1. Kenneth McCall, BSPharm, PharmD Associate Professor | UNE President | Maine Pharmacy Association

2. Objectives Discuss the gap between current rates and Healthy People 2020 goals for vaccinations. Categorize each of the CDC recommended flu vaccines based upon live/inactivated, route, prep., and storage. Discuss the influenza vaccines for 2014 including the new quadrivalent and mammalian cell vaccines. Identify vaccine contraindications and recommend vaccines based upon age and medical history. Apply ACIP recommendations and FDA approved indications for the CDC recommended vaccines.

3. Outline Background & Principles of Vaccination Influenza Vaccines Quadrivalent inactivated Quadrivalent live Mammalian High Dose Intradermal

6. Classification of Vaccines Live attenuated Weakened form of the “wild” virus or bacteria Inactivated Whole viruses or bacteria Fractions of viruses or bacteria *Epidemiology and Prevention of Vaccine-Preventable Diseases, 12th Edition

7. Classification of Vaccines Live attenuated: Measles, mumps, rubella, varicella, zoster, intranasal influenza Inactivated: hepatitis A, hepatitis B, influenza, pneumonia, diphtheria, tetanus, pertussis, HPV, meningicoccal *Epidemiology and Prevention of Vaccine-Preventable Diseases, 12th Edition

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9. 2014 Recommended Adult Immunization Schedule, by vaccine and age group www.cdc.gov/vaccines/schedules/hcp/adult.html

10. Vaccines that might be indicated for adults based on medical and other indications www.cdc.gov/vaccines/schedules/hcp/adult.html

11. 2014 Influenza Vaccination Recommendations Annual vaccination against influenza is recommended for all persons aged 6 months or older. Adults aged 18 to 49 years can receive the recombinant or mammalian vaccine. Healthy, nonpregnant persons aged 2 to 49 years without high-risk medical conditions can receive either intranasal, live vaccine or inactivated vaccine. Health care personnel who care for severely immunocompromised persons should receive inactivated vaccine. Adults 18 to 64 years can receive either the intramuscular or intraderm. Adults 65+ years can receive either the standard-dose or the high-dose. www.cdc.gov/vaccines/schedules/hcp/adult.html

12. What is the Healthy People 2020 goal for annual flu vaccination for adults 65 and older? 1. 100% 2. 90% 3. 70% 4. 50%

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15. Influenza Virus Strains Influenza A virus Moderate to severe illness All age groups Humans and other animals Influenza B virus Milder disease Primarily affects children Humans only Influenza C virus Rarely reported in humans No epidemics 15

16. 2013-14 Influenza Surveillance CDC has antigenically characterized 2,110 influenza viruses Influenza A 2009 H1N1 [1,657]: 99.9% of the 2009 H1N1 viruses tested were characterized as A/California/7/2009-like, the influenza A (H1N1) component of the 2013-2014 Northern Hemisphere influenza vaccine. Influenza A (H3N2) [269]: 98.1% of the influenza A (H3N2) viruses tested have been characterized as A/Texas/50/2012-like, the influenza A (H3N2) component of the 2013-2014 Northern Hemisphere influenza vaccine. Influenza B [184]: 124 (67%) of the 184influenza B viruses tested belong to B/Yamagata/16/88-lineage and the remaining 60 (33%) influenza B viruses tested belong to B/Victoria/02/87 lineage. Yamagata Lineage [124]: 124 influenza B/Yamagata-lineage viruses were characterized as B/ Massachusetts/2/1012-like, which is included as an influenza B component of the 2013-2014 Northern Hemisphere trivalent and quadrivalent influenza vaccines. Victoria Lineage [60]: 60 influenza B/Victoria-lineage viruses were characterized as B/Brisbane/60/2008-like, which is included as an influenza B component of the 2013-2014 Northern Hemisphere quadrivalent influenza vaccine.

