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Adult immunisation schedule

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immunisation schedule for various diseases in adults for developing countries

immunisation schedule for various diseases in adults for developing countries

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  • 1. Dr. A.P.NAveeN KumAr Chief sPeCiAlist (GeN. meD. ) visAKhA steel GeNerAl hosPitAl visAKhAPAtNAm steel PlANt
  • 2. Considerable controversy exists exists regarding Adult Immunisation especially in developing countries,such as India Lack of consensus regarding the optimal strategy VSGH 01/09/14
  • 3. Benefits include protection from      symptomatic illness improved quality of life and productivity and prevention of death. Social benefits include creation and maintenance of herd immunity against communicable disease prevention of disease outbreaks and reduction in health care related costs. VSGH 01/09/14
  • 4.  Benefits and risks are associated with using all immunobiologics (i.e. an antigenic substance or antibody containing preparation).  No vaccine is completely safe or effective.  Benefits of vaccine include partial or complete protection against infection for the vaccinated person and overall benefit to society as a whole. VSGH 01/09/14
  • 5.  Routine vaccines for all adults  Vaccines for high-risk exposure group ( healthcare workers,prisoners,students,military personnel,travelers,injection drug users,MSM )  Vaccines for persons at high risk for severe outcomes of infection (pregnant,elderly, chronic diseases )  Vaccines for household contacts of group 3 persons VSGH 01/09/14
  • 6.  The international guidelines do not address the issue of adult immunization in developing countries like India, unlike the most successful pediatric immunization.  In India lack of reliable data regarding epidemiology (burden of infectious diseases),  sparse published data regarding efficacy and safety of various immunization strategies and  data regarding objective monitoring of adequacy of immunization i.e. optimal antibody titers makes it difficult to come to any strong recommendations VSGH 01/09/14
  • 7.  Since 2005 two new tetanus toxoid, reduced diphtheria and acellular pertussis vaccines (Tdap) are available, 0.5 ml is administered IM in the deltoid.  Tdap vaccine was shown to be 92% efficacy in a recent RCT (Grade 1 b) VSGH 01/09/14
  • 8.  Whole cell pertussis vaccine is not used in adults because of its adverse effects and contraindicated in > 7 yrs.  Acellular pertussis vaccines are effective and less reactogenic  Two component Ap is more effective than monocomponent  Addition of pertactin and fimbria further increases efficacy  Recommended in adolescents and adults as a combination vaccine VSGH 01/09/14
  • 9.  Adult primary series: 3 doses of Td, Tdap can substitute one of the doses ◦ 3 doses: 0, +4 weeks, +6-12 months  Booster with either Td or Tdap For adults in the age group 18 to 64 years a booster of Td vaccine - every 10 years till the age of 65 , one dose of Tdap vaccine - in place of Td vaccine. VSGH 01/09/14
  • 10. Tdap 1 dose 2 weeks prior to contact  HCP - 1 dose of Tdap  VSGH 01/09/14
  • 11.  Planning pregnancy – 1 dose of Tdap  Pregnant Already immunised – 1 dose of Td in 2 or 3 trimester if > 10 yrs immunised Td received within 10 yrs – Tdap in postpartum  No h/o immunisation 3 doses – 0,1& 6 months Td starting in 2 or 3 trimester VSGH 01/09/14
  • 12.  H/o of TT doses wound  Not known  3 or > doses Minor wound Tdap / Td Tdap /Td if > 10 yrs Major Tdap/Td/TIG Tdap /Td if > 5 yrs VSGH 01/09/14
  • 13. Tdap vaccination deferred in moderate and severe infections Unstable neurologic conditions ADACEL BOOSTRIX VSGH 01/09/14
  • 14.  95% of adults develop protective antibody in 4 weeks  100% seroconvert after two doses  Indicated for: • Travelers to areas of high hepatitis A endemicity • Men who have Sex with Men (MSM) & IV Drug abusers • Patients with chronic liver disease • Patients who receive clotting factors  Administer: ◦ 2 dose schedule: 0 & +6-18 months VSGH 01/09/14 ◦ Single dose provides ~ 1 year immunity
  • 15.  Universal immunization for hepatitis is not recommended as yet.   There are single antigen ,HAV antigen vaccine and combination vaccines - HAV and HBV antigens  Adults at risk of developing hepatitis A and are negatives for anti HAV antibodies are likely to benefit most.   HAV immunoglobulin (0.02 ml/mg) seems more efficacious than vaccine in post exposure prophylaxis - especially in adults  Combine vaccine 4 dose schedule 0, 7, 21-30 days and booster at 12 months allows greater protection to travelers to VSGH 01/09/14 depart in less than 1 month .
