Its all about immunization options for adult population available in Bangladesh. [up to January, 2016]

1. Adult
Immunization
DR. TALHA-SAMI-UL-HAQUE
HMO
DEPT. OF MEDICINE
DHAKA MEDICAL COLLEGE HOSPITAL

2. What is immunization?
Immunization is the process whereby a person
is made immune or resistant to an infectious
disease, typically by the administration of a
vaccine. Vaccines stimulate the body's own
immune system to protect the person against
subsequent infection or disease.

3. History of Vaccination
 429 BC : Greek historian Thucydides noticed that
people who survive smallpox do not get re-infected.
 900 AD : Chinese discovered variolation
 1700s : Variolation spreads around the world
 1796 : Edward Jenner discovered vaccination in its
modern form and proved to the scientific community
that it worked.

4. EDWARD
JENNER
Discovered the small pox vaccine in
its modern form and proved to the
scientific committee that it worked.

5. History of Vaccination
 1890: Emil von Behring discovers the basis of DT vaccine
 1920s: Vaccines become widely available.
 1955: Polio vaccination begins.
 1956: WHO fights to eradicate smallpox.
 1980: Smallpox eradicated from the world.
 2008: Professor Harald zur Hausen awarded Nobel Prize for
discovery of HPV Vaccine.
 2013: Rotavirus vaccine and shingles vaccine introduced.

6. Louis
Pasteur
Discovered the rabies
vaccine

7. Vaccine Preventable Diseases [CDC]
 Anthrax
 Cervical Cancer
 Diphtheria
 Hepatitis A
 Hepatitis B
 Haemophilus
influenzae type b (Hib)
 Human
Papillomavirus (HPV)
 H1N1 Flu(Swine Flu)
 Rabies
 Rotavirus
 Rubella (German
Measles)
 Shingles (Herpes
Zoster)
 Smallpox
 Tetanus (Lockjaw)
 Tuberculosis
 Typhoid Fever
 Varicella (Chickenpo
x)
 Yellow Fever
• Influenza (Seasonal Flu)
• Japanese
Encephalitis (JE)
• Measles
• Meningococcal
• Mumps
• Pertussis (Whooping
Cough)
• Pneumococcal
• Poliomyelitis (Polio)

8. Vaccine-Preventable Adult
Diseases [CDC]
 Chicken Pox (Varicella)
 Diphtheria
 Flu (Influenza)
 Hepatitis A
 Hepatitis B
 Human Papillomavirus
(HPV)
 Measles
 Meningococcal Disease
 Mumps
 Pneumococcal
 Rubella
 Shingles (Zoster)
 Tetanus
 Whooping Cough
(Pertussis)

12. Influenza vaccination
 Annual vaccination against influenza is recommended
for all persons aged 6 months or older.
 Adults aged 18 years or older can receive the
recombinant influenza vaccine (RIV)
 Healthy, nonpregnant persons aged 2 to 49 years
without high-risk medical conditions can receive either
intranasally administered live, attenuated influenza
vaccine (LAIV)

13. Vaccines
 Trivalent inactivated influenza vaccine (TIV) and
 Live attenuated influenza vaccine (LAIV)
 The TIV contains
 A/17/California/2009/38(H1N1),
 A/Brisbane/ 10/2007 (H3N2), and
 B/Brisbane/60/2008 strains.
 Live attenuated influenza vaccine (LAIV) contains
 A/17/California/2009/38 like strain
 Schedule
 The TIV - annual, single dose of 0.5 ml IM or deep
subcutaneous injection.
 The LAIV – 0.5 ml intranasal (spray 0.25 ml per nostril)
13
Influenza cont…

14. Recommendations
 People aged > 19 years.
 Chronic obstructive pulmonary disease
(COPD).
 Cardiac diseases
 Diabetes Mellitus, Cancer
 Immunodeficiency, Renal Disease
 Haemoglobinopathies
 Pregnant Women
 Health Care Providers
 Adult household contacts
 Travelers to endemic area
14
Influenza cont…

15.  August - September is the optimal time to receive an annual flu
shot to maximize protection.
 Influenza vaccine may be given at any time during the influenza
season (typically October to March) or at other times when the risk
of influenza exists.
 May give with all other vaccines but as a separate injection.
Contraindications
 Previous anaphylactic reaction to this vaccine, to any of its
components, or to egg proteins.
 Moderate to severe acute illness or febrile illness.
15
Influenza cont…