18. US Influenza Vaccines: 2014 VaccineAge GroupDosageScheduleRoute Inactivated, Trivalent Standard Dose 6-35 mos0.25 ml1 or 2 shotsIM 3-8 years0.5 ml1 or 2 shotsIM >9 years0.5 ml1 shotIM Inactivated, Quadrivalent Standard Dose 3-8 years0.5 ml1 or 2 shotsIM >9 years0.5 ml1 shotIM Inactivated, Mammalian Trivalent Standard Dose >18 years0.5 ml1 shotIM Inactivated, Recombinant Trivalent Standard Dose 18-49 years0.5 ml1 shotIM Inactivated, Trivalent High Dose >65 years0.5 ml1 shotIM Inactivated, Trivalent Intra-dermal 18-64 years0.1 ml1 shotID Live, Quadrivalent Intranasal 2-8 years0.2 ml1 or 2Nasal 9-49 years0.2 ml1 doseNasal

19. New Influenza Vaccines: 2013-14 Fluarix ® (GlaxoSmithKline) – inactivated, quadrivalent vaccine FDA approved December 2012 People ages 3 years and older Fluzone® (Sanofi Pasteur) – inactivated, quadrivalent vaccine. FDA approved March 2013 People ages 6 months and older Flumist® Quadrivalent (MedImmune)– live, attenuated, quadrivalent vaccine FDA approved March, 2012 People ages 2 through 49 years Flucelvax® (Novartis)– trivalent inactivated vaccine grown in mammalian cells. FDA approved November, 2012 Adults 18 years and older Doesn’t list “severe allergic reaction to egg protein” in the contraindications Flublok® (Protein Sciences Corp.) – inactivated, trivalent, recombinant vaccine. FDA approved March 2013 People ages 6 months and older Doesn’t list “severe allergic reaction to egg protein” in the contraindications

20. Which of the following was the predominant flu strain of 2013-14? 1. Type B strain in trivalent vaccine 2. Type B strain not in trivalent vaccine 3. Type A H1N1 strain 4. Type A H3N2 strain

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22. New Influenza Vaccines: 2013-14 Fluarix ® (GlaxoSmithKline) – inactivated, quadrivalent vaccine which contains two type A and two type B strains FDA approved December 2012 People ages 3 years and older Fluzone ® (Sanofi Pasteur) – inactivated, quadrivalent vaccine which contains two type A and two type B strains FDA approved March 2013 People ages 6 months and older

23. Quadrivalent vs. Trivalent: Local Side Effects Fluarix [package insert]. Dresden, Germany: GlaxoSmithKline Inc; 2013.

24. Quadrivalent vs. Trivalent: Systemic Side effects Fluarix [package insert]. Dresden, Germany: GlaxoSmithKline Inc; 2013.

25. Quadrivalent vs. Placebo: Vaccine Efficacy Fluarix [package insert]. Dresden, Germany: GlaxoSmithKline Inc; 2013.

26. Administration Fluarix®: 0.5-mL dose IM - deltoid 1 inch, 25 gauge needle 26

27. Quadrivalent Influenza Vaccines contain which of the following? 1. Four type A strains 2. Two type A strains, 1 type B, & 1 type C 3. Two type A strains & 2 type B strains 4. Four type B strains

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29. New Influenza Vaccines: 2013-14 Flumist® Quadrivalent (MedImmune)– live attenuated vaccine which contains two type A and two type B strains FDA approved March, 2012 People ages 2 through 49 years

30. Live Attenuated Influenza Vaccine Indication Healthy people 2 through 49 years of age Contraindications Pregnant women People who have long-term health problems with: heart disease kidney or liver disease lung disease metabolic disease, such as diabetes asthma anemia, and other blood disorders Anyone with a weakened immune system Severe egg allergy 30 I pick my nose!

31. Immune Response Studies of FluMist Quadrivalent in Children and Adults A multicenter, randomized, double-blind study was performed to assess the immunogenicity of FluMist Quadrivalent compared to FluMist Trivalent in 2,312 children and adolescents 2 through 17 years of age. A multicenter, randomized, double-blind study was performed to assess the immunogenicity of FluMist Quadrivalent compared to FluMist Trivalent in 1,800 adults 18 through 49 years of age. Conclusion: In both studies, the addition of the second B strain did not result in immune interference to other strains included in the vaccine. FluMist Quadrivalent [package insert]. Gaithersburg, MD: MedImmune Inc; 2012.

