ADULT IMMUNIZATION

Clinic of Infectious Diseases, Lithuanian University of Health Sciences

 Immunization is necessary because:

- decision to be unvaccinated is decision to be responsible

for the risk of infectious disease
(e.g., tetanus cases in Lithuania)

- the pathogens circulate in the environment, and decreasing

in coverage of immunization is related to the outbreaks of
infectious diseases
(e.g., measles outbreaks in France, Sweden)

- because of the active migration dangerous of non-endemic

pathogens exist
(e.g., poliomyelitis in China, 2011)
Vaccines important for adult immunization:
Diphtheria (d)
Tetanus (T)
Whooping cough (ap)
Measles, Epidemic parotitis, Mumps (MMR)
Influenza
Pneumococcal infections
TBE
Chickenpox
Hepatitis A
Hepatitis B
HPV infection
Meningococcal infection

R. Chlibek et al. / Vaccine 30 (2012) 1529 1540

 Immunization recommendations for adults
fall into four categories:
Routine vaccines for all adults.

Vaccines for high-risk exposure groups (health care and other

institutional workers, prisoners, students, military personnel, travelers
to endemic areas, injection drug users).

Vaccines for persons at high risk for severe outcomes of infection

(pregnant women; the elderly; persons with chronic medical conditions,
including diabetes, alcoholism, immunodeficiency, and renal, hepatic,
respiratory, or cardiac disease).

Vaccines for household contacts of persons in group 3.

Immunization recommendations for adults

Young adults without laboratory evidence or a reliable history

of past vaccination or disease should be immunized against
measles, mumps, rubella, and varicella.
Unless they have documented proof of immunity, rubella
vaccine should be given to all nonpregnant women of
childbearing age.
Rubella-susceptible pregnant women should be vaccinated as
early as possible in the postpartum period.
Live-virus vaccines, such as MMR and varicella vaccines, are
contraindicated in pregnant women and immunosuppressed
individuals.
Immunization recommendations for adults
Current recommendations also include influenza
vaccine for routine annual administration to
individuals with chronic illness at any age, to
persons living in the same household as
chronically ill individuals, and to all adults 50
years of age.
Polyvalent pneumococcal polysaccharide vaccine
is similarly recommended for adults 65 years of
age and for all chronically ill persons.
 ADULT IMMUNIZATION
ROUTINE
Tetanus and Diptheria ( Td )
Pneumococcal ( Age >65 )
Influenza ( Age >65 )
Hepatitis B
MISSED CHILDHOOD VACCINES
Mumps, Measles and Rubella (MMR )
Varicella
 ADULT IMMUNIZATION
Other vaccines when indicated

Hepatitis A
Polio
Meningococcal
Typhoid
Rabies
Yellow fever
ADULT IMMUNIZATION in special
cases

Pregnancy
Health care workers
Animal handlers
Immunocompromised states
ADULT IMMUNIZATION: assessment

History of previous immunization

Hypersensitivity reactions to vaccine or
their component
Acute febrile illness
Contraindications to live vaccine
 Immunization recommendations for adults

A substantial proportion of adults no longer have protective

levels of antibodies against tetanus or diphtheria.
All adults who completed the pediatric series should be
boosted with Td (adult formulation) every 10 years.
If not previously immunized, adults require a primary
immunizing course of Td.
Dose 0.5 ml I/M at 0, 1 and 6-12 months
 Tetanus prophylaxis in wound management
Tetanus toxoid Clean Large
Immunization Minor Wound Dirty Wounds

Tetanus TIG Tetanus TIG

toxoid toxoid
None, Begin
incomplete, Pre Exp No Yes Yes
Unknown Series
Last booster
>5 years Booster No Yes Yes
Complete
Last booster No No No No
within 5 years

TIG - Tetanus Immunoglobulin

 ADULT IMMUNIZATION
Mumps, Measles and Rubella Vaccine
Live attenuated vaccine

Dosage: 0.5 ml subcutaneous

Seroconversion 95%

Lifelong immunity
ADULT IMMUNIZATION rubella exposure

All pregnant women with suspected rubella or

exposure to rubella must be investigated
serologically irrespective of a history of rubella
immunization, clinical rubella or previous positive
rubella antibody result
ADULT IMMUNIZATION influenza vaccine
Inactivated trivalent vaccine

Dosage: 0.5 ml I/M yearly usually October

Efficacy: 70-90% in healthy subjects <65

In elderly, prevents disease in 30-40% and death in

80%
 Influenza Vaccine Indications
Healthy adults > 65
Residents of nursing homes
Chronic respiratory, heart and renal
disease
Immunosuppressed
Health care workers
Travelers
Pregnant women
Pneumococcal Vaccine Indications

