR
• All non-pregnant women of
childbearing age must be offered
measles, mumps and rubella (MMR)
vaccination.
Level I, Grade A
@helenvmadamba

31. Target Population - MMR
• Upon completion or termination of
pregnancy, women who do not have
serologic evidence of rubella
immunity or documentation of
rubella vaccination should be
vaccinated with MMR before
discharge from the hospital or
birthing center.
Level I, Grade A
@helenvmadamba

32. Target Population - MMR
• Routine prenatal serologic testing
for rubella on all pregnant women
who lack acceptable evidence of
rubella immunity should be done.
Level I, Grade A
@helenvmadamba

33. Dose Regimen - MMR
• 0.5 mL, administered
subcutaneously, 1-2 doses
• Second dose of MMR vaccine,
administered 4 weeks after the first
dose is recommended for adults
Level I, Grade A
@helenvmadamba

34. Contraindications - MMR
• Severe allergic reaction after a
previous dose of the vaccine
• Pregnancy
• Severely immunocompromised
patients
@helenvmadamba

35. Precautions - MMR
• Women administered the MMR
vaccine should be advised not to get
pregnant during the next 4 weeks
post-vaccination
• Recent (≤11 months) receipt of
antibody-containing blood product
@helenvmadamba

36. Precautions - MMR
• History of thrombocytopenia or
thrombocytopenic purpura
• Need for tuberculin skin testing
• Moderate or severe acute illness
with or without fever
@helenvmadamba

37. Available Preparation - MMR
Vaccine Formulation
Measles, Mumps,
Rubella Virus Vaccine,
live-attenuated
0.5 mL
@helenvmadamba

38. TETANUS, DIPTHERIA,
PERTUSSIS

39. Target Population - TDaP
• Pregnant women with no previous
tetanus immunization or unknown
tetanus immunization history
should receive three doses of Td
vaccine to be given on month apart,
starting the second trimester. The
third dose can be given postpartum
as Tdap.
Level I, Grade A
@helenvmadamba

40. TDaP
• Pregnant women whose last Td/Tdap
vaccination was more than ten years
ago should receive Td booster in the
second or third trimester of
pregnancy.
Level I, Grade A
@helenvmadamba

41. Dose Regimen of TDaP
• The primary tetanus immunization
series consists of 3 Td injections
given intramuscularly. The first two
doses are given one month apart,
and the third dose is given 6-12
months after the second dose. The
third dose may be given as Tdap.
• Tdap dose is 0.5 mL administered
IM, preferably into the deltoid
muscle.
Level I, Grade A
@helenvmadamba

42. Contraindication - TDaP
• Severe allergic reaction (e.g.
anaphylaxis) after a previous dose or
to a vaccine component.
@helenvmadamba

43. Precaution - TDaP
• History of arthus-type
hypersensitivity reactions following
a previous dose of TT-containing
vaccine – defer vaccination until at
least 10 years have lapsed since the
last TT-containing vaccine.
@helenvmadamba

44. Adverse Events - TDaP
• Pain
• Redness or swelling
• Fever
• Headache or tiredness
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45. Available Preparations
Vaccine Formulation
Tetanus toxoid 0.5 ml/ampule
Tdap absorbed 0.5 ml/ampule
Tetanus-Diphtheria 0.5 ml/ampule
@helenvmadamba

46. INFLUENZA

47. Target Population –
Influenza Virus
• All pregnant and breastfeeding
women should receive the
inactivated flu vaccine
• Individuals belonging to the
following risk groups
– All children aged 6 months to 18 years
– All persons aged ≥ 50 years
– Other persons at risk for medical complications
from influenza
– All healthcare professionals
@helenvmadamba

48. Dosing Regimen –
Influenza Virus
• Infants, children and adolescents
aged 6 months to 18 years
• Women ≥ 19 years: given
intramuscularly, every year, as soon
as the newest/current WHO-
recommended vaccine strains
become available.
Level III, GPP
@helenvmadamba

49. Contraindications –
Influenza Virus
• Severe allergic reactions (e.g.
anaphylaxis) after a previous dose or
to a vaccine component, including
egg protein
@helenvmadamba

50. Precautions –
Influenza Virus
• Guillaine Barre Syndrome within 6
weeks of previous dose of influenza
vaccine
• Moderate or severe acute illness
with or without fever.
@helenvmadamba

51. Available Preparations –
Influenza Virus
Vaccine Formulation
Inactivated Split-
Influenza Virus
Vaccine
0.5 mL prefilled
syringe
Inactivated
Influenza Virus
Vaccine
0.25 mL and 0.5
mL prefilled
syringe
@helenvmadamba