32. Summary of solicited adverse reactions observed within 14 days after FluMist in Children 2-17 years FluMist Quadrivalent [package insert]. Gaithersburg, MD: MedImmune Inc; 2012.

33. Summary of solicited adverse reactions observed within 14 days after FluMist in Adults 18-49 years FluMist Quadrivalent [package insert]. Gaithersburg, MD: MedImmune Inc; 2012.

34. Administration Flumist®: 0.1-mL dose in each nostril Intranasal 34

35. Intranasal Administration Active inhalation (sniffing) by the patient is not required

36. Which of the following patients is a candidate for the live influenza vaccine? 1. 45 yo man with severe egg allergy 2. 27 yo healthy woman 3. 38 yo man with diabetes 4. 54 yo healthy man 5. 19 yo pregnant woman

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38. New Influenza Vaccines: 2013-14 Flucelvax® (Novartis)– trivalent inactivated vaccine grown in mammalian cells rather than chicken embryo cells. FDA approved November, 2012 Adults 18 years and older Doesn’t list “severe allergic reaction to egg protein” in the contraindications

39. Head-to-Head Comparison: Flucelvax vs. Placebo Barrett PN, et al. Lancet 2011;377:751-59

40. Flucelvax vs. Placebo Local & Systemic Adverse Reactions Flucelvax [package insert]. Cambridge, MA: Novartis Vaccines & Diagnostics Inc; 2012.

41. Flucelvax Compared to Agriflu Local Adverse Reactions Flucelvax [package insert]. Cambridge, MA: Novartis Vaccines & Diagnostics Inc; 2012. **Agriflu

42. Flucelvax Compared to Agriflu Systemic Adverse Reactions **Agriflu

43. Administration Flucelvax®: 0.5-mL dose IM - deltoid 1 inch, 25 gauge needle 43

44. Which of the following influenza vaccines does not include “severe egg allergy” as a contraindication? 1. Inactivated quadrivalent 2. Live quadrivalent 3. Inactivated trivalent intradermal 4. Inactivated trivalent high dose 5. Inactivated trivalent mammalian

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46. New Influenza Vaccines: 2013-14 Flublock® (Protein Sciences Corporation)– trivalent inactivated vaccine grown in insect cells rather than chicken embryo cells. FDA approved November, 2013 Adults 18 through 49 years of age. Doesn’t list “severe allergic reaction to egg protein” in the contraindications

47. Vaccine Efficacy against Culture-Confirmed Influenza in Healthy Adults 18-49 years

48. Frequency of Local and Systemic Reactions within 7 days of Flublok or Placebo in Adults 18-49 years

49. Administration Flucelvax®: 0.5-mL dose IM - deltoid 1 inch, 25 gauge needle 49

50. ACIP Recommendations for flu vaccination of person who report egg allergy.

51. Select an influenza vaccine for a healthy 37- year-old woman with severe egg allergy. 1. Flublok 2. Flumist 3. Fluzone 4. Fluarix

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53. Methods: Multicenter, randomized, double-blind controlled study HD vaccine (60 mcg of hemagglutinin per strain): N=2,575 SD vaccine (15 mcg of hemagglutinin per strain): N=1,262 in adults 65 years of age and older. 53 J Infect Dis. 2009;200(2):172-80

54. Comparison of responses to high-dose (HD) and standard-dose (SD) influenza vaccine 54 antibody titer level J Infect Dis. 2009;200(2):172-80

55. Comparison of systemic side effects to HD and SD influenza vaccine 55 J Infect Dis. 2009;200(2):172-80 Percent

56. Administration Fluzone HD®: 0.5-mL dose IM - deltoid 1 inch, 25 gauge needle 56

58. Intradermal Influenza Vaccine Indication Persons 18 through 64 years of age Contraindications Severe egg allergy 58

59. Intradermal vs Traditional IM needle Length

60. 30 Gauge Needle and Less Volume

61. Methods: Multicenter, randomized, double-blind controlled study ID vaccine (9 mcg of hemagglutinin per strain) N=1,803 IM vaccine (15 mcg of hemagglutinin per strain): N=452 in adults 18 to 60 years of age. Human Vaccines. 2010;6:346-54.

