A. Vaccination Schedule
- At Birth
- HepB (Hepatitis B Virus Vaccine) #1 - may be given up to 2 months of age
- HepB double dose and hepatitis B immune globulin (infants born to HBsAg+ mothers) [3]
- See recommendations below
- Two Months
- HepB #2 - should be given at least 1 month after first dose (range 1-4 months)
- DTaP #1
- HIB (Haemophilus influenzae type B conjugate vaccine) #1
- HIB-DTaP conjugate vaccines are now available [48]
- Inactivated Polio Vaccine (IPV) #1 (see below)
- Pneumococcal conjugate (heptavalent) vaccine (PCV) #1
- Four Months
- DTaP #2
- HIB #2 (or conbination HIB-DTaP vaccine)
- IPV #2
- PCV #2
- Six Months
- HepB #3 (must be >2 months after second dose; range 6-18 months)
- DTaP #3
- HIB #3 (depends on product; may be given at 12 or 15 months)
- IPV #3 (range 6-18 months)
- PCV #3
- Children 6-23 months old candidates for influenza vaccine [14]
- Twelve to 15 Months
- HepB #3 (if not given at 6 months)
- HIB #4 (dose #4 is optional and may not be clinically relevant [62])
- IPV #3 (if not given at 6 months)
- MMR (Measles / Mumps / Rubella) #1 or MMR+Varicella (Proquad®)
- PCV #4
- Varicella Zoster (VZV) Vaccine (anytime age 12-18 months if no clinical chicken pox) [44]
- VZV now available as part of MMR-Var (Proquad®)
- Fifteen to 18 Months
- DTaP #4
- HepB #3 (if not previously given)
- IPV #3 (if not given at 12-15 months)
- Four to 6 Years
- DTaP #5
- IPV #4
- MMR #2 (waiting until age 12 is no longer recommended) [3]
- Hepatitis A Vaccine (HAV) in selected (endemic) areas (age >2)
- Nine Years (up to 26 years): HPV vaccine (see below)
- Eleven to 12 Years
- HepB (booster if needed)
- Tetanus and Diphtheria Toxoids - booster (pertussis boosters may be needed) [68]
- MMR #3 (booster; if not given age 4-6 years)
- Varicella Vaccine #2 [94]
- Fourteen to 16 Years
- Tetanus and Diphtheria Toxoids (if not given at 11-12 years)
- Check anti-HBV titers; consider booster
- Booster Vaccinations
- Tetanus / Diphtheria / Pertussis booster (TDaP) every 10 years
- Rubella - pre-pregnancy check titers; boost if not protective
- Hepatitis - boost for high risk activity or immunosuppression if titers low
- Notes on Pertussis Vaccine
- Acellular pertussis vaccine has replaced cellular vaccine
- Acellular pertussis vaccine appears effective in ~70% and very well tolerated
- Acellular pertussis vaccine is effective in 92% of adolescents and adults [68]
- Combination DTaP is available and all Td boosters should be replaced with TDaP [19]
B. Adult Immunizations [9,10]
- Individuals Unvaccinated During Childhood
- Inactivated Polio Vaccine (IPV) should be given at 0, 1, 6 months
- Tetanus / Diphtheria (Td) Vaccine 0, 1, 6-12 months
- Measles / Mumps / Reubella (MMR) 0,1 months
- Varicella Zoster 2 doses (0, 4-8 weeks) if no evidence of VZV immunity [9]
- Hepatitis A (at risk): 0, 6-18 months
- Hepatitis B (all): 0, 1-2, 4-6 months
- Meningococal (at risk): 1 or more doses
- Herpes zoster vaccine: age >60 years (prevents zoster and post-herpetic neuralgia)
- HPV (papillomavirus): woman age <26 who have not completed 3 doses
- Boosters [10]
- Td boosters should be replaced with TDaP boosters (Adacel®, Boostrix®) q10 years [19]
- These TDaP boosters contain well tolerated acellular pertussis immunogens
- Persons MMR age (>12 or) 18-24 should have at least one vaccination [11]
- Persons in high risk groups should have at least one booster MMR
- High risk includes students living in dormatories, foreign travel, healthcare workers
- Influenza Vaccine (see below) [14,15]
- Vaccine is tailored to major strains and administered annually October-November (optimal)
- Inactivated intramuscular vaccine targeted to those at highest risk for complications
- Attenuated intransal vaccine (FluMist®) for anyone who wants it without contraindications
- High risk: pregnant women, persons >64 years old, children 6-23 months, patients 2-64 years old with chronic medical conditions, previous severe influenza infection
- Immunocompromised patients should only receive the inactivated vaccines
