Adult immunization [BANGLADESH]

Its all about immunization options for adult population available in Bangladesh. [up to January, 2016]

1. Adult Immunization DR. TALHA-SAMI-UL-HAQUE HMO DEPT. OF MEDICINE DHAKA MEDICAL COLLEGE hospital

2. What is immunization? Immunization  is the process whereby a person is made immune or resistant to an infectious disease, typically by the administration of a vaccine. Vaccines stimulate the body's own immune system to protect the person against subsequent infection or disease.

3. History of Vaccination 429 BC : Greek historian Thucydides noticed that people who survive smallpox do not get re-infected . 900 AD : Chinese discovered variolation 1700s : Variolation spreads around the world 1796 : Edward Jenner discovered vaccination in its modern form and proved to the scientific community that it worked.

4. EDWARD JENNER Discovered the small pox vaccine in its modern form and proved to the scientific committee that it worked.

5. History of Vaccination 1890: Emil von Behring discovers the basis of DT vaccine 1920s: Vaccines become widely available. 1955: Polio vaccination begins. 1956: WHO fights to eradicate smallpox. 1980: Smallpox eradicated from the world. 2008: Professor Harald zur Hausen awarded Nobel Prize for discovery of HPV Vaccine. 2013: Rotavirus vaccine and shingles vaccine introduced.

6. Louis Pasteur Discovered the rabies vaccine

7. Vaccine Preventable Diseases [CDC] Anthrax Cervical Cancer Diphtheria Hepatitis A Hepatitis B Haemophilus influenzae  type b ( Hib ) Human Papillomavirus (HPV) H1N1 Flu(Swine Flu ) Rabies Rotavirus Rubella (German Measles) Shingles (Herpes Zoster) Smallpox Tetanus (Lockjaw) Tuberculosis Typhoid Fever Varicella (Chickenpox) Yellow Fever Influenza (Seasonal Flu) Japanese Encephalitis (JE) Measles Meningococcal Mumps Pertussis (Whooping Cough) Pneumococcal Poliomyelitis (Polio)

8. Vaccine-Preventable Adult Diseases [CDC] Chicken Pox ( Varicella) Diphtheria   Flu (Influenza)  Hepatitis A  Hepatitis B  Human Papillomavirus (HPV)  Measles   Meningococcal Disease  Mumps   Pneumococcal Rubella   Shingles (Zoster)  Tetanus   Whooping Cough (Pertussis)

9. Influenza vaccination Annual vaccination against influenza is recommended for all persons aged 6 months or older. Adults aged 18 years or older can receive the recombinant influenza vaccine (RIV) Healthy , nonpregnant persons aged 2 to 49 years without high-risk medical conditions can receive either intranasally administered live, attenuated influenza vaccine (LAIV)

10. Vaccines Trivalent inactivated influenza vaccine (TIV) and Live attenuated influenza vaccine (LAIV ) The TIV contains A/17/California/2009/38 (H1N1), A/Brisbane/ 10/2007 (H3N2 ), and B/ Brisbane/60/2008 strains . Live attenuated influenza vaccine (LAIV) contains A/17/California/2009/38 like strain Schedule The TIV - annual , single dose of 0.5 ml IM or deep subcutaneous injection. The LAIV – 0.5 ml intranasal (spray 0.25 ml per nostril) 22-Jan-16 13 Influenza cont…

11. Recommendations People aged > 19 years. Chronic obstructive pulmonary disease (COPD ). Cardiac diseases Diabetes Mellitus, Cancer Immunodeficiency, Renal Disease Haemoglobinopathies Pregnant Women Health Care Providers Adult household contacts Travelers to endemic area 22-Jan-16 14 Influenza cont…

12. August - September is the optimal time to receive an annual flu shot to maximize protection. Influenza vaccine may be given at any time during the influenza season (typically October to March) or at other times when the risk of influenza exists. May give with all other vaccines but as a separate injection. Contraindications Previous anaphylactic reaction to this vaccine, to any of its components, or to egg proteins. Moderate to severe acute illness or febrile illness. 22-Jan-16 15 Influenza cont…