16. Side effects:
 Fever, malaise, shivering, fatigue, headache, joint or
muscle pain – Disappear within 1-2 days without
treatment.
 Rarely- neuralgia, paresthesia, convulsion, shock,
vasculitis.
Price range: 500 - 650 taka
Influenza cont…

17. Efficacy of Tdap vaccine - 92% in a recent RCT.
Dosage: 40IU/ 0.5ml IM injection.
Recommendations:
 For adults in the age group of 18 to 64 years
 Three dose series if never vaccinated at 0 and 4
weeks, the third 6-12 months after second
 One dose booster of Tdap every 10 years
17

18.  Health care personnel, especially those in direct contact with the
patients, who have not received Tdap vaccine should receive a single
dose of Tdap vaccine if 2 years or more have elapsed since the last
dose of Td vaccination.
 Women planning pregnancy should receive one dose of Tdap
vaccine if they had not received it previously.
18
Tdap cont…

19.  For Pregnant Women
Last dose Recommendation
> 10 Years 1 dose in 2nd or 3rd trimester
2-10 years 1 dose immediate postpartum
Never 3 doses 0, 1, 6 months
 During outbreak if previous unimmunized or Td before 2 years give
1 dose of Tdap
19
Tdap cont…

20. Tetanus Prophylaxis In Routine Wound
Management
*TIG: Tetanus immunoglobulin (250 IU IM)
**Yes, if more than 10 years since last dose
***Yes, if more than 5 years since last dose
For children less than 7 years, DTP may be given and above
7 years TT or Td .
20
Tdap cont…
Doses of TT Clean, minor
wounds
All other wounds
Given in past TT TIG* TT TIG*
Unknown,
<3doses
Yes No Yes Yes
≥ 3 doses No** No No*** No

21. Contraindications
 History of anaphylaxis to any component.
 History of encephalopathy within 7 days of previous
vaccination of Tdap.
 Moderate or severe acute illness, and those with
unstable neurologic conditions (e.g., stroke, acute
encephalopathies)
 Tdap vaccination is to be deferred until the acute illness
resolves.
21
Tdap cont…

22.  Side effects: transient swelling at injection
site, fever, malaise, nausea, vomiting, pruritus,
anaphylactic reaction.
 Price range: 100-300 taka
Tdap cont…

23. Varicella (Chickenpox)
vaccination
23
Live attenuated VZV (Oka strain) vaccines
for varicella virus are currently available.
• Dosage: 0.5ml SC
• Schedule:
 > 13 years - 2 doses are recommended.
– Interval between 2 doses should be 4–
8wks.

24. Varicella cont…
Recommendations:
• All susceptible adults and adolescents should be
vaccinated.
• It is especially important to susceptible persons
– Health care workers
– Family contacts of immunocompromised persons
– High risk of exposure (e.g., teachers, day care
employees, military personnel, and international
travelers).
24

25.  People with reliable histories of chickenpox (such as
self or parental report of disease) can be assumed to
be immune.
 For adults who have no reliable history, serologic
testing may be cost effective since most adults with a
negative or uncertain history of Varicella are immune.
25
Varicella cont…

26. Contraindications
 Previous anaphylactic reaction to this vaccine or to any of its
components.
 Pregnancy, or possibility of pregnancy within 1 month.
 Immunocompromised persons due to malignancies and
primary or acquired cellular immunodeficiency including
HIV/AIDS.
 Salicylates to be avoided for 6wks after receiving varicella
vaccine because of a risk of Reye’s syndrome.
PRICE RANGE: ~1500 taka
26
Varicella cont…

27. Human Papilloma Virus
vaccination
Papilloma virus infection is precursor to cervical cancer
 Types 16, 18 account for 70% of cervical cancers
Vaccines
Two types HPV vaccines are available.
 quadrivalent vaccine [HPV4] containing HPV virus
L1 protein like particles of HPV 6,11,16, and 18
 bivalent vaccine [HPV2] containing L1 VLPs of HPV
16,18.
Dosage: 0.5ml IM [ into deltoid muscle]
27

