1. Vaccination Recommendations Sepehr Khashaei Assistant Professor of Internal Medicine

2. Mr. Jones is a 55 y/o male who is admitted to the hospital for alcohol withdrawal. He has a laceration on his forehead that has been sutured by ER prior to admission. Assuming that his laceration is not dirty and that he has had his childhood and adolescence Tetanus series, in which situation does Mr. Jones need a Tetanus shot and if so, would you give him a Td vaccine or a Tdap vaccine?

3. He does not remember his last Tetanus shot.

4. His last Tetanus shot was with a Td and was 2 years ago?

5. His last Tetanus shot was with a Td and was 7 years ago?

6. His last Tetanus show was with a Td and was 12 years ago.

7. His last Tetanus shot was with Tdap and was 12 years ago.

8. His last shot was with a Td 2 years ago and he lives with his 32 y/o daughter and his 6 month old granddaughter.

9. His last shot was with a Td 6 years ago and he lives with his 32 y/o daughter and his 6 month old granddaughter.

10. Tetanus/diphtheria (Td) and Tetanus/diphtheria/acellular pertussis (Tdap) vaccination

11. Administer a one-time dose of Tdap to adults younger than age 65 years who have not received Tdap previously or for whom vaccine status is unknown to replace one of the 10- year Td boosters.

12. Tdap is specifically recommended for the following persons: – Pregnant women > 20 weeks gestation (pregnant women not vaccinated during pregnancy should receive Tdap immediately postpartum). – Adults, regardless of age, who are close contacts of infants younger than age 12 months (e.g. parents, grandparents, or child care providers) – Health care personnel.

13. Tdap can be administered regardless of interval since the most recent tetanus or diphtheria-containing vaccine.

14. Adults 65 years or older may receive Tdap.

15. Adults with unknown or incomplete history of completing a 3-dose primary vaccination series with Td-containing vaccines should begin or complete primary vaccination series. Tdap should be substituted for a single dose of the Td in the vaccination series with Tdap preferred as the first dose.

16. Tetanus vaccination is recommended for at least once every 10 years in any patient in any age group unless presenting with a dirty wound in which case it should be given if has not been given within the previous 5 years.

17. Definition of a clean wound: A superficial wound produced by uncontaminated sharp objects, either electively–e.g., surgical procedure or by accident, being cut by sharp glass or metal–eg, broken glass.

18. Of the following who should receive a zoster vaccine (per ACIP guildelines), assuming no other prior medical problems: – A 62 y/o female who has had a prior episode of herpes zoster – A 82 y/o male who has not had a prior episode of herpes zoster – A 52 y/o female who has not had a prior episode of herpes zoster – A 59 y/o male who has had a prior episode of herpes zoster

19. Indications for zoster vaccine A single dose is recommended for adults 60 years of age and older regardless of whether they report a prior episode of herpes zoster.

20. Zoster vaccine is contraindicated in severe immunodeficiency.

21. Influenza vaccination is usually given in fall or winter and comes in mainly two forms: – Trivalent inactivated vaccine (TIV) (could be standard dose or high dose and intradermal or intramuscular). – Live attenuated internasal vaccine (LAIV)(Flumist)

22. Which of the following patients should receive an influenza vaccine and if so, which vaccine (some may be able to get either vaccine)? – A healthy 35 y/o pregnant woman – A healthy 25 y/o male health care provider who works with leukemia patients. – A healthy 32 y/o male health care provider who works on general internal medicine wards. – A 45 y/o female with multiple myeloma. – A 67 y/o healthy patient. – A 45 y/o male with COPD – A 52 y/o healthy female HCP with h/o egg allergy.

23. Influenza vaccination recommendations

24. Recommended for all adults (including healthy adults ages 19-49 y/o without risk factors)

25. LAIV is approved only for healthy nonpregnant people ages 2-49 y/o.

26. Adults age 18-64 may be given any intramuscular TIV product or, alternatively, the intradermal TIV product.

27. Adults ages 65 y/o or older may be given standard-dose TIV or, alternatively, the high- dose TIV.

28. For LAIV, the following are contraindications: – Pregnancy – COPD and asthma – Cardiovascular disease (except HTN) – Renal, hepatic, neurological, hematologic, or metabolic (including DM) disorders – Immunosuppression (including that caused by medications or HIV) – Previous anaphylaxis to the vaccine.