52. PNEUMOCOCCAL BACTERIA

53. Target Population -
Pneumococcal Bacteria
• High risk patient who have not
received prior immunization or
whose prior vaccination status is
unknown.
– All persons >50 years of age,
particularly those living in institutions
– Persons with certain underlying chronic
medical conditions
@helenvmadamba

54. Target Population -
Pneumococcal Bacteria
• Immunocompromised persons ≥ 2
years of age
• Any adult 19 through 49 years of age
who is a smoker and has asthma
(Grade B)
@helenvmadamba

55. Target Population -
Pneumococcal Bacteria
• Revaccination with pneumococcal
polysaccharide vaccine (PPSV) is
recommended, at least 5 years after the
first dose particularly with the ff
populations: Grade A
– 50 to 64 years old
– 65 years and older who had a prior
dose with a lapse of at least 5 years
– People age 2 to 49 years with
immunocompromised condition Grade B
@helenvmadamba

56. Target Population -
Pneumococcal Bacteria
• Pneumococcal vaccination should be
recommended to pregnant and
breastfeeding women who are at
high risk for invasive pneumococcal
disease.
@helenvmadamba

57. Target Population -
Pneumococcal Bacteria
• The vaccine should preferably be
administered during the 2nd or 3rd
trimester of pregnancy as a general
safety precaution. Women at high
risk should be offered vaccination
before becoming pregnant.
@helenvmadamba

58. Dose Regimen –
Pneumococcal Bacteria
• Candidates for vaccination should
receive single 0.5 mL dose,
intramuscular (IM) or subcutaneous
(SQ) injection.
@helenvmadamba

59. Contraindication/ Precautions
– Pneumococcal Bacteria
• Hypersensitivity to any component
of the vaccine. Epinephrine
injection (1:1000) must be available
immediately in case of anaphylaxis
• Severely compromised
cardiovascular and/or pulmonary
function (since a systemic reaction
incurs significant risks)
@helenvmadamba

60. Contraindication/ Precautions
– Pneumococcal Bacteria
• Children <2 years as safety and
efficacy have not been established
for this group
@helenvmadamba

61. Adverse Reactions –
Pneumococcal Bacteria
• About 30-50% or patients who
received the PPSV had mild side
effect such as local erythema.
• Serious allergic reaction with the
PPSV is uncommon.
• Among children who received the
PCV, 10-20% developed local
erythema, tenderness or swelling
and 11% had low grade fever.
@helenvmadamba

62. Available Preparation –
Pneumococcal Bacteria
Vaccine Formulation
Pneumococcal 23-
valent polysaccharide
vaccine, PPSV23
0.5 mL prefilled
syringe
@helenvmadamba

63. HEPATITIS A

64. Target Population - Hepatitis A
• Women, 18 years old and above,
who have close contact with persons
with hepatitis A, must be vaccinated.
• Women travelling to or working in
countries with high or intermediate
prevalence of hepatitis A should be
vaccinated.
Level I, Grade A
@helenvmadamba

65. Target Population - Hepatitis A
• Women who use street drugs are
candidates for vaccination.
• Women with chronic liver disease
(including hepatitis B and C) should
receive hepatitis A vaccination.
Level I, Grade A
@helenvmadamba

66. Target Population - Hepatitis A
• Women previously treated with
clotting factor concentrates should
avail of hepatitis A vaccination.
• Women with occupational risk
including laboratory staff should be
vaccinated.
Level I, Grade A
@helenvmadamba

67. Post-exposure Prophylaxis -
Hepatitis A
• For susceptible healthy women up
to age 40 years, single-antigen
hepatitis A vaccine should be
administered as soon as possible
after exposure.
• Beyond 40 years, immune globulin
(Ig) is preferred. Vaccine can be
used if Ig cannot be obtained.
Level I, Grade A
@helenvmadamba

68. Dose Regimen - Hepatitis A
• Hepatitis A vaccine should be
administered by intramuscular route
for 2 doses, 6-12 months apart, for
lasting protection.
@helenvmadamba

69. Contraindications/Precautions
/Adverse Events - Hepatitis A
• Severe or life-threatening allergic
reaction to a previous dose of
hepatitis A vaccine is an absolute
contraindication.
• Severe or life-threatening allergic
reaction to any vaccine component
contraindicates the administration
of hepatitis A vaccine.
@helenvmadamba