62. Comparison of responses to Intradermal (ID) and Intramuscular (IM) influenza vaccine 62 Seroprotection Rate Human Vaccines. 2010;6:346-54.

63. Comparison of systemic side effects to ID and IM influenza vaccine 63 Percent Human Vaccines. 2010;6:346-54.

64. Comparison of local side effects to ID and IM influenza vaccine 64 Percent Human Vaccines. 2010;6:346-54.

65. Intradermal Injection Technique 1. Remove needle cap 2. Hold microinjection system between thumb and middle finger  Do not place fingers on the windows 3. Insert needle rapidly perpendicular to the skin 4. Inject using the index finger 5. Remove needle from the skin and activate the needle shield by pushing firmly on the plunger

66. Which side effect is more common with the intradermal influenza vaccine than the IM influenza vaccine? 1. Injection site pain 2. Headache 3. Fever 4. Injection site swelling 5. Malaise

68. Influenza Vaccines and Age Indications Indicated for those meeting age requirements and without contraindications

69. Influenza Vaccine Indications Indicated for individuals meeting age requirements. contraindicated **Patients with high risk medical conditions: including immunocompromised, chronic cardiovascular disease, Diabetes Mellitus, pulmonary disease, or metabolic disease.

70. Which of the following influenza vaccine(s) is/are appropriate for a healthy 16-year-old boy. 1. Fluzone 2. Fluzone ID 3. Fluzone HD 4. Flucelvax 5. 1 and 2

71. Which of the following influenza vaccines is NOT indicated for a 72-year old woman? 1. Inactivated trivalent IM vaccine 2. Inactivated quadrivalent vaccine 3. Inactivated high dose vaccine 4. Inactivated trivalent intradermal vaccine

72. A 35-year-old woman requests an annual flu shot. She has ulcerative colitis and is taking Prednisone 40 mg QD. Which flu vaccine(s) is/are appropriate? 1. Influenza intradermal vaccine 2. Influenza intramuscular vaccine 3. Influenza high dose vaccine 4. Flumist nasal spray 0.2 ml nasal 5. Either 1 or 2 6. Either 2 or 3 7. Either 2 or 4

79. 2014 ACIP Recommendations for Pneumococcal Vaccination in Adults Immunocompromised? yesno Previously received Pneumovax? yesno Administer Prevnar one or more years after last Pneumovax Administer Prevnar followed by Pneumovax 8 weeks later Age > 65? yesno Administer Pneumovax Lung, liver, kidney, heart disease, diabetes, smoking, nursing home? yes no Vaccine not recommended

80. 2014 ACIP Recommendations on Revaccination with Pneumovax in Adults Age > 65? yesno Previous Pneumovax > 5 years ago and prior to age 65? no Administer Pneumovax Vaccine not recommended Renal disease, Immuno- compromised? yesno Administer Pneumovax Previous Pneumovax > 5 years ago? Vaccine not recommended yes no Vaccine not recommended

81. Administration Pneumovax® / Prevnar ® : 0.5-mL dose IM - deltoid 1 inch, 25 gauge needle 81

82. A 54-year-old man is immuno-compromised due to asplenia. No prior pneumonia vaccination. What pneumonia vaccine(s) is/are recommended? 1. Pneumovax only 2. Prevnar only 3. Both; Pneumovax prior to Prevnar 4. Both; Prevnar prior to Pneumovax

83. A 67-year-old woman has a history of type 2 diabetes. No prior pneumonia vaccination. What pneumonia vaccine(s) is/are recommended? 1. Pneumovax only 2. Prevnar only 3. Both; Pneumovax prior to Prevnar 4. Both; Prevnar prior to Pneumovax

84. Which of the following statements about the administration of influenza and pneumonia vaccines is true? 1. Same day, opposite arm, separate syringe 2. Same day, same arm, mixed in 1 syringe 3. Must be separated by at least 7 days 4. Must be separated by at least 4 weeks