13. Side effects: Fever, malaise, shivering, fatigue, headache, joint or muscle pain – Disappear within 1-2 days without treatment. Rarely- neuralgia, paresthesia, convulsion, shock, vasculitis. Price range: 500 - 650 taka Influenza cont…

14. Diphtheria, Tetanus, Pertussis vaccination Efficacy of Tdap vaccine - 92% in a recent RCT. Dosage: 40IU/ 0.5ml IM injection. Recommendations: For adults in the age group of 18 to 64 years Three dose series if never vaccinated at 0 and 4 weeks, the third 6-12 months after second One dose booster of Tdap every 10 years 22-Jan-16 17

15. Health care personnel, especially those in direct contact with the patients, who have not received Tdap vaccine should receive a single dose of Tdap vaccine if 2 years or more have elapsed since the last dose of Td vaccination. Women planning pregnancy should receive one dose of Tdap vaccine if they had not received it previously. 22-Jan-16 18 Tdap cont…

16. For Pregnant Women Last dose Recommendation > 10 Years 1 dose in 2nd or 3rd trimester 2-10 years 1 dose immediate postpartum Never 3 doses 0, 1, 6 months During outbreak if previous unimmunized or Td before 2 years give 1 dose of Tdap 22-Jan-16 19 Tdap cont…

17. Tetanus Prophylaxis In Routine Wound Management * TIG: Tetanus immunoglobulin (250 IU IM) **Yes, if more than 10 years since last dose ***Yes, if more than 5 years since last dose For children less than 7 years, DTP may be given and above 7 years TT or Td . 22-Jan-16 20 Tdap cont… Doses of TT Clean, minor wounds All other wounds Given in past TT TIG* TT TIG* Unknown, <3doses Yes No Yes Yes ≥ 3 doses No** No No*** No

18. Contraindications History of anaphylaxis to any component. History of encephalopathy within 7 days of previous vaccination of Tdap . Moderate or severe acute illness, and those with unstable neurologic conditions (e.g., stroke, acute encephalopathies ) Tdap vaccination is to be deferred until the acute illness resolves. 22-Jan-16 21 Tdap cont…

19. Side effects: transient swelling at injection site, fever, malaise, nausea, vomiting, pruritus, anaphylactic reaction. Price range: 100-300 taka Tdap cont…

20. Varicella (Chickenpox) vaccination 22-Jan-16 23 Live attenuated VZV (Oka strain) vaccines for varicella virus are currently available. Dosage: 0.5ml SC Schedule: > 13 years - 2 doses are recommended. Interval between 2 doses should be 4–8wks.

21. Varicella cont… Recommendations : All susceptible adults and adolescents should be vaccinated. It is especially important to susceptible persons Health care workers Family contacts of immunocompromised persons High risk of exposure (e.g., teachers, day care employees, military personnel, and international travelers). 22-Jan-16 24

22. People with reliable histories of chickenpox (such as self or parental report of disease) can be assumed to be immune. For adults who have no reliable history, serologic testing may be cost effective since most adults with a negative or uncertain history of V aricella are immune. 22-Jan-16 25 Varicella cont…

23. Contraindications Previous anaphylactic reaction to this vaccine or to any of its components. Pregnancy, or possibility of pregnancy within 1 month. Immunocompromised persons due to malignancies and primary or acquired cellular immunodeficiency including HIV/AIDS. Salicylates to be avoided for 6wks after receiving varicella vaccine because of a risk of Reye’s syndrome. PRICE RANGE: ~1500 taka 22-Jan-16 26 Varicella cont…

24. Human Papilloma Virus vaccination Papilloma virus infection is precursor to cervical cancer Types 16, 18 account for 70% of cervical cancers Vaccines Two types HPV vaccines are available . quadrivalent vaccine [HPV4] containing HPV virus L1 protein like particles of HPV 6,11,16, and 18 bivalent vaccine [HPV2] containing L1 VLPs of HPV 16,18. Dosage: 0.5ml IM [ into deltoid muscle] 22-Jan-16 27