- In >64 year patients there was a ~50% reduction in hospitalizations for pneumonia and influenza [13]
- The vaccine is safe and effective in younger persons (18-65 years), and in areas with high attack rates of influenza, may be cost effective in this group [16]
- Pneumococcal Vaccine (see below) [67]
- Given once in most patients; >65 years age
- Functional or anatomic splenectomy (should be given q6 years)
- Immunosuppression - including lymphoma, multiple myeloma (probably q6 years), HIV
- Alcoholism, Smoking
- Major systems compromise
- Cerebral fluid leakage
- ~70% effective in preventing hospitalizations for pneumococcal infections
- May be repeated q5-10 years in immunocompromised hosts
- HBV
- Currently recommended for all at risk individuals
- Normal dosing is 3 vaccinations at 0,1 and 6 months
- Give to all Homosexual males and Household contacts of HBV carriers
- HIV Positive Patients
- Health care workers
- Hemophiliacs
- Recommend double dose at 0, 1, 2 and 6 months for hemodialysis and alcoholics
- HIB (H. influenza B; given once) - day care workers; consider in smokers
- Varicella Zoster Virus (VZV) Vaccine
- Recommended in all persons >60 years old
- In persons >60 years old, live-attenuated varicella zoster virus (VZV) vaccine reduced zoster ~50% and post-herpetic neuralgia ~67% [6]
- Vaccine associated with reduction of hospitalizations by 88%, ambulatory visits by 59% [90]
- Second vaccine dose 4-8 weeks after initial vaccination recommended [94]
- Lyme Disease vaccine has been withdrawn [12,52]
- Vaccinations for Travel
C. Special Circumstances
- HIV Positive Patients
- Check Hepatitis Status: Immunize if not already infected or immune
- Tetanus Boosters every 5 years
- Pneumococcal Vaccine
- HIB - may be helpful but no clear data
- Influenza Vaccine yearly
- Varicella vaccine is contraindicated
- Asplenia
- Includes functional (sickle cell and thalassemia) and surgical splenectomy
- Pneumococcal, meningococcal, influenza, and HIB vaccines should be given
- Prefer to give vaccines at least 2 weeks before elective splenectomy
- 23-valent pneumococcal and 4-valent meningococcal vaccines are effective in Hodgkin's Disease including those with splenectomy
- Complement Deficiency
- Meningococcal vaccine (4-valent)
- Pneumococcal vaccine is probably also helpful
- Glucocorticoid Immunosuppression
- Long term and high dose glucocorticoid therapy is indication for vaccinations
- Live virus vaccines (VZV and MMR) are generally contraindicated
- Influenza, pneumococcal, tetanus booster and possibly HIB vaccines should be given
- IPV can be given in appropriate patients
- Solid Organ Transplant Patients [74]
- Immunizations / boosters should not be done during first 6 months after transplant
- When possible, appropriate booster immunizations should be done prior to transplant
- Live virus vaccines should be completed at >4 weeks pre-transplant
- Live virus vaccines are not generally recommended in solid organ transplant recipients
- Booster recommendations are provided in "Transplantation Immunology" outline
- Malignancy
- Similar to glucocorticoid immunosuppressed patients
- Varicella (live virus VZV) vaccine protocol in selected patients
- Pregnancy [10]
- Live virus vaccines MMR and varicella are contraindicated
- Pneumococcal vaccine 1-2 doses recommended if at any risk
- HAV 2 doses recommended if at any risk
- HBV 3 doses recommended if at any risk
- Meningococcal in at risk (1 dose)
- Vaccinations for Travel
D. Bone Marrow Transplantation (BMT) [20]
- Most centers reimmunize patients 1-2 years after Allogeneic BMT
- Presence of graft versus host disease (GVHD) decreases vaccination efficacy
- Pneumococcal vaccine should be given at 7 and 24 months post-BMT
- H. influenza B (HIB) Vaccine should be given 6 months apart for 3 doses, begin 7 months
- Diphtheria and Tetanus (DT or DTaP) should be given after 12 months
- Enhanced inactivated poliovirus vaccine (eIPV)
- 3 doses, 1 months intervals, beginning at 12 months
