MEDICINE II

ADULT IMMUNIZATION
Erwin Carabeo, MD | 12 October, 2018
S2T1b
OUTLINE 1. Live Vaccines
I. History of Vaccination  Characteristics:
II. What is a vaccine o Able to replicate in the host
III. Major Principles & Methods in Vaccination o Attenuated (weakened) so they do not cause disease
IV. Basic Principles of Vaccine Immunology  Advantages:
V. Primary & Secondary Response o Induce broad immune response (cellular& humoral)
VI. Different Protocols to Immunization
o Low doses of vaccine are normally sufficient
VII. Herd Immunity
o Long-lasting protection are often induced
VIII. Immunization Schedule
IX. Contraindications & Precautions  Disadvantages:
X. Guidelines on Vaccination o May cause adverse reactions
Harrison’s Based Trans o May be transmitted from person to person
Appendix
Sample Questions CLASSIFICATION OF COMMON VACCINES FOR HUMANS
I. HISTORY OF VACCINATION PATHOGEN TYPE OF VACCINE
 Edward Jenner Vaccination - 1st recorded vaccination against
smallpox (May 14, 1796). Bacterial Cells
 Louis Pasteur (1870) - Adapted the principles of vaccination for his Anthrax
scientific work.
 Vaccination for prevention of rabies creates awareness on Cholera
Inactivated
immunization with scientific fundamentals. Pertussis
Plague
II. WHAT IS A VACCINE
Tuberculosis
 Vaccine - A substance that is introduced into the body to prevent Live, Attenuated
infection or a certain pathogen. It can be bacterial, viral, or parasitic Typhoid
infections. Viral Particles
 Without requiring exposure to the pathogen
Hepatitis A
 Vaccination:
o Cost effective method in controlling the infectious diseases Influenza
o Smallpox - Eradicated Inactivated
Rabies
o We have created herd Immunity in commonly preventable
diseases. Polio (Salk)
Polio (Sabin)
What Does the Vaccine Do?
 Trains the immune system to recognize and fight infection without Measles, Mumps, Rubella
requiring exposure to the pathogen. Rotavirus Live, Attenuated
Varicella (Chickenpox)
Goals of Vaccines and Immunization
 Disease Control - Reduction of disease incidence, prevalence Yellow Fever
morbidity and mortality to a locally acceptable level through
deliberate efforts. 2. Subunit Vaccines
 Disease Elimination - A more specific degree of disease control  Relatively easy to produce (not live)
defined as the reduction to zero of the incidence, or occurrence of a
 Induce little anti-viral T cell response (CTL)
specific disease within a geographic area that requires public health
o Viral and bacterial proteins are not produced within cells
efforts.
 Classically produced by inactivating a whole virus or bacterium by
 Disease Eradication - Reduction to zero of the worldwide incidence
heat and chemicals
or occurrence of specific disease as a result of deliberate
 The vaccine may be purified by selecting one or few proteins which
programmatic efforts.
confer protection
 Example: HPV vaccine created from 2 HPV proteins
III. MAJOR PRINCIPLES AND METHODS ON
VACCINATION Polysaccharides
 Many bacteria have polysaccharides in their outer membrane
MAJOR CATEGORIES OF VACCINES  Polysaccharide-based vaccines
o Neisseria meningitides
1. Live Attenuated Able to replicate in the host o Streptococcus pneumonia
 Generate T cell-independent response
2. Whole Killed Weakened, so they do not cause disease o Overcome by conjugating the polysaccharides to peptides
o This approach is used in vaccines (Pneumo 23 and HiB vaccine)
3. Subunit Part of the organism
Toxoid
4. Genetic Part of genes from an organism  Inactivated Toxins
 Toxoid based vaccines
Minimal essential information with least o Corynebacterium diphtheria
5. Epitope-Based
cross-reactive material o Clostridium Tetani
o Bordetella Pertussis

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Adult Immunization
Recombinant
 Hepatitis B virus (HBV) vaccine
o Originally based on the surface antigen purified from the blood of
chronically infected individual.
o Due to safety concern, the HBV vaccine became the first to be
produced using recombinant DNA technology (1986).