  • 16. Vaqta ( Merck )  Havrix ( GlaxoSmithKline )  Twinvix (GSK )  VSGH 01/09/14
  • 17.   On demand All adults at risk: • People who work or live in areas with high endemicity for Hepatitis B-Health-care workers • Occupational & recreational blood exposure • Travellers to areas of high hepatitis B endemicity • Sexual exposure: sex partner of hepatitis B patient, promiscuous sex (STD clinic patients), & MSM ,IV Drug abusers • ESRD on HD ,HIV infection & Chronic Liver Disease • Persons with Diabetes < 60 yrs. • Household contacts and sex partners of HbS Ag carrier VSGH 01/09/14
  • 18.  HBV vaccine is available as a recombinant vaccine for immunocompetent adult  20mcg is administered at 0, 1 and 6 months as an intramuscular injection in the deltoid using a 24 – 38 mm needle (level A).  Antibody titres rise 20 to 30% after the first dose, 75 to 80% after 2 nd dose and 90 to 95% after 3 rd dose.   Booster dose not routinely recommended.  CKD patient with declining antibody titers < 10 mIU/ml , < 100 Miu / ml in patients on dialysis a booster dose is recommended.  For patients of CKD and immunocompromised patients 2 doses of 20 mgs/ml at 0,1,2 and 6 months   VSGH 01/09/14
  • 19. VSGH 01/09/14
  • 20.  Further 3 doses  Retest after 2 months  40 mg at 0,1 &6  GM-CSF (150-300 MGS sc ) -24 hrs. later with 40 mgs VSGH 01/09/14
  • 21.  Live, attenuated, virus vaccine ◦ Contraindicated in pregnancy &  For children (>12 months) & adults, particularly adult: • • • • • • •  immunocompromised Health care workers Primary school teachers & day care workers Institutional residents and employees College students Military personnel Non-pregnant women of child bearing age International travelers 2 dose adult schedule: 0 & 4-8 weeks – No booster VSGH 01/09/14
  • 22.  Documentation of vaccination  h/o of varicella based on diagnosis  h/o of herpes zoster  Laboratory  Pregnant women- first dose in postpartum period or before discharge and second dose 4-8 weeks later  Avoid conception for 1 month after each dose e/o immunity VSGH 01/09/14
  • 23.  2 Vaccines are available containing attenuated like V2V (Oka Strain).  Varicella zoster immune globulin(V214) can be given to prevent Varicella in non immune, healthy individuals within 72 hours of exposure -125 units / 10 kg of body weight upto max.625  Vaccine is 2 doses 4 to 8 weeks apart.  All adults without e/o immunity – 2 doses  Second dose if 1 dose is recieved VSGH 01/09/14
  • 24.  Vaccine within 3 days  VZIG Immunocompromised persons Pregnant HIV CD4 <200 High dose steroids Neoplastic diseases  Varicella vaccine is delayed by 5 months after VZIG administration VSGH 01/09/14
  • 25.  Herpes zoster vaccine is being advocated to adults aged 60 years and above  Who are at risk for developing recurrent herpes zoster, such as patient with CKD, diabetes mellitus, rheumatoid arthritis and COPD  SINGLE DOSE IS ADVOCATED VSGH 01/09/14
  • 26.  MMR vaccine includes live, attenuated measles, mumps, and rubella virus  Contraindicated for immunosuppressed: ◦ Symptomatic HIV+ (asymptomatic OK) ◦ Steroids (>20 mg/day) ◦ Congenital immune deficiencies ◦ Leukemia, lymphoma, advanced malignancy ◦ Chemotherapy & radiation therapy VSGH 01/09/14