28. Schedule
 HPV4, 3 doses- 0.5ml IM at 0, 2, and 6 months.
 HPV2, 3 doses - 0.5 ml IM at 0, 1 and 6 months.
[For males, HPV4 is recommended in a 3-dose series for routine
vaccination at age 13 through 21 years. Males aged 22 through 26
years may be vaccinated if risk factor present.]
28
HPV cont…

29. Recommendations
 The vaccine has to be delivered prior to exposure to the HPV virus.
Therefore, the immunization must precede the sexual debut.
 Age for initiation for vaccination to be 10 - 12 years.
 Catch-up vaccination can be advised up to the age of 45 years.
29
HPV cont…

30. Contraindications
 Pregnancy
 Patients with hypersensitivity to any of the vaccine components.
 Not recommended for girls <10 year of age
Special situations
 The HPV vaccine is not contraindicated during lactation.
 The vaccine can be administered to immunosuppressed individuals.
30
HPV cont…

31. Several mild self limiting problems may occur with HPV vaccine:
 Pain at the injection site ( 8 people in 10)
 Redness or swelling at the injection site (1 in 4)
 Mild fever (100 oF) (1 in 10)
 Itching at the injection site (1in 30)
 Moderate fever (102 oF) (1 in 65)
 Headache, nausea, vomiting, diarrhea, myalgia.
 Others: RTI, Lymphadenopathy, anaphylactic reaction, syncope.
31
HPV cont…

32.  Price range: ~ 1600 taka
HPV cont…

33. Measles, Mumps And
Rubella vaccination
The measles and the rubella components are
produced using human diploid cells while the
mumps component is produced from chick
embryo.
Dosage: 0.5 ml should be administered
subcutaneously into outer aspect of the upper
arm.
33

34. Recommendations
 Adults who are > 18yrs of age should
receive at least one dose of MMR if
there is no serologic proof of immunity
or documentation of a dose given
previously.
 Adults in high-risk groups, such as
health care workers and international
travelers, should receive two doses.
 All women of childbearing age who do
not have acceptable evidence of rubella
immunity or vaccination.
34
MMR cont…MMR cont…

35. Schedule
 One or two doses are needed 12 wks apart.
 If a pregnant woman is found to be rubella susceptible, administer
MMR postpartum.
 Protection against measles after exposure: single dose within 72 hour
of contact.
35
MMR cont…MMR cont…

36. Contraindications
 Previous anaphylactic reaction to this vaccine, or to any of its
components.
 Pregnancy or possibility of pregnancy within 4 weeks (use
contraception).
 Persons immunocompromised due to cancer, leukemia, lymphoma,
immunosuppressive drug therapy, including high-dose steroids or
radiation therapy.
 Administration of blood or blood products:
 who received blood products: should wait at least 3 months before
vaccination and, if possible, blood products should be avoided for up to
2 weeks post vaccination.
 Vaccinated persons are not eligible to donate blood for 1 month after
vaccination.
36
MMR cont…MMR cont…

37. Side effects:
 Fever, atypical measles, syncope, malaise, irritability
 Vasculitis,
 Pancreatitis, vomiting, diarrhea,
 Diabetes mellitus
 Thrombocytopenia
 Anaphylaxis
PRICE RANGE: 400-500 taka.
MMR cont…

38. Pneumococcal vaccination
Two types:
 13-valent pneumococcal conjugate vaccine [PCV13]
and
 23-valent pneumococcal polysaccharide vaccine
[PPSV23] [for adult]

39. Schedule
A single standard dose (0.5 ml) is
administered by the intramuscular
or subcutaneous route.
Revaccination: 0.5ml IM or SC at
least after 5 years of 1st dose in case
of High risk people.
39
PPV cont…

40. Recommendations
 Adults who are 65yrs of age or older.
40
High risk people
• Anatomic asplenia
• Sickle cell disease
• Immunocompromised
persons including HIV
• Leukemia, Lymphoma
• Hodgkin’s disease
• Multiple myeloma
• Generalized malignancy
• Chronic renal failure
• Nephrotic syndrome
• Chemotherapy &
corticosteroids
• Organ or bone marrow
transplant.
• Pregnant women with high-
risk conditions
PPV cont…