3. Genetic Vaccines
 Introduced DNA and RNA into the host
 Injected (Naked)
 Coated on gold particles
 Carried by viruses
o Vaccinia, adenovirus, alphavirus
 Bacteria such as:
o Salmonella typhi, Mycobacterium tuberculosis
 Advantages - easy to produce & induce cellular response
 Disadvantages - Low response in 1st generation

4. Epitope-Based Vaccines
 Advantages:
o Can be more potent
Primary Response
o Can be controlled better
 Primary response (primary immunization) is relatively
o Can target multiple conserved epitopes in rapidly mutating
o Slow (4-7 days)
pathogens like HIV and Hepatitis C Virus (HCV)
o Small amount of antibody (low concentration of Ab)
o Can overcome safety concerns associated with entire organism or
o Low affinity antibody
proteins
o IgM first, IgG second (equal amounts of IgM and IgG)

IV. BASIC PRINCIPLES OF VACCINE Secondary Response

IMMUNOLOGY  Secondary response (secondary immunization or booster
 Innate Immunity- eg. Macrophages, neutrophils, and certain immunization) is relatively:
molecules is the first line of defense. It is fast (usually good to go) o Fast (2-4 days)
and usually effective. o Large amount of antibody
o High affinity antibody
 Adaptive Immunity- Mediated by B and T cells can be slow to
o Mostly IgG
respond (several days). It is highly effective when the innate immune
system cannot fully deal with the threat.  Often, a secondary (memory) response is so fast and effective in
removing antigens (pathogens), there are few or no symptoms
detected by the infected individual (protective immunity).
WHAT HAPPENS WHEN YOU GET INFECTED WITH A  Secondary responses are the reason we do not get certain
PATHOGEN infectious diseases more than once.
EXTRACELLULAR PATHOGEN INTRACELLULAR o Usually, secondary responses are milder already
(Bacteria, Parasites) PATHOGEN (Often Viruses)  Secondary responses also explain why vaccinations work, for
 Replicates inside of the vaccinations, instead of immunizing with something that makes you
 Replicates outside of the cells cells sick, a vaccine contains antigen that prime the immune response.
 Antibodies are required to  Cytotoxic T Cells (CTLs)
neutralize extracellular are required to eliminate VI. DIFFERENT PROTOCOLS TO
pathogens infection
 Humoral immunity (antibodies)  Cell-mediated “immunity" IMMUNIZATION
is essential (CTLs is essential) Passive Immunization
antibodies help too  There is no need to stimulate the immune system, yung mismong
vaccine na yung may effect immediately kaya maganda siya for
acute infections
V. PRIMARY AND SECONDARY RESPONSE
 Artificially created by passive method
 Can be created at short notice
 Effective for limited periods
 Antibodies are created in various sources from animals to humans
 Can be antiviral, antibacterial,
 Source can be animals, or humans,
o Human source will be effective for 3-6 months
o Animals (heterologous) effective for few weeks (since foreign
body siya, mabilis siyang nade-destroy ng body)
 Diphtheria antitoxin - Horse equine Diphtheria Botulism antitoxin
 Tetanus Antitoxin Equine
 Human Tetanus Immunoglobulin

Pooled Immunoglobulin
 Human normal immunoglobulin
 Used for short term prophylaxis
o E.g. Hepatitis A Immunoglobulins

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 PRECAUTION - condition that increases risk of adverse event or
Highly Successful Saves in Acute Infection that may compromise ability of the vaccine to evoke immunity
 Diphtheria Antitoxin o EXAMPLES: person who needs vaccination has just under-gone
 Tetanus Antitoxin blood transfusion
 Rabies Hyperimmune Globulin (HRIG) o Administering MEASLES VACCINE to a person with passive
 Varicella Zoster Hyperimmune Globulins (HZIG) immunity to measles from a blood transfusion
o MAY or MAY NOT give the vaccine. MAY give the vaccine when
Active Immunization its benefits outweigh the risks.