  • 27.    Born prior to 1957 considered measles & mumps immune Adults born since 1956 should have at least one dose of the two dose series One dose for women with either none or uncertain immunity ◦ Do not vaccinate pregnant women or women who might become pregnant within 4 weeks of vaccination Pregnant women with no e/o immunity – MMR after completion or termination of pregnancy and before discharge  Two doses indicated for: ◦ Adults exposed to measles ◦ Adults vaccinated with killed measles vaccine ◦ Adult students ◦ Health care workers without measles or mumps immunity ◦ International travelers  No booster after 2 doses Single dose only is advocated if h/o vaccination + VSGH 01/09/14 
  • 28. Double stranded DNA virus – more than 100 types   60 types  cutaneous infection  skin warts 40 types  mucosal & genital infection  Type 16 causes 50%; Types 16 + 18 cause 70%  Type 16 causes 10% of HPV genital infection in ♀s ◦ Causes squamous cell & adenocarcinoma ◦ Types 6 & 11  90% of anogenital warts ◦ 70% of cervical cancers, 80% of anal cancers, ◦ 60% of vaginal cancers, and 40% of vulvar cancers VSGH 01/09/14
  • 29.  Two vaccines are available -0.5 ml IM injection at 0, 2 and 6 months.  Gardasil (HPV),[3] specifically HPV types 6, 11, 16 and 18.  Cervarix - infection from HPV types 16 and 18   The vaccine has to be delivered prior to exposure to the HPV.  Therefore the immunization must precede the sexual debut  The HPV vaccine can be given simultaneously with other vaccines eg., Hepatitis B, Tdap.   Contraindicated in those who are hypersensitivity and pregnancy. No contraindication during lactation and immunocompromised.   VSGH 01/09/14
  • 30.  Quadrivalent (HPV4 ) or bivalent ( HPV2 ) recommended for females 11 or 12 yrs. And catchup vaccination from 13-26 Yrs.  Sexually active females not infected with any of the 4 types (6,11,16 &18) or 2 types ( 16 &18 ) receive full benefit of vaccination.  Less beneficial for females infected with one or more of vaccine types  Can be administered to persons with genital warts,PAP positive or positive HPV DNA test  In males 9-26 yrs. to reduce genital warts  DOSAGE SCHEDULE 0 , 1-2 & 6 MONTHS VSGH 01/09/14
  • 31.  Not recommended in pregnant women  Pregnancy testing not necessary before vaccination  Found pregnant during vaccination series no intervention is needed  Remainder of series is given after completion of pregnancy  Not specifically recommended for HCP  HCP should receive as recommended VSGH 01/09/14
  • 32. Recorded Influenza Pandemics VSGH 01/09/14
  • 33. When the antigenic match between vaccine and circulating virus is close, prevents  <65: prevents 70-90%  >65: prevents only 30-40% of clinical illness But: ◦ Prevents hospitalization in 50-60% ◦ Prevents death in 80% VSGH 01/09/14
  • 34.  Trivalent inactivated influenza vaccine (TIV) and live attenuated influenza vaccine (LAIV) are available in India. TIV is annual, single IM dose of 0.5 ml.  LAIV is administered by the intranasal route is approved for use in adults upto 50 years of age. Evidence recommends people at high risk for influenza related complication. VSGH 01/09/14
  • 35.  Annual vaccination for all persons > 6 months  Healthy, nonpregnant adults < 50 yrs without medical complications – live or inactivated  Others should receive inactivated  Adults >65 –receive standard vaccine or high dose influenza vaccine ( Fluzone ) VSGH 01/09/14
  • 36.  Two types (1) polysaccharide vaccines and (ii) conjugate vaccine are available.  Single dose 0.5 ml of reconstituted vaccine is administered subcutaneously in the deltoid region.  Useful in (a) during an outbreak b) during inter epidemic period and c) to travelers, pilgrims and people attending fairs and festivals d)incoming freshmen who live in dormitories e) asplenia ,splenectomy and sickle cell anemia patients  Ineffective in children < 2 yrs. Protection for 5 yrs. VSGH 01/09/14