25. Schedule HPV4, 3 doses- 0.5ml IM at 0, 2, and 6 months. HPV2, 3 doses - 0.5 ml IM at 0, 1 and 6 months. [For males, HPV4 is recommended in a 3-dose series for routine vaccination at age 13 through 21 years. Males aged 22 through 26 years may be vaccinated if risk factor present.] 22-Jan-16 28 HPV cont…

26. Recommendations The vaccine has to be delivered prior to exposure to the HPV virus . Therefore, the immunization must precede the sexual debut . Age for initiation for vaccination to be 10 - 12 years. Catch-up vaccination can be advised up to the age of 45 years. 22-Jan-16 29 HPV cont…

27. Contraindications Pregnancy Patients with hypersensitivity to any of the vaccine components. Not recommended for girls <10 year of age Special situations The HPV vaccine is not contraindicated during lactation. The vaccine can be administered to immunosuppressed individuals. 22-Jan-16 30 HPV cont…

28. Several mild self limiting problems may occur with HPV vaccine: Pain at the injection site ( 8 people in 10) Redness or swelling at the injection site (1 in 4) Mild fever (100 o F ) (1 in 10) Itching at the injection site (1in 30) Moderate fever (102 o F ) (1 in 65) Headache, nausea, vomiting, diarrhea, myalgia. Others: RTI, Lymphadenopathy, anaphylactic reaction, syncope. 22-Jan-16 31 HPV cont…

29. Price range: ~ 1600 taka HPV cont…

30. Measles, Mumps And Rubella vaccination The measles and the rubella components are produced using human diploid cells while the mumps component is produced from chick embryo. Dosage: 0.5 ml should be administered subcutaneously into outer aspect of the upper arm. 22-Jan-16 33

31. Recommendations Adults who are > 18yrs of age should receive at least one dose of MMR if there is no serologic proof of immunity or documentation of a dose given previously. Adults in high-risk groups, such as health care workers and international travelers, should receive two doses. All women of childbearing age who do not have acceptable evidence of rubella immunity or vaccination. 22-Jan-16 34 MMR cont… MMR cont…

32. Schedule One or two doses are needed 12 wks apart. If a pregnant woman is found to be rubella susceptible, administer MMR postpartum. Protection against measles after exposure: single dose within 72 hour of contact. 22-Jan-16 35 MMR cont… MMR cont…

33. Contraindications Previous anaphylactic reaction to this vaccine, or to any of its components. Pregnancy or possibility of pregnancy within 4 weeks (use contraception). Persons immunocompromised due to cancer, leukemia, lymphoma, immunosuppressive drug therapy, including high-dose steroids or radiation therapy. Administration of blood or blood products: who received blood products: should wait at least 3 months before vaccination and, if possible, blood products should be avoided for up to 2 weeks post vaccination. Vaccinated persons are not eligible to donate blood for 1 month after vaccination. 22-Jan-16 36 MMR cont… MMR cont…

34. Side effects: Fever, atypical measles, syncope, malaise, irritability Vasculitis, Pancreatitis, vomiting, diarrhea, Diabetes mellitus Thrombocytopenia Anaphylaxis PRICE RANGE: 400-500 taka. MMR cont…

35. Pneumococcal vaccination Two types: 13-valent pneumococcal conjugate vaccine [PCV13] and 23-valent pneumococcal polysaccharide vaccine [PPSV23 ] [for adult]

36. Schedule A single standard dose (0.5 ml ) is administered by the intramuscular or subcutaneous route. Revaccination: 0.5ml IM or SC at least after 5 years of 1 st dose in case of High risk people. 22-Jan-16 39 PPV cont…

37. Recommendations Adults who are 65yrs of age or older. 22-Jan-16 40 High risk people Anatomic asplenia Sickle cell disease Immunocompromised persons including HIV Leukemia, Lymphoma Hodgkin’s disease Multiple myeloma Generalized malignancy Chronic renal failure Nephrotic syndrome Chemotherapy & corticosteroids Organ or bone marrow transplant. Pregnant women with high-risk conditions PPV cont…