85. Which of the following vaccines is a live vaccine? 1. Pneumovax 2. Flumist 3. Prevnar 4. Fluarix 5. Fluzone HD

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90. Clinical Presentation of Herpes Zoster 1–3 Abnormal Skin Sensations Headache Photophobia Malaise Unilateral Dermatomal Rash Maculopapules/Vesicles Altered Sensitivity to Touch Unbearable Itching Cessation of New Vesicles Pustulation Scabbing Cutaneous Healing Neurologic Cutaneous Ophthalmic Visceral (rare) Prodrome Acute HZ RashEvolution of RashComplications? Pain (varying severity) “Aching”, “burning”, “stabbing”, “shock-like” 1.Oxman MN. In: Arvin AM et al, eds. Varicella-Zoster Virus: Virology and Clinical Management. Cambridge, UK: Cambridge University Press; 2000:246–275. 2.Weaver BA. J Am Osteopath Assoc. 2007;107(suppl 1):S2–S7. 3. Harpaz R et al. MMWR Morb Mortal Wkly Rep. 2008;57(RR-5):1–30. © Phototake. © Dr. P. Marazzi / Photo Researchers, Inc. Herpes Zoster Rash Follows a Dermatomal Distribution © Phototake.

92. Zoster Vaccination Rates are Low 1–3 1. Centers for Disease Control and Prevention (CDC). cdc.gov/vaccines/stats-surv/nhis/2009-nhis.htm. Accessed January 19, 2011. 2. Centers for Disease Control and Prevention (CDC). Morbid Mortal Wkly Rep. 2012;61(4):66–72. 3. Centers for Disease Control and Prevention (CDC). MMWR. 2013;62(4):61–76. 4. Harpaz R et al. Morbid Mortal Wkly Rep. 2008;57(RR-5):1–30.  More than 99.5% of US adults ≥40 years of age have serologic evidence of previous infection of varicella zoster virus; therefore, all older adults are at risk of zoster infection 4 % Vaccinated (cumulative) in Individuals Aged ≥60 Years Year 7% 10% 14% 2008 20092010 0 5 10 15 20 25 30 35 40 45 50 15.8% 2011 20102009 2008

93. Zoster Vaccine Indication ACIP recommends routine vaccination of all persons aged >60 years with 1 dose of zoster vaccine. NEW FDA LABELING: “ZOSTAVAX is a live attenuated virus vaccine indicated for prevention of herpes zoster (shingles) in individuals 50 years of age and older.” Persons who report a previous episode of zoster and persons with chronic medical conditions can be vaccinated unless those conditions are contraindications or precautions. Zoster vaccination is not indicated to treat acute zoster. 93 Recommendations of the Advisory Committee on Immunization Practices (ACIP) http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1.htm?s_cid=rr5705a1_e Zostavax ® [package insert]. Whitehouse Station, NJ: Merck; April 2011.

94. Vaccine Contraindications Allergy to neomycin or any vaccine component Pregnancy Immunocompromised status AIDS or other clinical manifestations of HIV, including persons with CD4+ T-lymphocyte values <200 per mm 3 malignant neoplasms affecting the bone marrow chemotherapy or radiation within the last 3 months Persons on immunosuppressive therapy, including high- dose corticosteroids (>20 mg/day of prednisone or equivalent) lasting two or more weeks 94

95. Efficacy of ZOSTAVAX ® (Zoster Vaccine Live) on Incidence of Herpes Zoster in Adults Aged  60 Years Based on the results of the Shingles Prevention Study (SPS) a RESULTS BY AGE GROUPS (YEARS) Placebo (n=10,356) ZOSTAVAX (n=10,370) Number of Zoster Cases 64 % in subjects 60–69 [95% CI: 56–71] Placebo (n=7,559) ZOSTAVAX (n=7,621) Number of Zoster Cases 41 % in subjects 70–79 [95% CI: 28–52] Placebo (n=1,332) ZOSTAVAX (n=1,263) Number of Zoster Cases 18 % in subjects  80 [95% CI: –29–48; NS] 334 122 261 156 47 37 Placebo (n=19,247) ZOSTAVAX (n=19,254) Number of Zoster Cases 51 % in subjects  60 [95% CI: 44–58] OVERALL LOWER INCIDENCE OF ZOSTER a 642 315 CI=confidence interval; NS=not significant. a In the Shingles Prevention Study, efficacy was evaluated in a placebo-controlled, double-blind clinical trial of ZOSTAVAX. 38,546 subjects 60 years of age or older were randomized to receive a single dose of either ZOSTAVAX (n=19,270) or placebo (n=19,276) and were monitored for the development of zoster for a median of 3.1 years (range, 31 days to 4.90 years).