  • 37.  2 doses recommended for adults with anatomic or functional asplenia or persistent complement component deficiency  Dosage 0 and 2 months  HIV -2 doses  Meningococcal conjugate vaccine ,quadrivalent (MCV4 ) 55 yrs. and younger  Meningococcal polysaccharide vaccine (MPSV4 ) 56 yrs. and older  Revaccination with MCV4 every 5 yrs. For adults at increased risk of infection VSGH 01/09/14
  • 38.  Not routinely recommended  Quadrivalent polysaccharide vaccine to Haj pilgrims  For travellers going to endemic countries > 2 yrs. - A single dose  On demand for high risk personnel VSGH 01/09/14
  • 39.  The polysaccharide vaccine most commonly used today -purified polysaccharides from 23 serotypes (1, 2, 3, 4, 5, 6b, 7F, 8,9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F and 33F).  This immune response is less robust than response by conj. vaccines  The vaccine is ineffective in children < 2 yrs. old, presumably   Non-responders are also common amongst older adults.   Immunization is not lifelong, so individuals must be re-vaccinated every 5–6 years.   Since no mucosal immunity is provoked, the vaccine does not affect carrier rates, promote herd immunity, or protect from upper or lower respiratory tract infections VSGH 01/09/14
  • 40.  The conjugated vaccine consists of capsular polysaccharides covalently bound to the diphtheria toxoid CRM197, which is highly immunogenic but non-toxic. [  This combination provokes a significantly more robust immune response  This results in mucosal immunity and eventual establishment of lifelong immunity after several exposures. [   The main drawbacks to conjugated vaccines are that they only provide protection against a subset of the serotypes covered by the polysaccharide vaccines.    The normal 4-dose series is given at 2, 4, 6 & 12–14 months of age. VSGH 01/09/14
  • 41.  Active against 88% of bacteremic pneumococcal pneumonia  Cross-reactive for an additional 8% of bacteremic disease  Prevents 60-70% of invasive disease  Does not prevent pneumococcal pneumonia Not effective in children < 2 y/o-does not respond to polysaccharide so a heptavalent protein conjugate vaccine is developed VSGH 01/09/14
  • 42.            All >64 y/o Chronic pulmonary disease (except asthma) Chronic cardiovascular disease Diabetes mellitus Chronic liver disease Chronic renal failure & nephrotic syndrome Asplenia – functional or anatomical (pre-surgery) Immunosuppression & HIV Neoplasia: leukemia, lymphoma, multiple myeloma Cochlear implants (pre-placement) Special populations: Native Americans & longterm-care-facility residents VSGH 01/09/14
  • 43.  After 5 years for : ◦ ◦ ◦ ◦  Chronic renal failure & nephrotic syndrome Asplenia – functional or anatomical Immunosuppression & HIV Neoplasia: leukemia, lymphoma, multiple myeloma For >65 y/o if: ◦ Vaccinated >5 years ago & ◦ <65 when first vaccinated VSGH 01/09/14
  • 44. 1 dose should be considered for persons who have sickle cell disease , leukemia or HIV infection or who had a splenectomy if they have not received the Hib vaccine previously VSGH 01/09/14