41. Contraindications:
 Known allergy
 Acute illness or relapse of chronic disease
 Vaccinated within 3 years
Side effects:
 Local reaction
 Fever, adenopathy, allergic reaction, headache, malaise.
Price range: ~1000 taka
PPV cont…

42. Hepatitis B vaccination
Protection (anti-HBs antibody titer of 10mIU/ml
or higher) after recombinant vaccine
 After first dose - 20% to 30%
 After second dose - 75% to 80%
 After third doses - 90% to 95%
Recommendations
 All unvaccinated adult risk for HBV infection
and
 All adults seeking protection from HBV
infection including post-exposure prophylaxis.
42

43. Dosage:
 For immunocompetent adults, 1ml (20 μg) of recombinant
vaccine is administered at 0, 1, and 6 months as an intramuscular.
 Adult patients receiving hemodialysis or with other
immunocompromising conditions should receive 1 dose of 40
mcg/mL administered on a 3-dose schedule at 0, 1, and 6 months
or 2 doses of 20 mcg/mL administered simultaneously on a 4-
dose schedule at 0, 1, 2, and 6 months.
HBV cont…

44. Pre vaccination screening:
 Pre vaccination screening in general population has not
been found to be cost effective.
 Pre vaccination screening may be cost-effective in adult
populations with a prevalence of HBV infection of >20%
such as
 Household or sexual contacts of HBsAg-positive
persons;
 HIV infected persons
 Injection drug users
 Men who have sex with men
 Patients with chronic liver disease (CLD)
 End-stage renal disease (ESRD).
44
HBV cont…

45. HBV cont…
45

46. BOOSTER DOSE:
 Booster doses of HBV vaccine are not indicated in
persons with normal immune status .
 For CKD patients, the need for booster doses should
be assessed by annual anti-HBs antibody titre testing.
 A booster dose should be administered when anti-HBs
levels decline to less than 10 mIU/ml & <100 mIU/ml
in patients on dialysis.
HBV cont…

47. Contraindications
 Previous anaphylactic reaction to this vaccine or to
any of its components.
 Moderate or severe acute illness.
 Severe immunodeficiency.
Side effects:
 GI disturbance, Musculoskeletal/ joint pain,
hypotension, tachycardia, dysuria, earache.
PRICE RANGE: 250-600 taka
47
HBV cont…

48. Hepatitis A vaccination
Two types:
 Live attenuated HAV vaccine
 Hepatitis A virus [inactivated] vaccine
Dosage:
1ml injection IM
48

49. Schedule
 At least single dose.
 2nd doses of 1ml as booster dose at 6-18 month
interval.
 Immune status for hepatitis A should be checked
Hepatitis A cont…

50. Recommendations
 The Expert Group felt that universal immunization for hepatitis A is not
recommended as yet.
 Not only is the vaccine costly, more epidemiological data are required to
ascertain its benefits.
 Adults at risk for acquiring hepatitis A, and adults who are negative for anti-
HAV antibodies are likely to benefit most in view of changing epidemiology.
 high-risk groups should be considered:
 travelers to areas of intermediate or high endemicity,
 those requiring life-long treatment with blood products,
 men who have sex with men,
 injection drug users.
 In addition, patients with chronic liver disease are at increased risk for fulminant
hepatitis A and should be vaccinated.
50
Hepatitis A cont…

51. Contraindications
 Previous anaphylactic reaction to this vaccine or to
any of its components.
 Moderate or severe acute illness.
 Safety during pregnancy has not been determined, so
benefits must be weighed against potential risk.
Side effects:
soreness, erythema, fever, malaise, anaphylaxis.
PRICE RANGE: 1000-1200 taka
51
Hepatitis A cont…

52. Meningococcal vaccination
Types
 Polysaccharide vaccines
 Bivalent (A&C)
 Quadrivalent (A,C,Y & W135)
 Conjugate vaccines.
 The vaccine does not induce herd immunity
and has no effect on nasopharyngeal carriage.
 Containing 50 μg of polysaccharide per dose.
 After reconstitution use within 8-12 hours.
52