96. Efficacy of ZOSTAVAX ® (Zoster Vaccine Live) on Incidence of PHN in Adults Aged  60 Years Who Developed Zoster Post-Vaccination The benefit of ZOSTAVAX in the prevention of PHN can be primarily attributed to the effect of the vaccine on the prevention of herpes zoster. 0 Overall Number of PHN Cases 8027 8.6 12.5 10 20 30 % of Zoster Cases With PHN 39% b Number of HZ Cases 642315 (95% CI: 7–59) ZOSTAVAX Placebo HZ=herpes zoster; PHN=postherpetic neuralgia. a PHN was defined as herpes zoster-associated pain rated as ≥3 on a 10-point scale and occurring or persisting at least 90 days after rash onset. b Age-adjusted estimate based on the age strata (60–69 and ≥70 years of age) at randomization. Based on the results of the Shingles Prevention Study (SPS) a

97. Efficacy of ZOSTAVAX ® (Zoster Vaccine Live) on Incidence of Herpes Zoster in Adults Aged 50–59 Years Based on the results of the ZOSTAVAX Efficacy and Safety Trial (ZEST) 1,a a Study Design for ZEST: In the ZOSTAVAX Efficacy and Safety Trial, efficacy was evaluated in a placebo- controlled, double-blind study of ZOSTAVAX. 22,439 subjects 50 to 59 years of age were randomized to receive a single dose of either ZOSTAVAX (n=11,211) or placebo (n=11,228) and were monitored for the occurrence of shingles for a median of 1.3 years postvaccination (range, 0 to 2 years). 1. Schmader KE et al. Clin Infect Dis. 2012;54:922–928. 99 30 Placebo (n=11,228) ZOSTAVAX (n=11,211) Number of Zoster Cases 70 % in subjects 50–59 [95% CI: 54–81]

98. Storage and Handling zoster vaccine must be stored frozen The vaccine must be discarded if not used within 30 minutes after reconstitution. New labeling: Zostavax may be stored and/or transported at fridge temp for up to 72 hours prior to reconstitution. Any unused vaccine at fridge temp should be discarded. 98 Zostavax ® [package insert]. Whitehouse Station, NJ: Merck; April 2011.

100. Administration Zostavax: 0.65-mL dose (reconstituted) SQ – upper, outer tricep 5/8 inch, 25 gauge needle 100

101. Which of the following statements about the administration of influenza and zoster vaccines is true? 1. Same day, opposite arm, separate syringe. 2. Same day, same arm, mixed in 1 syringe. 3. Must be separated by at least 7 days. 4. Must be separated by at least 4 weeks.

102. RR is a 70-year-old woman with COPD. She has no allergies. Her meds include albuterol, Pulmicort and Spiriva. She has an 80-pack-year history of smoking. She quit smoking 5 years ago. Her last pneumonia shot was 8 years ago. Which vaccine(s) is/are appropriate for her? 1. Pneumovax 0.5 ml IM 2. Influenza SD shot 0.25 ml IM 3. Influenza HD shot 0.5 ml IM 4. Flumist nasal spray 0.1 ml in each nostril 5. Zostavax 0.65 ml SQ 6. Both 1 and 2 7. 1, 2 and 5 8. 1, 3 and 5 9. 1, 4 and 5

104. Pathogen (Common name) Table PathogenClassificationTransmissionComplication Tetanus (lockjaw) Gram + Bacteria- toxin WoundRespiratory failure DiphtheriaGram + Bacteria- toxin RespiratoryMyocarditis/Neuritis Pertussis (whooping cough) Gram – BacteriaRespiratoryPneumonia