  • 45.  Is recommended as part of routine immunization in adolescents (Grade A).  Either the orals Ty21a vaccine or inject able VI polysacchride may be used. Entire community at risk during an outbreak should be vaccinated or at least individual aged 2 – 19yrs should be specifically given.  VSGH 01/09/14
  • 46.  No recommendation for routine vaccination of adults  Pregnancy – not safe  Injectable Vi – HIV <200  Both Ty21a &Vi - HIV >200 VSGH 01/09/14
  • 47.  Intra dermal two sites dose 0.1 ml day 0, 3, 7,14 & 28.  Passive immunization is carried out with human rabies immunoglobulin (HRIG) 10 20 IU/ug infiltrate the site of bite then rest is given IM. VSGH 01/09/14
  • 48.  The two currently available oral cholera vaccine are not recommended for routine adult immunization (grade C).  Ongoing Randomized control trial in Kolkata modify this recommendation.  Basic measures of safe drinking water, food hygiene and health education are key factors essential for control of cholera. VSGH may 01/09/14
  • 49.  Routine immunisation better avoided  Tetanus toxoid must  Diphtheria toxoid safe  Live viruses contraindicated  If risk of exposure is great other vaccines like polio,yellow fever,hep B, influenza,pneumococcal can be given in 2 or 3 trimester VSGH 01/09/14
  • 50.  Yellow fever and killed cholera vaccine  Routine immunization to polio,measles,DPT  Hep A ,meningococcal,rabies,Japanese B encephalitis,Plague for certain regions VSGH 01/09/14
  • 51.  Measles -0.25-0.50 ml /kg or 40-80 mg of IgG/kg active immunisation after 3-6 months  Rubella – 0.55 ml/kg or 90 mg of IgG /kg im  Tetanus – human tetanus immunoglobulin 10-20 mg of IgG /Kg IM  Rabies – human rabies immunoglobulin 20 IU/Kg  Hepatitis A – Immune serum globulin 0.02-0.04 ml/kg every 5 months VSGH 01/09/14
  • 52. For Healthy Adults: Vaccine 19-49 50-64 >65 q 10 yrs Td HPV 3 doses, ♀ MMR 1 or 2 doses Varicella 2 doses Influenza 1 dose q year Pneumococcal 1 dose Hepatitis A Hepatitis B Meningococcal VSGH 01/09/14
  • 53. For Adults with Health Problems: Vaccine 19-49 50-64 >65 Td HPV 1 dose MMR Varicella Influenza Pneumococcal 2 doses q year 1-2 doses Hepatitis A 2 doses Hepatitis B 3 doses Meningococcal 1 or more doses VSGH 01/09/14
  • 54.  Off schedule? – Do not restart series, just pick-up where left off and continue  Multiple vaccines? – Can usually co-administer vaccines, such as: Pneumococcal and influenza & travel vaccines Exceptions: ◦ Live virus vaccines: delay one for a month to avoid possible impaired immune response to either agent ◦ Immune globulins should not be given with live virus vaccines (exceptions: inactivated virus vaccines, oral polio, and yellow fever) VSGH 01/09/14
  • 55. Vaccine Administration   Ensure you are properly trained Always prepare and check the following for every injection or medication you give: − − − − − Right Patient Right Drug (vaccine) Right Dose Right Route (intramuscular, intradermal) Right Time (is scheduling correct) VSGH 01/09/14
  • 56. API GUIDELINES JAPI APRIL -2009.VOL-57 'Vaccine Information.org 'Vaccine Information for the Public and Health Professionals' http://www.sh.lsuhsc.edu/IntraGrad/micro/OLD -Micro289/2003/289%20PID %2003%20Vaccines%20.DOC http://www.bio.davidson.edu/Courses/Molbio/ MolStudents/01teparakh/Methods.htm http://web.uct.ac.za/depts/mmi/jmoodie/vacc2. html www.ImmunizeTexas.com www.immunize.org/catg.d/p2011.pdf* Department of health and human services Centers for Disease Control and Prevention VSGH 01/09/14

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