 Most ideal, cost effective, method to prevent communicable
diseases. Permanent Contraindication to Vaccination
 Severe allergy to a prior dose of vaccine or to a vaccine component
Active Immunization with Toxoids  Encephalopathy following pertussis vaccine
 Type 1
o Toxoids - single toxin modified CONDITION LIVE INACTIVATED
o Preserved antigenicity
o Loses its toxicity Allergy to vaccine component C C
o E.g. Tetanus toxoid, Diphtheria toxin Encephalopathy C
Inactivated / Killed Vaccine Pregnancy V V
 Microbes are killed Immunosuppression C V
o Pertussis (whooping cough)
o Influenza (flu) Severe Illness P P
o Poliomyelitis (Salk)
Recent Blood Product P V
Live Attenuated Vaccine C – Contraindicated
 Inactivation destroys pathogenicity P – Precaution Needed
 Protective immunity retained V – Vaccinate if
 Contained living organisms with reduce virulence
o Live polio vaccine (Sabin) X. GUIDELINES ON VACCINATION
o Yellow fever 17D strain
Adverse Reactions
 Local
VII. HERD IMMUNITY o Pain, swelling, redness at the site of injection
 When most of the people in a community ere immune to particular o Common with inactivated vaccines
infection - natural transmission is inhibited. o Usually mild and self-limited
 It works on infections transmitted from person to person only  Systemic
o Fever, malaise, headache
VIII. IMMUNIZATION SCHEDULES o Non-specific
o May be unrelated to vaccine
 Depends on: Need, Efficacy, Safety, and Ease of Administration.
 Allergic
o Due to vaccine or vaccine component
GUIDELINES ON VACCINE SCHEDULE o Rare
o Risk minimized by screening
ANTIBODY AND LIVE VACCINES*
Product given first Action AVAILABLE VACCINES CURRENTLY BEING USED
Wait 2 weeks before giving
VACCINE Vaccines in the Developing Countries
antibody
ANTIBODY (Blood / blood Wait >3 months before giving the Live Attenuated Vaccine Inactivated, Killed Vaccine
products, immunoglobulin) vaccine  BCG  Tdap
SPACING OF VACCINES NOT GIVEN SIMULTANEOUSLY  MMR  Hib Conjugated
 Polio (Oral)  Inactivated Polio
Combination Minimum Interval
 Typhoid  Influenza
Two live vaccines injected 4 weeks  Influenza  Pneumococcal
 Yellow Fever  Hepatitis B
All other vaccines None  Rotavirus  Meningococcal
*di raw sila pwedeng pagsabayin sila antibody at live vaccine kasi si  Rabies
former could eliminate the latter.  Cholera
 Plague
IX. CONTRAINDICATION & PRECAUTION  Anthrax
 CONTRAINDICATION - condition that substantially increases the
risk of serious adverse reaction to vaccination
o EXAMPLES:
 Anaphylactic shock
 Administering FLU VACCINE to a person with a true
anaphylactic allergy to egg could cause serious illness or death
in the recipient
o VACCINE NOT GIVEN

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FROM HPIM 19TH ED: IMMUNIZATION ASSESSING CONTRAINDICATION AND PRECAUTIONS
 Contraindication – condition that increases the risk of a serious
I. VACCINE IMPACT adverse reaction to vaccination. DO NOT GIVE VACCINE IF
DOCUMENTED. This includes
DIRECT AND INDIRECT EFFECTS o Anaphylaxis and pregnancy
 DIRECT EFFECTS
- Protect individuals against infection and thereby prevent ANAPHYLAXIS PREGNANCY
symptomatic illnesses  A severe allergic reaction  CI for live virus vaccines
- Blunt severity of clinical illness (e.g., anaphylaxis) to a  May affect fetus
- Reduce complications previous dose of a vaccine  Live virus vaccines are
 HERD IMMUNITY – Indirect impact; to reduce transmissions of or to one of its components usually not secreted in the
infectious agents from the immunized to others thereby reducing  Commonly: egg protein, breast milk
impact spread gelatin, yeast, natural
- The level of immunization in a population that is required to rubber latex in vials and
achieve indirect protection of unimmunized people varies syringes
substantially with the specific vaccine IMMUNOSUPPRESSION
 CI for live virus vaccines
CONTROL, ELMINATION AND ERADICATION OF VACCINE  Immunosuppression may be from: HIV, Malignancy (general or
PREVENTABLE DISEASE blood),
 Associated with goals of controlling, eliminating, or eradicating a  Dose, duration, and route of administration of a drug may also
disease. influence the degree of immunosuppression.