- With chronic GVHD, vaccinated at 12, 24, and 36 months
- Oral polio vaccine is no longer available
- Hepatitis B Vaccine is recommended and can be given as for eIPV
- Titers can be checked 3 months after vaccinations
- MMR (live virus) vaccine should be delayed until 2 years post-BMT
E. Poliovirus
- Enhanced inactivated poliovirus vaccine (eIPV) available
- OPV is no longer available
F. Measles, Mumps, Rubella (MMR)
- Called MMR; live attenuated virus combination
- Rubella titers should be checked in all pregnant females
- Should not be used for immunocompromised persons (this is a live virus)
- Boosters are required for all persons; now recommended age 4-6 [2]
- Overall seroconcersion rates are 98% for rubella and ~83% for mumps
- Single Dose MMR gives ~80% seroconversion for measles; 2 doses >98% [11]
- MMR may be given to children with mild illness without efficacy reduction
- Newer MMR do not contain egg proteins and are safe in persons with egg allergies
- Slight (2.7X) increase in risk of febrile seizures in children within 2 weeks of MMR, but no longterm sequellae or increase in epilepsy [83]
- No link between MMR vaccination and autism [78,79]
G. Hepatitis B Vaccine (HBV) [3,39]
- Recommended (and cost effective) for all infants and children [21,22]
- Expansion to general population is under study
- Vaccines are based on surface antigens, so recipients convert to HBsAb+ (HBsAg-, HBcAb-)
- Two recombinant vaccines (using surface antigen) are available: Energix-B®, Recombivax®
- Three doses are required, and cost is high
- Pediatric doses are about half of adult doses; immunosuppressed patients received 2X dose
- Vaccination against HBV reduces incidence of hepatocellular Ca [10]
- All infants born to HBsAg+ mothers receive hepatitis B immune globulin + vaccine [3]
- Booster vaccinations unnecessary in immunocompetent persons [50]
- However, in immunocompromised persons, test anti-HBS titer
- Booster vaccinations should be given when titer is below 10 mIU/mL [50]
- Combination hepatitis B and A vaccine now available (3 doses at 0, 1, 6 months) [66]
- Vaccination (including hepatitis B vaccine) does not increase risk of multiple sclerosis (MS) or of MS relapse [59,60]
- HBV vaccine induces protective antibody levels for at least 15 years in most people [87]
H. Hepatitis A Vaccine (HAV Vaccine) [9,23,39]
- High risk Populations should be vaccinated:
- Frequent raw shellfish intake
- Travelling to endemic areas
- Children living in 17 states with highest incidence of HAV
- Efficacy of Inactivated Virus Vaccine
- 96% of recipients have high antibody titers in 30 days
- About 80% effective in prevention of secondary HAV infection (household contacts) [42]
- HAV vaccination in children lead to reduction in disease rates ~75% [89]
- Overall 90-100% effective in preventing disease
- Two Formulations: Havrix® or Vaqta®, both given as 0.5mL or 1.0mL aliquots
- Adult dose is 1.0mL initially, then booster in 6-12 months
- Pediatric Use
- Doses are about half of adult doses (0.5mL)
- Vaccinating children in an endemic area prevents disease and outbreaks and is safe [71]
- Immune globulin
- Effective for pre-exposure prophylaxis ~90% of cases
- Effective for post-exposure prophylaxis ~85% of cases
- HAV vaccine about as effective as immune globulin for post-exposure prophylaxis [18]
- Combination Hepatitis A+B vaccine now avaialble (Twinrix®, see above) [66]
I. Influenza Virus Vaccine [14,70]
- Clear benefits with essentially no risks in healthy and chronically ill elderly persons [38]
- Types [14]
- Parenteral (injected) inactivated - FluShield®, Fluvirin®, Fluzone®, Fluarix®
- Fluzone® Preservative free also available
- Intranasal live vaccine - approved 2003 for age >5 years; FluMist® [15]
- Both inactivated and live attenuated vaccines are effective against influenza virus strains that have shown significant drift from vaccine strain [4]
- Safe and more effective than trivalent killed vaccine in children without history of wheezing/asthma 12-59 months old [95]