53. Schedule
 A single dose of 0.5 ml SC in deltoid region.
 Revaccination with A,C,Y & W135 every 5 years is
recommended for adults previously vaccinated who
remain at increased risk for infection (e.g., adults with
anatomical or functional asplenia, persistent
complement component deficiencies, or
microbiologists)
53
Meningococcal cont…

54. Recommendations
The meningococcal vaccine can be used in selected
populations in certain situations, such as
 During an outbreak (HCW, Lab. worker, Close contacts
)
 During inter-epidemic period
 To travelers, pilgrims(Quadrivalent), people attending
fairs and festivals(bivalent 10-14 days prior).
54
Meningococcal cont…

55.  Mass vaccination may be considered depending on the
age-specific attack rate, geographical distribution of
cases, and the availability of vaccine.
 During the inter-epidemic period, to personnel living in
dormitories; military recruits; jail inmates;
immunocompromised individuals.
 Adults with anatomic or functional asplenia, or terminal
complement component deficiencies.
55
Meningococcal cont…

56. Contraindications
 Previous anaphylactic reaction to this vaccine or to any of its
components.
 GBS patient.
Side effects:
GI symptoms, Local reaction, fever, malaise, anaphylaxis.
Price range: 500-600 taka.
Meningococcal cont…

57. Haemophilus influenzae type
b (Hib) vaccination
 Hib vaccine is not required for healthy children after 5 years of
age.
 One dose of Hib vaccine should be administered to persons
who have anatomical or functional asplenia or sickle cell
disease or are undergoing elective splenectomy if they have
not previously received Hib vaccine. Hib vaccination should be
done 14 or more days before splenectomy is suggested.

58.  Recipients of a hematopoietic stem cell
transplant (HSCT) should be vaccinated with a
3-dose regimen 6 to 12 months after a
successful transplant, regardless of vaccination
history; at least 4 weeks should separate
doses.
Hib cont…

59.  Dosage: 10mcg IM injection
 Contraindication: Hypersensitivity to any
component.
 Side effect: Local reaction, fever, malaise.
 Price range: 200-500 taka
Hib cont…

60. Herpes zoster (shingles)
vaccination
 Shingles is caused by a reawakening of
the chickenpox virus
 Symptoms – rash usually along nerve
pathways
 Very painful and debilitating
 20-30 % people can expect to get
shingles in their lifetime
60

61. Schedule
 Single 0.65 ml dose subcutaneously in the upper arm.
 The vaccine must be used within 30 minutes after
reconstitution.
61
Herpes Zoster cont…

62. Recommendations
 Recommended for persons > 60 years.
 High risk for developing recurrent herpes zoster, such as
 Patients with chronic medical conditions (CKD, diabetes mellitus,
rheumatoid arthritis, and chronic pulmonary disease);
 Persons who are likely to have severe immunosuppression in
near future.
62
Herpes Zoster cont…

63. Rabies vaccination
 Production and use of nerve-tissue rabies vaccines
should be discontinued and replaced with cell-culture-
based vaccines (CCVs).
 Recommended for anyone who will be at continual,
frequent or increased risk of exposure to the rabies
virus, either as a result of their residence or
occupation. Travelers with extensive outdoor exposure
in rural high-risk areas where immediate access to
appropriate medical care may be limited should also
be vaccinated regardless of the duration of stay.

64.  Dosage: 1ml Intramuscular administration: For
adults and children aged ≥2 years, the vaccine
should always be administered in the deltoid
area of the arm.
Rabies cont…

65. Schedule:
 Pre exposure Immunization/ primary vaccination: D0, D7,
D21, D28
 Post exposure Rx:
 Non vaccinated: D 0, 3, 7, 14, 28 [with immunoglobulin if need]
 Previously Vaccinated <3 years: D 0, 3
 Previously Vaccinated >3 years: D 0, 3, 7, 14, 28 [with
immunoglobulin if need]
Rabies cont…

66.  Contraindication:
only pre exposure: severe fever, acute disease, known
hypersensitivity to component.
Side effects: Local reaction, GI sumptoms, dyspnea,
wheezing.
Price range: 500-650 taka
Rabies cont…

67. Typhoid vaccination
Types:
 Vi polysaccharide typhoid vaccine
X Ty21a live oral vaccine [liquid form]
 Ty21a live oral vaccine [capsule form]