38. Contraindications: Known allergy Acute illness or relapse of chronic disease Vaccinated within 3 years Side effects: Local reaction Fever, adenopathy , allergic reaction, headache, malaise. Price range : ~1000 taka PPV cont…

39. Hepatitis B vaccination Protection (anti-HBs antibody titer of 10mIU/ml or higher) after recombinant vaccine After first dose - 20% to 30% After second dose - 75% to 80% After third doses - 90% to 95% Recommendations All unvaccinated adult risk for HBV infection and All adults seeking protection from HBV infection including post-exposure prophylaxis . 22-Jan-16 42

40. Dosage: For immunocompetent adults, 1ml (20 μg ) of recombinant vaccine is administered at 0, 1, and 6 months as an intramuscular . Adult patients receiving hemodialysis or with other immunocompromising conditions should receive 1 dose of 40 mcg/mL administered on a 3-dose schedule at 0, 1, and 6 months or 2 doses of 20 mcg/mL administered simultaneously on a 4-dose schedule at 0, 1, 2, and 6 months. HBV cont…

41. Pre vaccination screening: Pre vaccination screening in general population has not been found to be cost effective. Pre vaccination screening may be cost-effective in adult populations with a prevalence of HBV infection of >20% such as Household or sexual contacts of HBsAg -positive persons; HIV infected persons Injection drug users Men who have sex with men Patients with chronic liver disease (CLD) End-stage renal disease (ESRD). 22-Jan-16 44 HBV cont…

42. HBV cont… 22-Jan-16 45

43. BOOSTER DOSE: Booster doses of HBV vaccine are not indicated in persons with normal immune status . For CKD patients, the need for booster doses should be assessed by annual anti-HBs antibody titre testing. A booster dose should be administered when anti-HBs levels decline to less than 10 mIU/ml & <100 mIU/ml in patients on dialysis. HBV cont…

44. Contraindications Previous anaphylactic reaction to this vaccine or to any of its components. Moderate or severe acute illness. Severe immunodeficiency. Side effects: GI disturbance, Musculoskeletal/ joint pain, hypotension, tachycardia, dysuria, earache. PRICE RANGE : 250-600 taka 22-Jan-16 47 HBV cont…

45. Hepatitis A vaccination Two types: Live attenuated HAV vaccine Hepatitis A virus [inactivated] vaccine Dosage: 1ml injection IM 22-Jan-16 48

46. Schedule At least single dose. 2 nd doses of 1ml as booster dose at 6-18 month interval. Immune status for hepatitis A should be checked Hepatitis A cont…

47. Recommendations The Expert Group felt that universal immunization for hepatitis A is not recommended as yet. Not only is the vaccine costly, more epidemiological data are required to ascertain its benefits. Adults at risk for acquiring hepatitis A, and adults who are negative for anti-HAV antibodies are likely to benefit most in view of changing epidemiology. high-risk groups should be considered: travelers to areas of intermediate or high endemicity , those requiring life-long treatment with blood products , men who have sex with men, injection drug users. In addition, patients with chronic liver disease are at increased risk for fulminant hepatitis A and should be vaccinated. 22-Jan-16 50 Hepatitis A cont…

48. Contraindications Previous anaphylactic reaction to this vaccine or to any of its components. Moderate or severe acute illness. Safety during pregnancy has not been determined, so benefits must be weighed against potential risk. Side effects: soreness, erythema, fever, malaise, anaphylaxis. PRICE RANGE : 1000-1200 taka 22-Jan-16 51 Hepatitis A cont…

49. Meningococcal vaccination Types Polysaccharide vaccines Bivalent (A&C) Quadrivalent (A,C,Y & W135) Conjugate vaccines. The vaccine does not induce herd immunity and has no effect on nasopharyngeal carriage . Containing 50 μg of polysaccharide per dose. After reconstitution use within 8-12 hours. 22-Jan-16 52

50. Schedule A single dose of 0.5 ml SC in deltoid region. Revaccination with A,C,Y & W135 every 5 years is recommended for adults previously vaccinated who remain at increased risk for infection (e.g., adults with anatomical or functional asplenia , persistent complement component deficiencies, or microbiologists) 22-Jan-16 53 Meningococcal cont…