- Egg Allergies and Inactivated Parenteral Vaccine:
- Caution in patients with egg allergies
- If vaccine egg protein content is <1.2µg/mL, patients with egg allergies may safely receive vaccine [69] ci. Inactivated influenza vaccine is safe and beneficial; asthmatics should receive it [69]
- Recommendations for Influenza Vaccination 2007-8 [44]
- All persons at least 6 months old without contradindication
- Should definitely be given to persons at high risk of influenza complications
- Children ages 6-59 months old, all persons >50 years old, all chronic medical conditions
- All women who will be pregnant during influenza season
- Residents of nursing homes and long-term care facilities
- Health-care workers involved in direct patient care [49]
- Out-of-home caregivers and household contacts of children <5 years of age
- Given yearly, usually in October through January [14]
- Vaccine consists of three distinct serotype hemagluttinen (H) and neuraminidase (N) antigens and is therefore "trivalent"
- Year 2007 Vaccine: A/Solomon Islands/3/2006 (H1N1), A/Wisconsin67/2005 (H3N2) and B/Malaysia/2506/2004
- Vaccine Utility
- Vaccinating healthy working adults <65 years reduces lost workdays, influenza- like illness, physician visits [57]
- Vaccination associated with 27-45% reduction hospitalizations in elderly [65,85]
- Vaccinating healthy working adults is cost-effective when viral strains and vaccine strains are the same [57,70]
- Influenza vaccination in elderly persons reduces their risk of hospitalizations for cardiac disease + stroke ~20%, respiratory infection ~30%, and any-cause death ~50% [81]
- Vaccinating children in day care also reduced febrile respiratory illness in contacts 80% [56]
- Vaccinating elementary school students associated with reduced influenza symptoms in students and their households [7]
- Live Intranasal Vaccine (FluMist®) [15,22]
- Three strains (2 influenza A, 1 B) attenuated by reassortment with mutant virus
- Efficacy ~90% in chilren 15-71 months old
- Reduced febrile respiratory illness, workdays lost, physician visits in adults 18-64
- Efficacy likely 10-15% better than inactivated virus
- Increase in runny nose, nasal congestion, headache versus placebo
- FDA approved for healthy people 5-49 years old, 0.25mL per nostril annually
- Neurological Adverse Events [41]
- No increased risk for neurologic or other diseases with vaccines after 85
- The influenza A New Jersey/swine flew vaccine from 1976-77 caused a clear increase in Guillain-Barre Syndrome
- As effective in HIV+ as in HIV- persons regardless of CD4+ T cell counts [46]
J. Pneumococcus [67]
- Older 23-valent nonconjugated and newer conjugated hepta (7-) valent vaccines available
- Vaccine issues, risk factors, reviewed as early as age 50 in all patients
- At least 30% of persons age 50-60 should receive pneumococcal vaccine
- There is little risk in taking vaccine, and increased use is strongly recommended
- Vaccine is cost effective for preventing bacteremia as well [27]
- Nonconjugated 23 Valent Polysaccharide Vaccine
- Requires intact T-lymphocyte independent immunity (direct B-cell activation)
- Poor or no responses in infants and young (age <2) children
- Given once for normal hosts (at high risk and >age 60-65)
- Given q3-6 years for immunocompromised hosts and persons with chronic diseases
- Children age <4 undergoing heart transplants respond poorly to single dose vaccine [37]
- 23-vaccine most beneficial in reducing pneumococcal bacteremia in age >65 years [82]
- No effect on incidence of pneumococcal pneumonia in age >65 years [82]
- Nonjugated vaccine has broader coverage but lower responses than conjugated vaccine
- Heptavalent Conjugate Vaccine [51]
- Pneumococcal capsular polysaccharides linked to diphtheria toxoid derivative CRM197
- Uses T-lymphocyte dependent immune responses with high vaccination rates
- Recommended for ALL infants <2 years old
- Also recommended for children 2-5 years old at increased risk for pneumococcus
- Strongly consider in any patient with poor immune function