 CONTROL
- Reduce poor illness outcomes  Precaution – condition that may increase the risk of an ADE that
- Limits disruptive impact may compromise the ability of the vaccine to evoke immunity. MAY
- Reduce work absences and school OR MAY NOT BE GIVEN, DEPENDING ON BENEFIT-RISK
- Decrease in health care utilization  Contraindications and Precautions may be temporary, defer
 ELIMINATION administration to another time
- Requiring the reduction to zero of cases in a defined  SEE APPENDIX:
geographic area but sometimes defined as reduction in the o Table 148-3 contraindications precaution for commonly used
indigenous sustained transmission of an infection in a vaccines to adults (must read)
geographic area.
o Recommended adult immunization schedules US, 2013
 ERADICATION
- Achieved when its elimination can be sustained without
ongoing interventions III. VACCINE INFORMATION STATEMENTS
- Only example; smallpox
- Current target for eradication: polio  A VIS is a one-page (two-sided) information sheet produced by
 Detection of a case of disease that has been targeted for eradication the CDC that informs vaccine recipients (or their parents or legal
or elimination is considered a sentinel event that could permit the representatives) about the benefits and risks of a vaccine
infectious agent to become reestablished in the community or  The use of these VISs is encouraged but is not mandated.
region. Therefore, such episodes must be promptly reported to
public health authorities. IV. STORAGE AND HANDLING
OUTBREAK DETECTION AND CONTROL  Injectable vaccines are packaged in multidose vials, single-dose
 Factors increasing vaccine- preventable diseases vials, or manufacturer-filled single-dose syringes.
(1) Low rates of immunization that result in an accumulation of
susceptible people (e.g., measles resurgence among Live attenuated nasal-spray
Single-dose Sprayers
vaccination abstainers); influenza vaccine
(2) Changes in the infectious agent that permit it to escape Capsules Oral typhoid vaccine
vaccine-induced protection (e.g., non-vaccine-type MMR
pneumococci);
Varicella
(3) Waning of vaccine-induced immunity (e.g., pertussis among Lyophilized powders that
adolescents and adults vaccinated in early childhood) Zoster
must be reconstituted
(4) Point-source introductions of large inocula (e.g., food-borne Meningococcal polysaccharide
exposure to hepatitis A virus vaccines

PUBLIC HEALTH REPORTING
 Clinicians and laboratory staff have a responsibility to report some
vaccine-preventable disease occurrences to local or state public
health authorities according to specific case-definition criteria
 A prompt response to vaccine-preventable disease outbreaks can
greatly enhance the effectiveness of control measures.
II. IMMUNIZATION PRACTICE STANDARDS
WHO TO VACCINATE
 Immunization history should be assessed and recorded,
o Used to identify needed vaccinations according to the most
current version of the adult immunization schedule
 Standing orders – give to nurse or another physician
o Why? To lower barriers in adult immunization
 Lyophilized (freeze-dried) powder and diluent come in separate vials
- Diluents – not interchangeable; specifically formulated for each
type of vaccine → only the specific diluent provided by the
manufacturer for each type of vaccine should be used
- Once lyophilized vaccines have been reconstituted, their shelf-
life is limited and they must be stored under appropriate
temperature and light conditions.
o Varicella and zoster – must be protected from light and
administered within 30 minutes of reconstitution
o MMR – must be protected from light but can be used up
to 8 hours after reconstitution
o Single-dose vials of meningococcal polysaccharide
vaccine – must be used within 30 minutes of
reconstitution
 Multidose vials – must be used within 35 days

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 Vaccines are stored either at:
- Refrigerator temperature (2-8°C)
o Inactivated vaccines (e.g., inactivated influenza,
pneumococcal polysaccharide, and meningococcal
conjugate vaccines)
o Live attenuated nasal-spray influenza vaccine
o Diluents (may also be stored at room temperature)
- Freezer temperature (-15°C or colder)
o Vials of lyophilized-powder live-virus vaccines (e.g.,
varicella, zoster, and MMR vaccines)
 Storage and handling errors → loss of vaccines worth millions
 Improperly stored vaccine → inadequate immune responses
 CDC recommendations on the standard of vaccine storage and
handling practices
- Stand-alone units – i.e., self-contained unit that either
refrigerate or freeze but do not do both – maintain required
temperatures better than combination refrigerator/freezer
o Dormitory-style combines refrigerator/freezer should
NEVER be used for vaccine storage
- Temperature must be monitored and recorded at least twice
each workday
o Ideally, continuous thermometers that measure and record
temperature all day and all night are used, and minimum
and maximum temperatures are read and documented
each workday.
o The CDC recommends the use of calibrated digital
thermometers with a probe in a glycol-filled bottle.