51. Recommendations The meningococcal vaccine can be used in selected populations in certain situations, such as During an outbreak (HCW, Lab. worker, Close contacts ) During inter-epidemic period To travelers , pilgrims( Quadrivalent ), people attending fairs and festivals(bivalent 10-14 days prior). 22-Jan-16 54 Meningococcal cont…

52. Mass vaccination may be considered depending on the age-specific attack rate, geographical distribution of cases, and the availability of vaccine. During the inter-epidemic period, to personnel living in dormitories; military recruits; jail inmates; immunocompromised individuals. Adults with anatomic or functional asplenia , or terminal complement component deficiencies. 22-Jan-16 55 Meningococcal cont…

53. Contraindications Previous anaphylactic reaction to this vaccine or to any of its components . GBS patient. Side effects: GI symptoms, Local reaction, fever, malaise, anaphylaxis. Price range : 500-600 taka. Meningococcal cont…

54. Haemophilus influenzae type b ( Hib ) vaccination Hib vaccine is not required for healthy children after 5 years of age . One dose of Hib vaccine should be administered to persons who have anatomical or functional asplenia or sickle cell disease or are undergoing elective splenectomy if they have not previously received Hib vaccine. Hib vaccination should be done 14 or more days before splenectomy is suggested.

55. Recipients of a hematopoietic stem cell transplant (HSCT) should be vaccinated with a 3-dose regimen 6 to 12 months after a successful transplant, regardless of vaccination history; at least 4 weeks should separate doses . Hib cont…

56. Dosage : 10mcg IM injection Contraindication : Hypersensitivity to any component. Side effect : Local reaction, fever, malaise. Price range : 200-500 taka Hib cont…

57. Herpes zoster (shingles ) vaccination Shingles is caused by a reawakening of the chickenpox virus Symptoms – rash usually along nerve pathways Very painful and debilitating 20-30 % people can expect to get shingles in their lifetime 22-Jan-16 60

58. Schedule Single 0.65 ml dose subcutaneously in the upper arm. The vaccine must be used within 30 minutes after reconstitution. 22-Jan-16 61 Herpes Zoster cont…

59. Recommendations Recommended for persons > 60 years. High risk for developing recurrent herpes zoster, such as Patients with chronic medical conditions (CKD, diabetes mellitus, rheumatoid arthritis, and chronic pulmonary disease); Persons who are likely to have severe immunosuppression in near future. 22-Jan-16 62 Herpes Zoster cont…

60. Rabies vaccination Production and use of nerve-tissue rabies vaccines should be discontinued and replaced with cell-culture-based vaccines (CCVs ). Recommended for anyone who will be at continual, frequent or increased risk of exposure to the rabies virus, either as a result of their residence or occupation. Travelers with extensive outdoor exposure in rural high-risk areas where immediate access to appropriate medical care may be limited should also be vaccinated regardless of the duration of stay.

61. Dosage: 1ml Intramuscular administration: For adults and children aged ≥2 years, the vaccine should always be administered in the deltoid area of the arm. Rabies cont …

62. Schedule: Pre exposure Immunization/ primary vaccination: D0, D7, D21, D28 Post exposure Rx: Non vaccinated: D 0, 3, 7, 14, 28 [with immunoglobulin if need] Previously Vaccinated <3 years: D 0, 3 Previously Vaccinated >3 years: D 0, 3, 7, 14, 28 [with immunoglobulin if need] Rabies cont …

63. Contraindication: only pre exposure: severe fever, acute disease, known hypersensitivity to component. Side effects: Local reaction, GI sumptoms , dyspnea, wheezing. Price range: 500-650 taka Rabies cont …

64. Typhoid vaccination Types: Vi polysaccharide typhoid vaccine Ty21a live oral vaccine [ liquid form] Ty21a live oral vaccine [capsule form]