29. Egg allergy is no longer a contraindication to influenza vaccine. No skin tests are needed before the vaccine is given. The entire dose may be given as once, followed by 30-minute observation period, in egg-allergic patient.

30. Precautions to influenza vaccine Moderate to severe acute illness H/o GBS within 6 wks following previous influenza vaccination For LAIV only: receipt of anti-influenza antiviral therapy 48 hours before vaccination. Avoid use of these drugs for 14 days after vaccination.

31. Mrs. Garcia is admitted for cellulitis of his leg and is being treated with iv antibiotics in the hospital. In which of the following situations would you give Mrs. Garcia a pneumonia polysaccharide vaccine (PPSV) as inpatient (prior to discharge) or shortly after discharge as outpatient?

32. She is 55 years old with history of moderate COPD, no prior h/o pneumococcal vaccinations, and not on chronic oral corticosteroids.

33. She is 55 years old with history of moderate COPD, unknown h/o pneumococcal vaccinations, and not on chronic oral corticosteroids.

34. She is 55 years old with history of moderate COPD, prior h/o pneumococcal vaccination at age 51, and not on chronic oral corticosteroids.

35. She is 55 years old with history of moderate COPD, prior h/o pneumococcal vaccination at age 48, and not on chronic oral corticosteroids.

36. She is 55 y/o with no prior medical problems and not on any medications and no prior pneumococcal vaccination.

37. She is 67 y/o with no prior medical problems and not on any medications and no prior pneumococcal vaccinations.

38. She is 45 years old with history of splenectomy due to MVA at age 30 and prior h/o pneumococcal vaccination at age 31.

39. She is 45 years old with history of splenectomy due to MVA at age 30 prior h/o pneumococcal vaccination at age 31 and 37.

40. She is 67 years old with history of splenectomy due to MVA at age 30 prior h/o pneumococcal vaccination at age 31 and 37.

41. She is 82 years old with history of splenectomy due to MVA at age 30 prior h/o pneumococcal vaccination at age 31 and 37.

42. She is 32 years old and is currently 22 weeks pregnant with history of splenectomy due to MVA at age 25 and prior h/o pneumococcal vaccination at age 25.

43. She is 55 years old and she smokes 1/2 ppd but she has no h/o prior pneumococcal vaccinations and has no COPD and no prior medical problems.

44. She is 82 y/o and has moderate COPD and not on oral steroids and received a pneumococcal vaccine at age 67.

45. Indications for Pneumococcal polysaccharide vaccination (PPSV)

46. Age of 65 years or older without a history of PPSV vaccination.

47. Adults younger than age 65 with any of the following: – Chronic lung disease (COPD, asthma) – Chronic cardiovascular disease – DM – Chronic liver disease (including cirrhosis) – Alcoholism – Immunocompromising conditions – Asplenia (functional or anatmic) – Smokers – Residents of nursing homes or long-term care facilities.

48. Vaccination during chemotherapy or radiation therapy should be avoided. When cancer chemotherapy or other immunosupressive therapy is being considered, the interval between vaccination and initiation of immunosuppressive therapy should be at least 2 weeks.

49. Revaccination with PPSV One-time revaccination 5 years after 1 st dose for persons 19-64 y/o with: – Chronic renal failure or nephrotic syndrome – Asplenia (functional or anatomic) – Immunocompromising conditions (HIV, leukemia, lymphoma, multiple myeloma, generalized malignancy, receiving chemotherapy, on chronic corticosteroids, received an organ or bone marrow transplant). Once at age 65 or later if at least 5 years have passed since last previous dose.

50. Contraindications to Pneumococcal vaccine Severe allergic reaction (e.g. anaphylaxis) after a previous dose or to a vaccine component.

51. Precautions to PPSV vaccine Moderate to severe acute illness with or without fever.

52. Important Best Practice Points Tdap should be given at least once to each adult patient when the Tetanus shot is due (or earlier if certain risk factors for pertussis). Age >65 is no longer a contraindication. All adults >60 y/o should be vaccinated with zoster vaccine once regardless of if h/o shingles or not, unless severely immunocompromised. Egg allergy is no longer a contraindication to influenza vaccination. When not sure about which influenza vaccine to give, give the standard intramuscular TIV vaccine. Low grade fever with mild illness is not a contraindication to pneumonia or influenza vaccination.