V. ADMINISTRATION OF VACCINES
SC - Live virus vaccines (varicella, zoster, and MMR)
- Inactivated vaccines (except meningococcal
polysaccharide vaccine, which is given SC)
IM - 23-valent pneumococcal polysaccharide vaccine
(may also be given SC but IM is preferred d/t low risk
of injection-site reactions
 Administration of vaccines to adults
- SC: 5/8-inch needle into the upper outer-triceps area
- IM: deltoid muscle; needle length is based on the recipient’s
sex and weight to ensure adequate penetration to the muscle
Needle Men Women
1-inch <152 lbs (<70 kg)
1 to 1.5-inch 152-260 lbs (70-118 kg) 152-200 lbs (70-90 kg)
1.5-inch >260 lbs (>118 kgs) >200 lbs (>90 kg)
 Aspiration
- The process of pulling back on the plunger of the syringe after
skin penetration but prior to injection
- NOT NECESSARY because no large blood vessels are
present at the recommended vaccine injection sites
 Multiple vaccines can be administered at the same visit; indeed,
administration of all needed vaccines at one visit is encouraged.
- Sites should be separated by 1-2 inches to differentiate any
local reactions
 Vaccine and immune globulin preparation administered
simultaneously (e.g., Td vaccine and tetanus immune globulin) →
separate anatomic site should be used for each injection
 For certain vaccines (e.g., HPV and Hep B), multiple doses are
required for an adequate and persistent antibody response.
- The recommended vaccination schedule specifies the interval
between doses.
- Many adults who receive the first dose in a multiple-dose
vaccine series do not complete the series or do not receive
subsequent doses within the recommended interval → vaccine
efficacy and/or duration of protection may be compromised
- Recall systems – implementation can prompt patients to return
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- Except oral typhoid vaccination, interruption in the schedule
dose does not require restarting of the entire series or the
addition of extra doses
 Syncope may follow vaccination, majority occurring within 15 min
- Serious injuries (skull fracture and cerebral hemorrhage) have
occurred
- Adolescents and young adults should be seated or lying during
vaccination and 15 min after vaccination
 Anaphylaxis – rare complication
- Facilities should have an emergency kit containing aqueous
epinephrine for administration in the event of a systemic
anaphylactic reaction
VI. MAINTENANCE OF VACCINE RECORDS
 All vaccines administered should be fully documented in the
patient’s permanent medical record
 Should include:
- Date of administration
- Name or common abbreviation of the vaccine
- Vaccine lot number and manufacturer
- Administration site
- VIS edition
- Date the VIS was provided
- Name, address, and title of person who administered the
vaccine
VII. VACCINE SAFETY MONITORING AND
ADVERSE EVENT REPORTING
PRELICENSURE EVALUATIONS OF VACCINE SAFETY
 Before vaccines are licensed by the FDA, they are evaluated in
clinical trials with volunteers.
- Phase 1 trials
o Small, usually involving <100 volunteers
o Purpose: To provide basic evaluation of safety and to
identify common adverse events
- Phase 2 trials
o Larger, may involve several hundred participants
o Purpose: To collect additional information on safety as
well as to evaluate immunogenicity
o Data gained can be used to determine the composition of
the vaccine, the number of doses required, and a profile of
common adverse events
o Vaccines that appear promising are evaluated in phase 3
- Phase 3 trials
o Involve several hundred to several thousand volunteers
o Purpose: To demonstrate vaccine efficacy and provide
additional information on vaccine safety
POSTLICENSURE MONITORING OF VACCINE SAFETY
 Adverse events – untoward events that occur after immunization
and that might be caused by the vaccine product or vaccination
process
 The National Childhood Vaccine Injury Act (NCVIA) of 1986 requires
healthcare providers to report certain adverse events that follow
vaccination.
 As a mechanism for the reporting, the Vaccine Adverse Event
Reposting System (VAERS) was established in 1990, jointly
mandated by the CDC and FDA
- Anyone can file a reports, including healthcare providers,
manufacturer, and vaccine recipients or their parents or
guardians
- Information asked:
o Type of vaccine received
o Timing of vaccination
o Time of onset of the adverse event
o Recipient’s current illnesses or medications
o History of adverse events following vaccination
o Demographic characteristics (e.g., age and sex)
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- The information is entered into a database. The individual who
reported receives a confirmation letter by mail with a VAERS
identification number.
- In selected cases of serious adverse reaction, the patient’s
recovery status may be followed up at 60 days and 1 year after
vaccination.