65. Dosage: Vi polysaccharide typhoid vaccine: one parenterally administered dose 0.5 ml the capsule form of Ty21a (for use in individuals from the age of 5 years) requires 3 or 4 orally administered doses . Booster - In most endemic settings, a booster dose of the concerned vaccine 3 to 7 years after the primary immunization seems appropriate. Typhoid cont …

66. Contraindications Previous anaphylactic reaction to this vaccine or to any of its components. Moderate or severe acute febrile illness. Safety during pregnancy has not been determined, so benefits must be weighed against potential risk. Side effects: Local reactions, fever, malaise, GI symptoms, urticaria . PRICE RANGE : 300-450 taka 22-Jan-16 69 Typhoid cont …

67. Recommended Vaccines for Healthcare Workers [CDC ] Healthcare workers should maintain an immunization history for: Hepatitis B Influenza * MMR Varicella (chickenpox) Tetanus, diphtheria, pertussis Meningococcal ** Typhoid** Poliomyelitis ** 22-Jan-16 71 * Receive annually ** For specific healthcare personnel

68. Recommended vaccines for travelers to BANGLADESH [CDC] 22-Jan-16 72 Source : CDC All travelers : measles-mumps-rubella (MMR) vaccine, diphtheria-tetanus-pertussis vaccine, varicella (chickenpox) vaccine, polio vaccine, and your yearly flu shot . Most travelers : Hepatitis A, typhoid Some travelers : hepatitis B, Japanese Encephalitis, malaria [preventive management], Rabies.

69. Adult Immunization Challenges Inadequate funding for vaccines and administration in public programs Lack of knowledge – both patients and providers Poor public health and private infrastructure for vaccine delivery. Lack of availability of vaccine. High cost of vaccine. 22-Jan-16 73

70. Reasons -Aware but not receiving vaccine 22-Jan-16 74 Source: Johnson et al, Barriers to Adult Immunization, The American Journal of Medicine, Vol 121, No 7B, July 2008

71. Reasons -Aware but not receiving vaccine 22-Jan-16 75 Source: Johnson et al, Barriers to Adult Immunization, The American Journal of Medicine, Vol 121, No 7B, July 2008

72. Reasons -Aware but not receiving vaccine 22-Jan-16 76 Source: Johnson et al, Barriers to Adult Immunization, The American Journal of Medicine, Vol 121, No 7B, July 2008

73. Documentation Provide copy of Vaccine Information Statement ( VIS)to patient Documents to be maintained Date vaccination & next dose Vaccine manufacturer Lot number Dose & site of vaccine Vaccinator’s initials 22-Jan-16 77

74. Vaccine Administration Health care personnel should get proper training before administrating vaccine. Always prepare and check the following for every vaccination you give: Right Patient Right Drug (vaccine) Right Dose Right Route (intramuscular, SC, intradermal ) Right Time (is scheduling correct) 22-Jan-16 78

75. Standards for Adult Immunization Practices Make immunizations available Adult immunization services are readily available Barriers to receiving vaccines are identified and minimized Patient “out-of-pocket” immunization costs are minimized Assess patients’ immunization status Health care professionals routinely review the immunization status of patients Health care professionals assess for valid contraindications Communicate effectively with patients Patients are educated about risks and benefits of immunization in easy-to-understand language 22-Jan-16 79

76. Administer and document immunizations properly Persons who administer vaccines are properly trained Simultaneous administration of indicated vaccine doses Immunization records for patients should be accurate All personnel who have contact with patients are appropriately vaccinated 22-Jan-16 80 Standards for AI cont….

77. Implement strategies to improve immunization rates. Systems are developed and used to remind patients and health care professionals when immunizations are due and to re-call patients who are overdue Standing orders for immunizations are employed Regular assessments of immunization coverage levels are conducted in a provider’s practice Patient oriented and community based 22-Jan-16 81 Standards for AI cont….

78. Recommendations (CDC) Finances Research on barriers Public and Provider Education Standards of Care Improved vaccines (immunogenicity, safety) Supply of Vaccines Support for programs and partners Legislative and regulatory strategies 22-Jan-16 82

79. T h a n k y o u