Healthy adults >60

Asplenia or splenic dysfunction

Chronic heart, lung or liver disease

Chronic renal disease

Immunosuppressed states
 ADULT IMMUNIZATION: Varicella

Live attenuated vaccine

Dosage: 0.5 ml s/c. 2 doses 4-6 weeks apart
Seroconversion in 95%

Indications
Health care workers
Workers at day care centers
Non pregnant women
Immunization recommendations for adults
Hepatitis B vaccine is recommended for individuals at high risk from clinical,
occupational, behavioral, and travel exposures, including:

patients undergoing hemodialysis,

routine recipients of clotting factors,
health care workers exposed to potentially infected blood or blood products,
individuals living and working in institutions for the mentally handicapped,
travelers to highly endemic countries,
persons at elevated risk for sexually transmitted diseases,
injection drug users,
household contacts of known carriers of hepatitis B surface antigen.
 Hepatitis B
Recombinant DNA vaccine
Serological testing before immunization (antiHBcor)
Dose: 1 ml I/M in deltoid at 0, 1 and 6 months
Serological testing of high risk group 1-4 months after
immunization (antiHBs)
Good responders: AntiHBs >100mIU/ml
Poor responders: AntiHBs 10-100mIU/ml
Non responders: Anti HBs < 10mIU/ml
 Adverse events
An adverse reaction or vaccine side effect is an untoward effect caused
by a vaccine that is extraneous to its primary purpose.
An adverse event can be either a true vaccine reaction or a coincidental
event.
Modern vaccines, while safe and effective, are associated with adverse
events that range from infrequent and mild to rare and life-threatening.
The decision to recommend the use of a vaccine involves an assessment
of the risks of disease and the benefits and risks of vaccination.
 Adverse events

Vaccine components, including protective antigens, animal proteins introduced

during vaccine production, and antibiotics or other preservatives or stabilizers,
can certainly cause allergic reactions in some recipients.
Allergic reactions may be local or systemic and include urticaria and serious
anaphylaxis.
The most common extraneous allergen is egg protein introduced when
vaccines such as those for measles, mumps, influenza, and yellow fever are
prepared in embryonated eggs.
 Contraindications

Among the valid contraindications applicable to all vaccines

are a history of anaphylaxis or other serious allergic
reactions to a vaccine or vaccine component and the
presence of a moderate or severe illness, with or without
fever.
 Contraindications

Diarrhea, minor respiratory illness, mild to moderate local reactions to a

previous dose of vaccine, the concurrent or recent use of antimicrobial
agents, mild to moderate malnutrition, and the convalescent phase of an
acute illness are not valid contraindications to routine immunization.

Failure to vaccinate because of these conditions is increasingly viewed

as a missed opportunity for immunization.
 Simultaneous Administration of Multiple
Vaccines
There are no contraindications to the simultaneous administration of several
vaccines.
The use of combination vaccines can potentially reduce the required number
of injections.
Simultaneous administration of the most widely used live and inactivated
vaccines has not resulted in impaired antibody responses or in increased
rates of adverse reactions.
Simultaneous administration is useful in any age group when the potential
exists for exposure to multiple infectious diseases during travel to endemic
countries.
When live-virus vaccines are not given together on the same day, an interval
of at least 30 days should be allowed.
 Handling of vaccines
Vaccines should be kept at 2 to 8C and, with the
exception of varicella vaccine, should not be
frozen.
Varicella should be kept frozen at -15C.
Measles vaccine must be protected from light,
which inactivates the virus.
The management of health-care worker
exposures to the blood-borne infectious
pathogens
Hepatitis B Virus (HBV), Hepatitis C Virus (HCV),
and Human Immunodeficiency Virus (HIV)

Bloodborne viruses
Can produce chronic infection
Transmissible in healthcare settings
Preventing Transmission of Bloodborne
Viruses in Healthcare Settings

Promote hepatitis B vaccination

Treat all patients as potentially
infectious
Use barriers to prevent blood/body
fluid contact
Prevent percutaneous injuries
 Factors Influencing Occupational
Risk of Bloodborne Virus Infection

Prevalence of infection among patients

Risk of infection transmission after a blood

exposure

Nature and frequency of blood exposures

Prevalence of Bloodborne Virus Infection
in Patients

Generally higher in hospitalized patients

than general population
Varies with geographic area
Varies with patient group
Elements of Postexposure Management
Wound management
Exposure reporting
Assessment of infection risk
type and severity of exposure
bloodborne infection status of source
person
Appropriate treatment, follow-up, and
counseling
 Postexposure Management:
Wound Care