- Limitations of passive reporting:
o The events following vaccination are merely reported; the
system cannot assess whether a given type of event
occurs more often than expected after vaccination.
o Event reporting is incomplete and is biased toward events
that are believed to be more likely to be due to vaccination
and that occur relatively soon after vaccination.
 Vaccine Safety Datalink project in 1991
- Initiated to obtain more systematic information on adverse
events occurring in both vaccinated and unvaccinated persons
- Directed by the CDC; include nine managed-care organizations
in US
- Member databases include:
o Information on immunizations
o Medical conditions
o Demographics
o Laboratory results
o Medication prescriptions
- Postlicensure evaluations of vaccine safety may be conducted
by the vaccine manufacturer (often required by the FDA as a
condition of vaccine licensure)
VIII. CONSUMER ACCESS TO AND DEMAND
FOR IMMUNIZATION
CONSUMER ACCESS TO IMMUNIZATION
 Vaccine use can be improved by removing barriers to the patient or
consumer
 Financial barriers have been important constraints, particularly
among uninsured adults
- Extended office hours
- Scheduled vaccination-only clinics where waiting times are
reduced
- Provision of vaccines outside “medical home” can expand
access for adults who do not make medical visits frequently.
DEMAND FOR IMMUNIZATION
 Health promotion efforts aimed at increasing demand for
immunization are common
 Attitudes and beliefs related to vaccination are considerable
impediments to consumer demands
- Adults view vaccines as important for children but are less
familiar with vaccinations targeting disease prevention in adults
- Several vaccines are recommended for adults but self-
identification as high-risk individual is relatively rare
- Many adults with chronic diseases are more motivated to
receive vaccine to protect their family instead of reducing their
own risk
 Some vaccines are explicitly recommended for persons with the goal
of reducing risk of transmission (example is vaccination of pregnant
women against influenza and pertussis for the protection of
newborn)
IX. STRATEGIES FOR PROVIDERS AND
HEALTH CARE FACILITIES
RECOMMENDATION FROM THE PROVIDER
 Recommendation from doctor or nurse has more weight than
recommendations from professional societies or endorsements by
celebrities
 Providers should be well informed about vaccine risks and benefits
so that they can address patient’s common concerns
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SYSTEM SUPPORTS
 Medical offices can incorporate methods to ensure that providers
consistently offer specific immunizations to patients with indications
for specific vaccines
 Manual or automated reminders and standing orders have improved
vaccination coverage in both office and hospital settings
 Specialty providers (like OB-GYNE) may be the only providers
serving high-risk patients with indications for selected vaccines
IMMUNIZATION REQUIREMENTS
 Vaccination against selected communicable diseases is required for
attendance at universities, colleges, and service in the military
 Some are also required for travel to certain countries.
VACCINATION OF HEALTH CARE STAFF
 Area of focus for medical settings is vaccination of healthcare
workers
 CDC and ACIP recommend influenza vaccination of all health care
personnel
X. VACCINATION IN NON MEDICAL SETTINGS
 Receipt of vaccination in medical offices is most frequent among
young children and adults > 65 years of age
 Vaccination may also occur at health department venues,
workplaces, retail sites, and schools or colleges
 When vaccines are given in nonmedical settings, it is important for
standards of immunizations to be followed
 Detailed documentation may be required for employment, school,
attendance, and travel.
XI. PERFOMANCE MONITORING
 Tracking of immunization coverage at national, state, institution, and
practice levels can yield feedback to practitioners and programs and
facilitate quality improvement
 Influenza and pneumococcal vaccine coverage rates have been
higher among persons > 65 years of age than among high risk 18 to
64 year olds
XII. FUTURE TRENDS
 Vaccines developed in 20th century targeted common acute
infectious diseases of childhood
 More recent vaccines prevent chronic conditions prevalent among
adults
 Hepatitis B vaccine prevents hepatitis B–related cirrhosis and
hepatocellular carcinoma, zoster vaccine prevents shingles and
postherpetic neuralgia, and HPV vaccine prevents some types of
cervical cancer, genital warts, and anogenital cancers and may also
prevent some oropharyngeal cancers
 Research is ongoing on vaccines to prevent insulin-dependent
diabetes mellitus, nicotine addiction, Alzheimer’s disease
 Strategies for vaccine development: incorporating molecular
approaches such as DNA, vector, and peptide vaccines
 New technologies in vaccine delivery: transdermal and other needle-
less routes of administration.