68. Dosage:
 Vi polysaccharide typhoid vaccine: one parenterally
administered dose 0.5 ml
 the capsule form of Ty21a (for use in individuals from
the age of 5 years) requires 3 or 4 orally administered
doses.
 Booster - In most endemic settings, a booster dose of
the concerned vaccine 3 to 7 years after the primary
immunization seems appropriate.
Typhoid cont…

69. Contraindications
 Previous anaphylactic reaction to this vaccine or to
any of its components.
 Moderate or severe acute febrile illness.
 Safety during pregnancy has not been determined, so
benefits must be weighed against potential risk.
Side effects:
Local reactions, fever, malaise, GI symptoms, urticaria.
PRICE RANGE: 300-450 taka
69
Typhoid cont…

71. Recommended Vaccines for
Healthcare Workers [CDC]
Healthcare workers should maintain an immunization
history for:
 Hepatitis B
 Influenza *
 MMR
 Varicella (chickenpox)
 Tetanus, diphtheria, pertussis
 Meningococcal**
 Typhoid**
 Poliomyelitis**
71
* Receive annually
** For specific healthcare personnel

72. Recommended vaccines for
travelers to BANGLADESH [CDC]
72
Source : CDC
All travelers: measles-mumps-rubella (MMR) vaccine,
diphtheria-tetanus-pertussis vaccine, varicella
(chickenpox) vaccine, polio vaccine, and your yearly
flu shot.
Most travelers: Hepatitis A, typhoid
Some travelers: hepatitis B, Japanese Encephalitis,
malaria [preventive management], Rabies.

73. Adult Immunization
Challenges
 Inadequate funding for vaccines and
administration in public programs
 Lack of knowledge – both patients and
providers
 Poor public health and private infrastructure
for vaccine delivery.
 Lack of availability of vaccine.
 High cost of vaccine.
73

74. Reasons -Aware but not receiving
vaccine
74
Source: Johnson et al, Barriers to Adult Immunization, The American Journal of Medicine,
Vol 121, No 7B, July 2008

75. Reasons -Aware but not receiving
vaccine
75
Source: Johnson et al, Barriers to Adult Immunization, The American Journal of Medicine,
Vol 121, No 7B, July 2008

76. Reasons -Aware but not receiving
vaccine
76
Source: Johnson et al, Barriers to Adult Immunization, The American Journal of Medicine,
Vol 121, No 7B, July 2008

77. Documentation
 Provide copy of Vaccine Information Statement
(VIS)to patient
 Documents to be maintained
 Date vaccination & next dose
 Vaccine manufacturer
 Lot number
 Dose & site of vaccine
 Vaccinator’s initials
77

78. Vaccine Administration
 Health care personnel should get proper training before
administrating vaccine.
 Always prepare and check the following for every
vaccination you give:
 Right Patient
 Right Drug (vaccine)
 Right Dose
 Right Route (intramuscular, SC, intradermal)
 Right Time (is scheduling correct)
78

79. Standards for Adult
Immunization Practices
 Make immunizations available
 Adult immunization services are readily available
 Barriers to receiving vaccines are identified and minimized
 Patient “out-of-pocket” immunization costs are minimized
 Assess patients’ immunization status
 Health care professionals routinely review the immunization status of patients
 Health care professionals assess for valid contraindications
 Communicate effectively with patients
 Patients are educated about risks and benefits of immunization in easy-to-
understand language
79

80.  Administer and document immunizations properly
 Persons who administer vaccines are properly trained
 Simultaneous administration of indicated vaccine doses
 Immunization records for patients should be accurate
 All personnel who have contact with patients are appropriately
vaccinated
80
Standards for AI cont….

81.  Implement strategies to improve immunization rates.
 Systems are developed and used to remind patients and health
care professionals when immunizations are due and to re-call
patients who are overdue
 Standing orders for immunizations are employed
 Regular assessments of immunization coverage levels are
conducted in a provider’s practice
 Patient oriented and community based
81
Standards for AI cont….

82. Recommendations (CDC)
 Finances
 Research on barriers
 Public and Provider Education
 Standards of Care
 Improved vaccines (immunogenicity, safety)
 Supply of Vaccines
 Support for programs and partners
 Legislative and regulatory strategies
82

83. Thank you