- Covers ~80% of invasive childhood pneumococcal infections in USA
- This vaccine reduces acute otitis media caused by serotypes in the vaccine >50% [61]
- Reduced rates of invasive pneumococcal disease in children by 30% (50% in <2 year olds) [24]
- Efficacy ~80% in very high risk populations of young children [25]
- In general, the 23-valent nonconjugated vaccine is not as immunogenic as conjugated
- Dosage: 3 total for 7-11 months, 2 total for 12-23 months, 1-2 for >23 months
- Conjugated vaccine covers nearly all pencillin-resistant pneumococcal strains
- Dosage: 3 total for 7-11 months, 2 total for 12-23 months, 1-2 for >23 months [12]
- Very safe in postmarketing studies similar to other vaccines [26]
- Use in children strongly associated with reduction in invasive pneumococcal disease in adults >50 years old [91]
K. Haemophilus influenza Type B (HIB) [3]
- All newborns
- For all immunosuppressed young patients
- Questionable whether immunosuppressed adults derive benefit
- Nearly 75% reduction in invasive H. influenza B infection in Alaska after vaccine use [53]
- HIB-DTaP conjugate vaccines are now available and very effective [48]
- HIB disease in Kenya reduced by ~8X observed only 3 years after institution of vaccine [92]
L. Meningococcus [28,54,76]
- Most common strain in USA and Europe is now Group B (was group C previously)
- Preferred Multiserotype Vaccine (Menomune®)
- Covers serotypes A, C, Y, and W-135
- Mainly used in military personell and in outbreaks
- College freshman living in dorms have high rates and may be immunized
- Age 15 or higher is now generally recommended (single dose)
- Indications for Vaccination
- Mainly used in military personell and in outbreaks in USA
- College freshman living in dorms have high rates now recommended
- Travel to endemic areas, particularly in Third World (Sub-Saharan Africa, Saudia Arabia)
- High risk, especially splenectomized and complement deficient patients
- Vaccine is 75-85% effective in preventing spread of Group C infections for age >9 [58]
- In age 2-9, vaccine effectiveness was ~40%
- In age <2 years, vaccine was not effective
- Standard vaccination schedule may lead to waining immunity after 1 year [84]
- Vaccine is used in controlling spread, and is generally not given routinely
M. Tetanus Vaccine
- 48-64 cases of tetanus per year in USA, mainly in young adults
- Vaccine is a purified toxoid usually given with Diphtheria ±Pertussis
- Efficacy is generally excellent, but wanes with time
- Boosters are now recommended every ten years (q5 years for HIV patients)
- Combined Tetanus/Diphtheria/Pertussis (5 component) Vaccine (Tdap) [88]
- Increasing reports of pertussis in adults have driven this combination vaccine
- 94% of volunteers vaccinees with Tdap have protective antibody concentrations
- Similar incidence of local and systemic reactions with Td versus Tdap vaccines
- Only ~25% of >70year old patients are adequately vaccinated
N. Varicella Zoster (VZV) Vaccine [2,30,44]
- Live vaccines are FDA approved for prevention of primary infection and reactivation
- Primary Vaccination (Varivax®)
- Live vaccine recommended for immunocompetent persons >12 months of age without any history of varicella infection
- In intensely exposed children, reduced risk of chicken pox >80% [31]
- Effiacy 87-97% for preventing moderate and severe infection [64]
- Vaccine efficacy wanes after ~1 year, but breakthrough cases remain mild [8]
- Strongly recommend that vaccination rates be increased
- Reduced mortality by >50% in USA since implementation [17]
- Likely that vaccine reduces incidence of shingles, but this is not proved
- Presence of asthma or other hyperreactive airways diseases may reduce efficacy [31]
- Adult dosage is two doses of 0.5mL sc vaccine, second dose is 1-2 months after first
- Very few serious adverse events reported, most with unclear relationship to vaccine [55]
- Secondary Vaccination (Zostavax®) [5,6]
- Live attenuated vaccine with ~14 times as much VZV as Varivax®