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APPENDIX

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Erwin Carabeo, MD |12 October, 2018
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Erwin Carabeo, MD |12 October, 2018
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REFERENCES
3A 2016
Harrison’s Principles of Internal Medicine

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Erwin Carabeo, MD |12 October, 2018
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QUIZ TIME!
1. Which type of immunization/vaccine is contraindicated 9. A 63 year old man with diabetes and peripheral vascular
during pregnancy? disease. Select the most appropriate prophylaxis.
A. Live, bacterial vaccines C. Immunoglobulin a. Rabies vaccine
B. Inactivated vaccines D. Toxoids b. Pneumococcal vaccine
c. Hepatitis B vaccine
2. Which of the following vaccine is safe to be given to d. Meningococcal vaccine
pregnant patients?
A. Influenza vaccine C. HPV vaccine 10. Approximately one third of patient infected with this virus
B. MMR D. Varicella vaccine may respond to treatment with interferon alpha.
a. Norwalk virus
3. Which of the following vaccines are composed of b. Rotavirus
inactivated bacterial or viral components? c. Human herpesvirus 6
a. Tetanus d. Hepatitis C virus
b. Varicella
c. Influenza 11. Which of the following sexually transmitted infections (STI)
d. Measles can be prevented through vaccination?
A. Hepatitis B
4. Which of the following vaccine/s is/are contraindicated in a B. Hepatitis C
pregnant woman? C. Syphilis
a. Varicella D. Gonorrhea
b. Measles
c. Mumps 12. A first year vet-med student was bitten by a dog he was
d. All of the above examining, he claims to have had anti-rabies immunization 1
year ago. What do you recommend?
5. A 65 year old man was hospitalized for an exacerbation of A. Rabies vaccine booster on days 0 & 3
newly diagnosed COPD. You discharged him 4 weeks ago and B. Give rabies immune globulin
now presents at the OPD for follow up. He has never received C. Wound treatment
any adult vaccinations. Which of the following preventive D. All of the above
approach for pneumonia will you recommend to your patient?
a. Pneumococcal vaccine 12. A social worker frequently assigned to areas of calamity
b. Pseudomonal vaccine consulted for prophylaxis against Typhoid. She claims to have
c. Haemophilus influenzae type B vaccine immunization with one injection of Vi polysaccharide vaccine 5
d. Influenza vaccine years ago. What do you recommend?
A. Live attenuated vaccine 1 capsule as a booster
6. Contraindications for administering a live attenuated vaccine B. 3 doses of live attenuated oral typhoid vaccine
include all of the following EXCEPT: C. Gamma globulin
a. Acute febrile illness D. None of the above
b. Recent administration of immune globulin host
c. Immunosuppressive disorder or compromise 14. Most vaccine for adults can be given also to pregnant
d. Administration of another live vaccine women EXCEPT:
A. Tetanus, diphtheria C. MMR, Varicelia
7. In storing vaccines, the following should be remembered B. Pneumococcal, influenza D. Rabies, Hepatitis B
EXCEPT:
A. DPT vaccine can be stored in the freezer and thawed 15. Which of the following vaccines is especially indicated in a
B. The diluents should be in the area where the solvent is splenectomized patient:
C. Never keep vaccine in the door of the refrigerator a. Pneumococcal
D. If the vaccine stored above or below safe temperature it b. Hepatitis B
will not lose its potency if it is for a short period of time c. Tetanus
only. d. Polio
8. Measles vaccine is an example if a:
A. Killed vaccine C. Live, attenuated viral vaccine 16. The person recommended receiving influenza vaccine:
B. Live vaccine D. Live attenuated bacterial A. Person > 65 years of age
vaccine B. Women in first trimester of pregnancy
C. Hypertensive patients
D. With prodromal phase of upper respiratory infection

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 MEDICINE II
ADULT IMMUNIZATION
Erwin Carabeo, MD |12 October, 2018
ANSWERS:
1. Live, bacterial vaccines are contraindicated during
pregnancy. According to CDC (2017), “Live vaccines
administered to a pregnant woman pose a theoretical
risk to the fetus; therefore, live, attenuated virus and
live bacterial vaccines generally are
CONTRAINDICATED during pregnancy”. All of the
remaining choices could be given to pregnant women but
precautionary measures should be done in cases of
allergy (just like the non-pregnant women).
2. Influenza vaccine is the only vaccine that could be given
safely to any pregnant woman since this is an inactivated
vaccine. However, HPV (derived from HPV protein) is
also not a live vaccine, but why is this not the answer?