Clean wounds with soap and water

Flush mucous membranes with water
Application of antiseptics or disinfectants
 Postexposure Management:
The Exposure Report
Date and time of exposure
Procedure details: what, where, how, with
what device
Exposure details: route, body substance
involved, volume/duration of contact
Information about source person and
exposed person
Exposure management details
 Postexposure Management:
Assessment of Infection Risk
Type of exposure Source person
percutaneous presence of HBsAg
mucous membrane
presence of HCV
non-intact skin
antibody
bites resulting in blood
exposure presence of HIV
Body substance antibody
blood if source unknown,
bloody fluid assess epidemiologic
potentially infectious and clinical evidence
fluid or tissue
 Postexposure Management:
Evaluating the Source

Informed consent should be obtained in

accordance with state and local laws
Confidentiality of the source person
If the HBV, HCV, and/or HIV status of the
source is unknown, perform testing
Perform testing as soon as possible
 Postexposure Management:
Evaluating the Source

Presence of hepatitis B surface antigen (HBsAg)

indicates source is infected with HBV
Repeatedly reactive results by EIA for anti-HCV
should be confirmed by supplemental test (HCV
PCR)
EIA for anti HIV, consider rapid test if EIA testing
cannot be completed within 24-48 hours
Elements of Postexposure Management:
HBV
Baseline evaluation and testing of exposed
person with unknown HBV immune status
Consideration of treatment
when to give
what to give
Follow-up testing and counseling
 Postexposure Management:
Baseline HBV Testing of Exposed Person
Test for anti-HBs if person has been
vaccinated, but vaccine response is unknown
Baseline testing not necessary if exposed
person has not been vaccinated or vaccine
response is known
Recommended Postexposure Management: for
Exposure to HBV
Vaccination and antibody Treatment when source is HBsAg
status of exposed person positive

Unvaccinated HBIG x 1 and initiate hepatitis B

vaccine series
Previously vaccinated
Known responder No treatment

Known nonresponder HBIG x 1and initiate re-vaccination

or
HBIG x 2

Antibody response Test exposed person for anti-HBs

unknown 1. If adequate, no treatment
2. If inadequate, HBIG x 1
and vaccine booster
 Hepatitis B Vaccine: Long-Term Efficacy

Anti-HBs titers decline to <10 mIU/mL in 30-50%

of adults within 8-10 years after vaccination

Immune memory remains intact for at least 20

years after immunization
 Postexposure Management:
Follow-up HBV Testing of Exposed Person

Perform follow-up anti-HBs testing in healthcare

personnel who receive hepatitis B vaccine
test for anti-HBs 1-2 months after last dose
anti-HBs response to vaccine cannot be
ascertained if HBIG received in the previous
3-4 months
Elements of Postexposure Management:
HCV

Baseline evaluation and testing

Follow-up testing and counseling
 Postexposure Management:
Baseline HCV Testing of Exposed Person

If HCV-positive source, test exposed person for

anti-HCV and ALT
If source not infected, baseline testing not
necessary
 Postexposure Management:
Follow-up of HCV-Exposed HCP
Test for anti-HCV and ALT 4-6 months after exposure
Test for HCV-RNA at 4-6 weeks for earlier diagnosis
of HCV infection.
No guidelines for therapy during acute infection
when HCV infection identified early, refer worker to
a specialist for proper management
 Postexposure Management:
HCV Postexposure Counseling

Refrain from donating blood, plasma, organs,

tissue, or semen.
No need for:
modification of sexual practices or refraining from
becoming pregnant
special precautions to prevent secondary
transmission.
modification to patient care responsibilities for
exposed person, even if HCV infected
 Elements of Postexposure Management: HIV
Baseline evaluation and testing of exposed
person (EIA standard test)
Consideration of treatment
when to give
what to give
Follow-up testing and counseling
 Initiation of HIV post exposure prophylaxis

If indicated, start as soon as possible (48 h) after

exposure

Post exposure prophylaxis should be administered

for 4 weeks, if tolerated
Re-evaluation of HIV-Exposed Person
Consider reevaluation of the exposed person
within 48 hours
additional information about the source
person may become available
if the source person has a negative HIV
antibody test, stop post exposure
prophylaxis
 Postexposure Management HIV:
Basic Regimen
Basic 2-drug regimens:
Preferred:
Zidovudine + lamivudine
or
Tenofovir + emtricitabine
 Postexposure Management
HIV: Expanded Regimen
Expanded 3-drug regimens:
Preferred:
Lopinavir/ritonavir (Kaletra) + basic 2-drug regimen

Alternative:
Atazanavir ritonavir
Fosamprenavir ritonavir
Efavirenz + basic 2-drug regimen
 Postexposure Management:
Follow-up HIV Testing of Exposed Person

If source HIV positive, test at 6 weeks, 3

months, 6 months
EIA standard test