- Approved for prevention of herpes zoster (shingles) in persons at least 60 years old
- In persons >60 years old, reduced shingles by 50% and post-herpetic neuralgia ~67% [6]
- Single dose recommended in all persons >60 years regardless of previous disease [96]
- Adverse effects very mild, mainly injection site reactions
- Dose: single sc injection 0.65mL
- Heat-inactivated vaccine in development particularly for immunocompromised persons [77]
O. Herpes Simplex Type 2 (HSV2) Vaccine [32]
- Neutralizing antibodies to HSV type 2 glycoproteins B and D are protective
- New vaccines based on gB2 and gD2 protines with new adjuvant MF59 under study
- This subunit vaccine induces both antibody and cellular immunity to HSV-2
- Stage II clinical trials underway
P. Typhoid Fever Vaccine [9]
- ~500 cases annually in USA due to Salmonella typhi; millions in developing countries
- New capsular polysaccharide vaccine bound to nontoxigenic pseudomonas exotoxin A
- This vaccine has enhanced immunogenecity
- Requires two injections 6 weeks apart
- Vaccine efficacy 91% in 2-5 year old children
- Vaccine is recommended for pregnant and immunocompromised persons
- Vaccine is given to persons traveling to endemic areas
Q. Rotavirus Vaccine [43]
- Rotavirus is major cause of severe diarrhea, mainly in children
- About 100 deaths per year in USA, and >800,000 deaths / year worldwide
- Four major serotypes cause disease in humans and can cause disease in rhesus monkeys
- Quadravalent vaccine (RotaShield®) withdrawn from market [29,33]
- Live virus attenuated in rhesus monkeys
- Demonstrated efficacy in USA and Venezuala [34]
- Vaccine withdrawn from market due to increased risk of intussusception [33]
- Human Rotavirus Vaccine [40,43,98]
- Attenuated live human rotavirus vaccine RIX4414 G1P(8), Rotarix®
- Derived from an attenuated G1 (P8) human isolate called 89-12
- Two oral doses of vaccine given
- Vaccine reduced incidence of rotavirus ~90%, hospitalizations 85%
- Severe diarrhea reduced 90-100%
- Mild fever in 20% of vaccinated subjects after first dose only
- No increased risk of intussusception compared with placebo
- Pentavalent Human-Bovine WC3 Reassortment Vaccine [45]
- 3 oral doses
- Hospitalizations reduced 95% after 3rd dose
- Reduced severe diarrhea 98%
- No increased risk of intussusception compared with placebo
R. Staphylococcus Vaccine [73]
- Major cause of nosocomial pneumonia and skin infections
- Major problem in patients on dialysis
- Capsular polysaccharide (types 5 and 8) vaccine in development
- This vaccine showed 57% reduction in Staphylococcal bacteremia over 40 weeks
S. Anthrax Vaccine [36,47]
- Indicated for vaccination of military (and more recently civilians) in US
- Provides protection against anthrax
- Current vaccine is a sterile filtrate of cultures from an avirulent strain
- Given as 0.5mL subcuteneous injections at 0, 2, 4 weeks, and at 6, 12, 18 months
- Appears to be effective in preventing anthrax, which is usually transmitted by animals
- Reduces incidence of cutaneous and inhalational anthrax
- No effect on pregnancy, birth rates or adverse birth outcomes [75]
T. Human Papillomavirus Virus (HPV) [72,80,93,97]
- Recombinant Quadrivalent Vaccine (Gardasil®)
- Approved and recommended for females 9-26 years old to prevent HPV associated disease
- Includes types 6, 11, 16 and 18
- Prevents genital wars, precancerous cervical, vaginal, vulvar lesions, cervical cancer
- 98% reduction in serious pre-cancerous (CIN2/3, CIS) cervical lesions after 3 doses [72]
- Essentially 100% effective in preventing any anogenital lesions after 3 doses in women [80]
- Composoite of 4 trials in ~10,000 patients showed 99% efficacy in women negative for HPV 16 or 18 at the beginning of the trial [97]
- Administered as 3 separate 0.5mL intramuscular injections at 0, 2, 6 months
- Need for booster is not yet known
- Bivalent vaccine also effective for prevention, but no therapeutic benefit in infection [86]
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