Well, according to CDC, “If a woman is found to be
pregnant after initiating vaccination series, the
remainder of the 3-dose series should be DELAYED
until completion of pregnancy”.
3. Influenza is the only inactivated vaccine among the
choices. Varicella and measles vaccines are both live
vaccines, while tetanus is a toxoid.
4. All the choices are contraindicated since they are all live
vaccines.
5. “CDC recommends people with asthma, COPD, or other
conditions that affect the lungs get a yearly flu vaccine. If
you have a lung condition, you should also
get pneumococcal vaccines—once as an adult before
65 years of age and then two more doses at 65 years
or older. Your doctor may recommend additional
vaccines based on your lifestyle, travel habits, and other
factors.”
6. Administering live vaccines to people with acute febrile
illness could just worsen the patient’s condition because
of the relative weakness of the immune system. Similarly,
immunocompromised patients should not be
administered live vaccines. Recent (or same-time)
administration of antibody and vaccine is also not
recommended since the antibody can interfere with the
vaccine; thus decreasing its efficacy (sabi ‘to ni Doc
during lecture). So, the answer is D. In fact, MMR, which
are all live component vaccines, is recommended.
7. “If stand-alone freezer is manual defrost, must defrost
regularly and have another storage unit that maintains
appropriate temperatures for temporary storage during
defrosting”. So, correct si A. “Some diluents must be
refrigerated and others may be stored in the refrigerator
or at room temperature... If possible, store diluent next to
the corresponding vaccine.” So, tama rin naman si B. to
“Store vaccines away from walls, coils, cooling vents, top
shelf, ceiling, door, floor, and back of unit”. So, tama si C.
“Vaccines exposed to temperatures outside the
recommended ranges can have reduced potency and
protection.” So, the answer is D (reference: CDC).
8. Measles is a live, attenuated viral vaccine.
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S2T1b
9. “CDC recommends people with heart disease get
a yearly flu vaccine. They should also
get pneumococcal vaccines—once as an adult before
65 years of age and then two more doses at 65 years or
older... CDC recommends people with diabetes
get pneumococcal vaccines (once as an adult
before 65 years of age and then two more doses at 65
years or older), a yearly flu vaccine, and a hepatitis B
vaccine series (for those between the ages of 19 and
59). If you are 60 years or older, talk to a health care
professional to see if you should get hepatitis B
vaccine.” Although Hep B is also indicated, according
to CDC, people with diabetes are at increased risk for
pneumonia so ito yung dapat mas i-address. And
remember the question asked about the most
appropriate for the patient (reference: CDC).
10. The standard of care for patients with chronic
hepatitis C infection is represented by pegylated
interferon-α (Peg-IFN) and ribavirin. These drugs
determine complex antiviral, immunomodulatory, and
antiproliferative actions, which can cause serious side
effects such as leukopenia/neutropenia and
alterations in the cytokine network (CDC, 2012).
11. Need for CDC to say more? Alam na natin ‘to. Hep B
is the answer. Balik first year pag di alam lol.
12. Since the patient already had his rabies vaccine a
year ago, he would only need vaccine booster for his
dog bite. Sabi sa FCM, at least 5 years maximum
ang duration of efficacy ng rabies vaccine. For high-
risk individuals who are continuously exposed to
possible rabies infection, a booster dose as often as
every 6 months to 2 years may be required (CDC).
13. If continued or repeated exposure to Salmonella serotype
Typhi is expected, repeat doses of typhoid vaccine are
needed to maintain immunity. An optimal revaccination
schedule for the Vi polysaccharide vaccine has not been
established; however, the manufacturer recommends a
repeat dose every 2 years after the primary dose if
continued or renewed exposure is expected. The
manufacturer of Ty21a recommends revaccination with
the entire 4-dose series every 5 years if continued or
renewed exposure to Salmonella serotype Typhi is
expected (CDC). The answer is B.
14. MMR and varicella vaccines are live vaccines so they are
contraindicated for pregnant women.
15. Pneumococcal vaccine should be given to
splenectomised patients due to their increased
susceptibility for capsular pathogens.
16. “Statement 3. Annual vaccination with influenza vaccine
is recommended for 65 years old and above
(Moderate grade, strongly recommended)” – Philippine
Academy of Family Physicians, 2017 (CPG Wellness and
Care for Older Persons).
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