70. Contraindications/Precautions
/Adverse Events - Hepatitis A
• Moderate or severe ilnnes at the
time of vaccination may defer the
scheduled administration.
• Safety of the hepatitis A vaccine for
pregnant women has not been
determined.
@helenvmadamba

71. Contraindications/Precautions
/Adverse Events - Hepatitis A
• The most commonly reported
adverse reaction following hepatitis
A vaccination is local reaction at the
site of injection.
@helenvmadamba

72. Available Preparations -
Hepatitis A
Vaccine Formulation
Inactivated hepatitis A
vaccine
1 ml/vial
Combined inactivated
hepatitis A and B
vaccine
1 mL prefilled
syringe
@helenvmadamba

73. HEPATITIS B

74. Target Population - Hepatitis B
• Women 18 years old and above who
belong to the high risk groups:
– Healthcare and public safety and security
workers who may have exposure to blood
in the workplace
– Persons in training for allied health
professions
– Hemodialysis patients and those receiving
blood and blood products including
transplant candidates
Level I, Grade A
@helenvmadamba

75. Target Population - Hepatitis B
• Women 18 years old and above who
belong to the high risk groups:
– Patients in early course of chronic liver
diseases
– Sexually transmitted disease (STD)
clinic clients
– Multiple sexual partners or prior STD
– Inmates of correctional facilities
Level I, Grade A
@helenvmadamba

76. Target Population - Hepatitis B
• Women 18 years old and above who
belong to the high risk groups:
– Clients and staff of institutions for
development disability
– Travelers to high endemicity areas
– Overseas foreign workers
– Injection drug users
– Household contacts and sexual
partners of hepatitis B virus carriers
Level I, Grade A
@helenvmadamba

77. Target Population - Hepatitis B
• Hepatitis B vaccine may be
administered to a pregnant woman
who is otherwise eligible for it.
• All HBsAg-negative pregnant women
seeking STD treatment who have not
been previously vaccinated should
receive hepatitis B vaccination.
Level III, Grade B
@helenvmadamba

78. Dose Regimen - Hepatitis B
• Hepatitis B vaccine is administered
intramuscularly in 3 doses at 0, 1, 6-
12 months.
• The accelerated schedule should be
given in 4 doses at 0, 1, 2, 12
months.
• The rapid schedule should be given
in 4 doses at 0, 7, 21 days and 12
months.
@helenvmadamba

79. Contraindications/Precautions/
Adverse Events - Hepatitis B
• A severe allergic reaction to vaccine
component or to a prior dose of
hepatitis B vaccine is a
contraindication to further doses of
the vaccine.
• Persons with moderate or severe
acute illness should not be
vaccinated until their condition
improves.
@helenvmadamba

80. Contraindications/Precautions/
Adverse Events - Hepatitis B
• Minor illnesses like upper
respiratory tract infection is not a
contraindication to vaccination.
@helenvmadamba

81. Available Preparation -
Hepatitis B
Vaccine Formulation
Recombinant hepatitis B
virus vaccine
20 mcg/mL
5 mL
@helenvmadamba

82. Levels of Evidence
Level Definition
I Evidence obtained from at least one properly
randomized controlled trial
II-1 Evidence obtained from well-designed controlled
trials without randomization
II-2 Evidence obtained from well-designed cohort or
case control analytic studies, preferably from more
than one center or research group
II-3 Evidence obtained from multiple time series with
or without the intervention
III Opinions of respected authorities, based on clinical
experience, descriptive studies and case reports or
reports of expert committes
@helenvmadamba

83. Grades of Recommendation
Grade Definition
A There is good evidence to support the recommendation of
the practice in immunization for Filipino women.
B There is fair evidence to support the recommendation of the
practice in immunization for Filipino women.
C There is insufficient evidence to recommend for or against
the inclusion of the practice in immunization for Filipino
women.
D There is fair evidence to support the recommendation that
the practice be excluded in immunization for Filipino women.
E There is good evidence to support the recommendation that
the practice be excluded in immunization for Filipino women.
GPP A good practice point (GPP) is a recommendation for best
practice based on the experience of the Technical Working
Group.
@helenvmadamba

84. #HealthXPH tweetchat
Healthcare Conversations on Twitter
Saturdays 9:00 p.m. to 10:00 p.m.
@helenvmadamba
https://www.facebook.com/helenvmadamba
http://helenvmadamba.blogspot.com
These slides are available on
http://www.slideshare.net/HelenMadamba/

85. IMMUNIZATION FOR
FILIPINO WOMEN
Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
August 17, 2016
@helenvmadamba