105. Diseases20 th Century Annual Morbidity 2010 Reported Cases Percent Decrease Smallpox29,0050100% Polio (paralytic)16,3160100% Measles530,21761>99% Mumps162,3442,52898% Pertussis200,75221,29189% Diphtheria21,0530100% Rubella47,7456>99% Congenital Rubella Syndrome 1520100% Tetanus580899% Haemophilus influenzae 20,00027099% Comparison of 20 th Century and current US Morbidity of VPDs

106. New FDA Approval – July 8, 2011 US FDA has expanded the age indication for Boostrix® vaccine to prevent tetanus, diphtheria, and pertussis (whooping cough) to people ages 65 and older. Boostrix® is the first vaccine approved to prevent all three diseases in people 65 and older. Adacel® is approved for persons 11 through 64 years. Boostrix ® [package insert]. Rixensart, Belgium: GlaxoSmithKline; July 2011. Adacel® [package insert]. Swiftwater, PA: Sanofi Pasteur Inc.; February 2012.

107. Tetanus, diphtheria, and pertussis (Td/Tdap) Vaccination 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. Tdap is specifically recommended for the following persons: pregnant women more than 20 weeks’ gestation, adults, regardless of age, who are close contacts of infants younger than age 12 months (e.g., parents, grandparents, or child care providers), and health-care personnel. Tdap can be administered regardless of interval since the most recent tetanus or diphtheria containing vaccine. Pregnant women not vaccinated during pregnancy should receive Tdap immediately postpartum. Adults 65 years and older may receive Tdap.

108. Administration Boostrix®/Adacel®: 0.5-mL dose IM - deltoid 1 inch, 25 gauge needle 108

109. AB is a 52-year-old woman with hypertension. She has no allergies. Her meds include amlodipine 10 mg PO QD. She smokes 1 PPD. Her newborn grandson lives with her. Which vaccine(s) is/are appropriate for her? 1. Pneumovax 0.5 ml IM 2. Influenza SD shot 0.5 ml IM 3. Influenza HD shot 0.5 ml IM 4. Flumist nasal spray 0.1 ml in each nostril 5. Zostavax 0.65 ml SQ 6. Tdap 0.5 ml IM 7. 1, 2 and 5 8. 1, 3 and 5 9. 1, 2, 5 and 6

111. Pathogen (Common name) Table PathogenClassificationTransmissionComplication Influenza (flu) virusRespiratoryPneumonia PneumococcusGram + BacteriaRespiratoryMeningitis/Bacteremia Varicella (chicken pox) virusRespiratoryBacterial infection Zoster (shingles) virusLatent varicellaNeuralgia HPV (genital warts) virusSexual contactCervical cancer MeningococcusGram - BacteriaRespiratoryInvasive disease Tetanus (lockjaw) Gram + Bacteria-toxinwoundRespiratory failure DiphtheriaGram + Bacteria-toxinRespiratoryMyocarditis/Neuritis Pertussis (whooping cough) Gram - BacteriaRespiratoryPneumonia MeaslesvirusRespiratoryDiarrhea, pneumonia MumpsvirusRespiratoryMeningitis RubellavirusRespiratoryArthritis Hepatitis AvirusFecal-oralAcute/chronic hepatitis Hepatitis BvirusBlood-serous fluidsAcute hepatitis

112. Adult Vaccine Table VaccineVaccine Type Route / Reconstitute SeriesStorage Influenza IIVInactivatedIM / No1x annuallyFridge FlumistLiveIntranasal / No1x annuallyFridge PneumovaxInactivatedIM or SQ / No1-2 dosesFridge ZostavaxLiveSQ / Yes1 doseFreezer Gardasil (HPV4) Cervarix (HPV2) InactivatedIM / No3 dosesFridge TdInactivatedIM / No1 q 10 yearsFridge TdapInactivatedIM / No1x, then TdFridge VarivaxLiveSQ / Yes2 dosesFreezer MMRLiveSQ / Yes1-2 doses Fridge or Freezer Menactra, Menveo Menomune (MPSV4) InactivatedIM / No1-2+ dosesFridge Havrix, VaqtaInactivatedIM / No2 dosesFridge Recombivax-HB Engerix-B InactivatedIM / No3 dosesFridge